The Breast 44S1(2019) S79-S142
Goals: Nipple sparing mastectomy in the setting of Risk Reducing Surgery for gene mutation carriers has been validated as a safe oncologic option while aesthetic indications restrict the method to small and medium sized, non- ptotic breasts. However, increasingly more patients ask for nipple preserving mastectomy, as they consider the loss of the nipple not an acceptable option.
Methods: A 43 year old woman, diagnosed with a BRCA -1 gene mutation, presented for bilateral Risk Reducing Mastectomy and asked for preservation of her nipples and immediate reconstruction. Her breast imaging was negative of suspicious findings. She had no co- morbid conditions andwas a smoker. She had hypertrophic ptotic breasts and opted for smaller sized reconstructed breasts. After informed consent of the patient and abstention from smoking for 4 weeks, a bilateral mastectomy with the following components was conducted:
- Wise pattern skin reduction of the breast envelope
- Bi- pedicle vertical, superior and inferior, dermal flap for preservation of Nipple – Areola complex
- Subcutaneous mastectomy
- Tissue Expanders placement at the 1st stage of immediate reconstruction
- Replacement of Tissue Expanders with Silicone Implants and scar revisions at the 2nd stage of reconstruction.
Results: Almost 2 kg of each breast were removed. At the immediate postoperative period of the first stage there were some areas of delayed wound healing that resolved in about 4–6 weeks. Both Nipple- Areola complexes were well vascularized with no discolouration. No nipple sensation was evident but some erectile function could be elicited. Tissue expansion was completed in 4 months. Replacement of expanders with implants and skin revisions were conducted in 8 months. At 4 months after the final operation, the patient was very satisfied with the aesthetic result of her breasts along with the improvement of her body posture due to downsizing of the new breasts.
Conclusions: The preservation of nipple areola complex in the setting of subcutaneous mastectomy for a patient with very large and ptotic breasts is usually deemed not feasible. In this case, the complex was spared by utilizing superior and inferior dermal vascularization of the nipple, along with skin reduction and 2 stage tissue expander reconstruction. Risk factors optimization, meticulous development of dermal flaps and gradual tissue expansion that compensated for borderline vascularization of the nipple, were key components for the success of the operation.
Conflict of Interest: No significant relationships.