Nipple-sparing mastectomy has revolutionized mastectomy reconstruction outcomes. The patient keeps her nipple areolar complex, and the scar is often able to be hidden below the breast reconstruction. Since a scar on the breast also influences the shape of the breast, the resulting reconstruction has a prettier, rounder shape. Nipple-sparing mastectomy (NSM) does, however, have more risk because since more skin is saved, it has a poorer blood supply. This can translate into more wound healing issues in terms of infection, skin loss, nipple loss and even implant loss. This is especially true in large breasted women, irradiated breasts, breasts with scars or breasts that have more droop and therefore more skin.
The Journal of Surgical Oncology in 2012 introduced a technique to counteract these problems. It is called a surgical delay procedure, and it gained some popular attention after Angelina Jolie had this procedure prior to her bilateral prophylactic mastectomies with reconstruction. The nipple-delay procedure is performed by the cancer surgeon and involves making the same incision as would be made for the mastectomy and then releasing the undersurface of the nipple and surrounding skin from the breast for about two inches. It allows the blood vessels in the skin under and around the nipple to dilate so that when the mastectomy is performed about two weeks later, the nipple has already accommodated to the new circulation pattern and will survive. As of June, 2015, we have used this technique on more than 90 breasts, and all of the nipples have survived! You can read about this under Publications on my website – “Surgical Delay of the Nipple Areolar Complex in High-Risk Nipple-Sparing Mastectomy Reconstruction.”
If the patient has cancer, then the tissue under the nipple will be biopsied at the time of the delay to make sure that the nipple can be saved from a cancer point of view. The lymph nodes can be sampled at this time as well. This allows the patient to have a shorter operation at the time of the mastectomy.
In summary, the nipple-delay procedure has the disadvantage of an added operation. The advantages are allowing more patients to be candidates for nipple-sparing mastectomy, safer surgeries with fewer complications and increasing the chances that we will be able to skip the expander to go directly to implant (DTI). I will be very happy to discuss this procedure with you in more detail when you come in to discuss and plan your breast reconstruction.