Nipple-Sparing Mastectomy

Overview

The breast surgeons at Massachusetts General Hospital are national leaders in performing nipple-sparing mastectomies (NSM). In 2006, Mass General developed a new technique for NSM, based on the microscopic anatomy of the nipple. Since then, it has been offering NSMs to eligible women, including those with high risk and those with breast cancer. Our NSM program is one of the largest in the country, with more than 400 NSM procedures performed annually.

What Is a Nipple-Sparing Mastectomy?

NSM is a procedure for individuals who are considering a mastectomy to treat breast cancer or to prevent breast cancer, such as patients with BRCA gene mutations.

During NSM, breast surgeons preserve all of the skin of the breast, including the nipple and areola. Plastic and reconstructive surgeons perform breast reconstruction during the same operative procedure using the patient’s skin as part of the breast reconstruction. With this technique, the reconstructed breast looks more like the original, natural breast.

Safe nipple preservation requires complete removal of all breast tissue as in a standard mastectomy, while preserving all the breast skin. Careful pathology testing is performed on the overall breast. The breast ducts are removed from inside and directly underneath the nipple to ensure they are free of cancer.

Highly Specialized Surgeons

Mass General's NSM surgeons are pioneers in surgical breast reconstruction, mastectomy and breast cancer surgery. All breast surgeons at Mass General are completely dedicated in their practices and provide our patients with the most specialized breast care.

Under the direction of Barbara L. Smith, MD, PhD, an international leader in developing surgical guidelines for safe and effective techniques in NSM, our surgeons developed one of the country’s largest nipple-sparing program, which follows safe guidelines established through years of research.

Collaborative Team of Specialists

A team of specialists, working together to ensure the best outcomes, care for all patients undergoing nipple-sparing mastectomy. These include:

• Anesthesiologists from the Department of Anesthesia, Critical Care and Pain Medicine
• Breast surgeons from the Division of Gastrointestinal & Oncologic Surgery
• Perioperative nurses who specialize in caring for our patients
• Reconstructive surgeons from the Division of Plastic and Reconstructive Surgery

In addition, patients being treated for breast cancer are cared for by a multidisciplinary team of breast cancer subspecialists, including:

• Breast pathologists
• Breast radiologists
• Genetic counselors
• Medical oncologists
• Physical therapists
• Radiation oncologists

Prospective Candidates

In the past, there were concerns that very few women with breast cancer could have a safe nipple-sparing surgery. Before the launch of our NSM program, a team of researchers led by Dr. Smith performed careful studies of the microscopic anatomy of the nipple and its blood vessels. With this knowledge, we designed a new NSM approach that thoroughly removes breast tissue from inside the nipple, while keeping its blood supply safe.

We have used this technique since 2007 and have found that many women with breast cancer can safely keep their nipples. Prior to surgery, we perform careful breast imaging and physical examinations to confirm that no tumor is present in the nipple. As part of surgery, breast tissue removed from inside and directly underneath the nipple is thoroughly tested to make sure it is safe to leave the nipple in place.

Every new cancer patient's diagnosis is reviewed by a multidisciplinary team to determine if NSM is an option. In addition to cancer-related factors, we also consider cosmetic factors when deciding if NSM is a good option.

NSM to Prevent Breast Cancer

Risk-reducing, or prophylactic, mastectomies may be performed for a woman known to have a mutation in a breast cancer risk gene, such as a BRCA 1 or BRCA 2 mutation, that gives her a very high risk of breast cancer. These preventative mastectomies are sometimes also performed in women with a very strong personal or family history of breast cancer. For women at very high risk of developing breast cancer, risk reducing nipple-sparing mastectomy is supported by national guidelines and lowers breast cancer risk by more than 90%, according to a study in the New England Journal of Medicine.

If you have a strong family history of breast cancer and are interested in genetic counseling and testing to determine your breast cancer risk, contact Mass General’s Center for Cancer Risk Assessment at 617-724-1971. Our certified genetic counselors work closely with our breast surgeons for seamless, coordinated care for women with mutations in breast cancer risk genes.

Breast Reconstruction

Breast reconstruction generally requires several procedures. Many women can begin breast reconstruction at the time of mastectomy (known as immediate reconstruction). Delayed reconstruction typically begins weeks or months after the mastectomy and often depends on whether you are undergoing radiation therapy and/or chemotherapy, amongst other factors.

Your Mass General care team will determine whether you are a candidate for immediate or delayed reconstruction as well as your personal health factors.

Additional Options for Breast Reconstruction

Mass General offers many options for breast reconstruction, including:

• Autologous breast reconstruction, which involves transferring tissue from another part of the body to the breast
  • Deep inferior epigastric perforator (DIEP) flap: procedure uses only fat and skin from the patient's abdomen, preferable option
  • Latissimus dorsi flaps: procedure uses tissue from the patient's back for breast reconstruction
  • Superficial inferior epigastric artery (SIEA) flap: procedure uses skin and fat from the lower abdomen to create a new breast
  • Transverse myocutaneous gracilis (TMG) flap: procedure uses tissue from the thigh is transferred to the breast
  • Transverse rectus abdominus myocutaneous (TRAM) flap: procedure uses tissue from the lower abdomen to create a new breast
• Lymphatic surgery and lymph node microsurgical transfer to treat lymphedema
• Pre-pectoral muscle-sparing implant breast reconstruction
• Single stage direct-to-implant breast reconstruction

Specializing in Single-stage Breast Reconstruction Surgery

Mass General reconstructive surgeons have perfected the single-stage direct-to-implant reconstruction. While most reconstructive surgeons at other centers typically perform two or three surgeries to complete the reconstructive process, most patients undergoing nipple-sparing mastectomy at Mass General have their permanent implant placed at the time of mastectomy. This means that most patients only have a single surgery and a single recovery, which decreases pain, minimizes disruptions to work and family life and reduces costs.

Specializing in Pre-pectoral Muscle-sparing Breast Reconstruction

Pre-pectoral muscle-sparing breast reconstruction is the least invasive method of breast reconstruction and is currently only performed in a few of centers around the country. Mass General is the first hospital to perform this procedure in New England. Many of our plastic surgeons are nationally known for pioneering pre-pectoral muscle-sparing breast reconstruction.

To perform this minimally invasive method of breast reconstruction, our surgical oncologists and plastic surgeons coordinate as a team to optimize the mastectomy and reconstructive procedures. Muscle-sparing breast reconstruction optimizes recovery with reduced pain, decreases length of stay and allows patients to return to treatment or activities earlier. Importantly, the reconstructed breast is more natural, does not contract or move when the arm moves, as often happens in sub-pectoral breast reconstruction. The pre-pectoral muscle-sparing breast reconstruction is commonly performed as a single-stage procedure, also unique to our approach at Mass General.

Nipple Tattooing

Nipple tattooing, which can be done for cosmetic purposes following mastectomy, is available at Mass General. You can speak with your physician about the health considerations you should be aware of, if you are considering nipple tattooing following mastectomy.

Learn about breast reconstruction 

Frequently Asked Questions

What does the preserved nipple look and feel like?
The nipple looks very much like your original nipple. Some changes in nipple size, projection and color are possible. As for all mastectomies, women experience permanent numbness of their breast skin, including the skin of the nipple.

What are the chances I will lose my nipple if I have nipple-sparing mastectomy?
Approximately 3-4% of cancer patients need to have their nipple removed due to finding cancer in the tested nipple margin. Another 2% of patients need to have their nipple removed due to healing problems of the nipple.

How painful is the procedure?
We work closely with our anesthesia colleagues to provide nerve blocks to provide pain relief for patients having nipple-sparing mastectomies. This minimizes pain after surgery, and most patients do not require intravenous pain medications after surgery. Pain after surgery is managed with a short period of narcotic pain pills, but mainly with non-narcotic muscle relaxants such as, acetaminophen and Neurontin.

What is recovery like?
Most patients spend one night in the hospital. Most patients can expect to return to full activity in six to eight weeks.

What can I expect at my first appointment?
At your appointment, you'll meet with specialists in breast surgery and reconstructive surgery. If you're undergoing surgery as a preventative measure, you'll also meet with a genetics counselor.

How can I prepare for surgery?
Your care team will contact you prior to your surgery with preoperative instructions specific to your treatment program. These instructions will tell you how to manage any medication that you are currently taking and let you know if you need to have any preoperative blood work or imaging.

What can I expect after surgery?
About seven to ten days after your surgery, your surgeon will call you with pathology results. These results will determine the next steps in your treatment program. If necessary, your surgeon will arrange follow-up appointments with other providers.