Nipple pathology in total skin-sparing mastectomy:Implications for immediate reconstruction

Purpose: The management of occult tumor involvement of the nipple during total skin-sparing mastectomy (TSSM) and immediate reconstruction is not well addressed in the literature. We reviewed our experience with positive nipple core biopsies, comparing outcomes of different management options. Methods: Mastectomy and implant/expander reconstructions over a 5-year period were reviewed. Patient characteristics, type of mastectomy, and complications were analyzed. Patients were grouped by type of mastectomy/immediate reconstruction and delayed reconstruction to compare outcomes. Positive intraoperative core nipple biopsy cases formed a subset of the TSSM group. Results: Forty-four of 240 (18%) caseswere TSSMs performed through inferolateral incisions. All were reconstructed immediately, 24 with tissue expanders and 20 with implants. Major complications (necrosis, infection, seroma) were significantly lower than for skin-sparing mastectomies, but higher than delayed reconstruction. One case of full thickness nipple necrosis occurred. Seven of the TSSM group had positive core nipple biopsies (16%). Three of these patients underwent nipple excision and tissue expander placement at the initial surgery, of which 2 developed subsequent mastectomy skin flap necrosis requiring explantation. A third patient underwent staged nipple excision without complication. The remaining 3 patients underwent delayed nipple resection at the time of tissue expander replacement without complication. Pathology in the nipple core was invasive ductal carcinoma and ductal carcinoma in situ. No TSSM patients have developed local recurrence at follow-up. Conclusions: Concurrent excision of the nipple and an inferolateral incision increase the incidence of skin flap necrosis. Delaying nipple excision may prove to be a safer option.