High risk/preventative mastectomy: For breasts with significant ptosis what is the best technique for nipple sparing mastectomy?

Two surgeons offering vastly different approaches for NSM. 1st suggests mastopexy (anchor incision) 3 months prior w/ a nipple delay. 2nd surgeon suggests horizontal bat wing/periareolar incision with bilateral extension to reposition nipple. Having difficulty finding any info on bilateral extension approach which would be executed at the time of mastectomy. What are pros and cons to both? Which will yield best results and least complications? Which has better chance for nipple survival?

Doctor Answers 5

Breast reconstruction if you have ptosis

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This is a great question, and because nipple sparing mastectomy is so new, there's no "right answer" or "standard of care". For my patients, if they are super droopy I'll use a straight vertical incision between the nipple and the inferior mammary crease. This incision takes up a lot of the extra skin and the nipple comes up a lot. If they are just a little bit droopy, then I go for the inferior mammary crease incision... I'm amazed how much the patient's skin will spring up and then they don't need any kind of lift scar. I never delay it or do a lift first as this is more, possibly unnecessary, surgery. I also need to say that the MOST important thing you can do is to pick a great general surgeon/surgical oncologist. This is the doctor that removes the breast. Most doctors have around a 15% rate of mastectomy flap necrosis (SERIOUSLY, 15% chance that the skin may die) which I find completely unacceptable. Pick someone who has a rate of less than 1%, ie, dead skin or nipples almost NEVER happens to their patients. Ask your plastic surgeon what your general surgeon's rate is, they are usually more realistic about this than the general surgeon is about themselves.

Beverly Hills Plastic Surgeon
4.7 out of 5 stars 16 reviews

Nipple Delay

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It is hard to give the best answer without photos and an in-person examination, as every patient's particular anatomy will be different. For severe ptosis in a patient who is having prophylactic mastectomies, I personally favor the nipple delay procedure. Since you don't currently have cancer, you have time to be able to achieve the best cosmetic result possible. The nipple delay procedure with anchor pattern lift will place the scars in a favorable location to enable further adjustments/refinements in the future. It has the better chance of preserving complete nipple and areolar viability without even loss of pigmentation (though that is easy to correct with tattooing later on). Also the scar burden is much worse with the bat-wing or lateral extension approach, which would be more acceptable only if you currently had cancer and couldn't afford to wait.

If your ptosis is not severe however, your tissue will shrink down a bit from the mastectomy itself and the nipple/areola position can be tacked up on the chest wall at the first stage during the mastectomy and tissue expander placement. Your result will look strange at first, but at stage 2 during the expander to implant exchange, excess skin can be removed to refine your shape. This can sometimes be done entirely via an incision in the fold beneath the breast. Finally, for the ultimate result, ask your surgeon about fat transfer to the breasts at stage 2 to create a result that completely mimics a cosmetic breast surgery.

On a final note, with regard to nipple viability with mastectomies, often the determining factor for success is the skill of the breast oncologic surgeon, not your plastic surgeon. It is the breast surgeon who has to be careful not to thin the tissue too much directly below the nipple and areola to ensure viability. Your best results will be obtained by choosing a center where the surgical breast oncologists work hand in hand with plastic surgeons on a daily basis. This team approach will yield both the best breast care and the best reconstructive success. Please reference the web link below for an example of this sort of team approach. Good luck!

Mark Gaon, MD
Newport Beach Plastic Surgeon

Mastectomy for ptotic (droopy) breasts

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look at the before and after pictures of the surgeons to get an idea of what to expect from their work. You may want to talk to another patient of theirs as well. Lastly, everyone heals differently. It may be that your skin is more elastic than you think. Many of our patients who think the need (or just want) a lift when they present for mastectomy actually do very well when a fuller implant is placed and the skin is allowed to retract. Minor adjustments to lift the nipple after NSM are sometimes all that is needed. Remember: you can always take it away later, but you can't put it back once it isn't gone. Consider getting opinions from many doctors. Choose someone with lots of experience in NSM and reconstruction after NSM.

Heather Richardson, MD, FACS
Beverly Hills General Surgeon
5.0 out of 5 stars 2 reviews

Nipple sparing mastectomy

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There are several mastopexy incisions traditionally used in plastic surgery.  The measurements from the nipple to fold help me decide which combination of of incisions to use.  The bat wing periareolar incision would not be an incision I would use for a mastopexy.  After appropriate healing you can decide which reconstructive technique makes the most sense.

Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage (DTI) or two stage. One stage reconstructions are best for patients without a great deal of sagging and moderate breast size.  This allows for the placement of an implant to fill out the pocket left by the mastectomy without excess skin. Two stage reconstructions are started by placing expanders at the time of mastectomy. Tissue expanders can be placed above or below the muscle.  If placed above the muscle they are completely wrapped in alloderm. Expanders are inflated initially in the operating room and in the office as an outpatient.  Exchange to permanent implants can be performed after the desire volume has been reach and adequate wound healing has occurred.

Breast Ptosis

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Given the non-urgency, I would perform the best breast lift possible and heal: full anchor mastopexy with some reduction if necessary to help give you a lifted and tight breast. I would wait at least 3 to 6 months for the nipple sparing mastectomy (and I presume a single stage implant reconstruction). 
Best of luck!

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 100 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.