High risk/preventative mastectomy: For breasts with significant ptosis what is the best technique for nipple sparing mastectomy?
Doctor Answers 5
Breast reconstruction if you have ptosis
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!
Mastectomy for ptotic (droopy) breasts
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.
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Nipple sparing mastectomy
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.
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!
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.