Nipple-sparing Mastectomy and Ptosis: Using a Free Nipple Graft with Tissue Expander Reconstruction

Background: Nipple-sparing mastectomies are increasingly offered to women with breast cancer given the evidence for oncologic safety and improved cosmetic outcomes. Women with significant ptosis are often excluded due to potential nipple malposition and increased risk of nipple ischemia. The use of a harvested free nipple graft may allow women with ptosis to conserve their nipple -areolar complex. Methods: This is an IRB approved retrospective study of breast cancer patients at an academic center with ptosis who underwent free-nipple graft mastectomies with a single plastic surgeon and 5 dedicated breast surgeons from 2014-2017. The primary outcomes were free nipple graft viability and the need for revision. Secondary outcomes included post-operative complications. Results: Fourteen women with ptosis underwent skin and nipple-sparing mastectomy with breast reconstruction involving use of harvested free-nipple graft. More than half of the women were diagnosed with early-stage invasive breast cancer (42% stage 1, 14% stage 2). Four women underwent mastectomy for prophylaxis or other benign reasons. All of the women had significant ptosis during the pre-operative evaluation (57% grade 2 ptosis, 36% grade 3 ptosis, and 7% uncategorized), with an average BMI of 30. None were active smokers. In the postoperative period, one had partial nipple necrosis in combination with skin flap necrosis and positive margin (7%). Other complications included infection (14%) and hypopigmentation (14%). All nipples lost sensation and full projection. Conclusions: This is a novel approach using a free nipple graft with a skin envelope reducing mastectomy and immediate expander-based reconstruction. This successful approach allows women with ptosis to undergo nipple-sparing mastectomy with preservation of the nipple -areolar complex.