Surgical Treatment Of Nipple Malposition In Nipple Sparing Mastectomy Implant Reconstruction
Methods/Technique: A retrospective chart review was conducted on a prospectively-collected IRB-approved database of NSM cases with immediate implant-based reconstruction performed by a single plastic surgeon between July 2006 and October 2012. Malposition was graded as mild displacement (1cm), moderate (2cm), and severe (>3cm).
Results/Complications: 319 NSMs were reviewed. Malposition occurred in 13.79% (n=44). Significant factors were age (p<0.0001), diabetes mellitus (p=0.024), body mass index (p=0.0093), preoperative sternal notch to nipple distance (p=0.015), preoperative breast base width (p=0.0001), peri-areolar mastectomy incision with lateral extension (p <0.0001), prior radiation therapy (p=0.0004), prior ipsilateral lumpectomy (p=0.0125), unilateral NSM (p=0.0004), and postoperative NAC ischemia (p=0.0174). Smoking status, breast volume resected, implant size, inframammary mastectomy incision, acellular dermal matrix, and single-stage reconstruction were not significant.
19/44 (43.2%) malposition cases were satisfied and deferred surgical correction (9 mild, 7 moderate, 3 severe). 8/44 (18.2%) cases were not offered surgical correction because of an inadequate skin envelope secondary to radiation tissue fibrosis, contracture, or thinning. 8/44 (18.2%) cases were corrected with crescent mastopexy (7 mild, 1 severe), 3/44 (6.8%) with implant exchange and pocket revision (1 moderate, 2 severe), 4/44 (9.1%) with free nipple grafts (4 severe), and 2/44 (4.5%) with pedicled nipple transposition (2 severe). Of note, 2/44 (4.5%) had nipple excision and reconstruction secondary to recurrence. There were no incidences of nipple necrosis or nipple malposition after surgical correction.
Conclusion: NSM followed by immediate implant-based reconstruction has an identifiable risk of nipple malposition. We found several risk factors to be significantly associated with nipple malposition. Various surgical options are available to correct nipple malposition based on clinical presentation and are safe procedures in a well-selected patient population to improve overall cosmesis.