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Nipple Sparing & Transplantation After Breast Surgery

Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery.   Full references are given for both below.

There are many techniques used for nipple reconstruction which should tell you that none is perfect.  One of the main issues is loss of nipple projection over time.  So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect!

The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios.   Spear and colleagues did a literature review and came to the following conclusion:

It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.

There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….

Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial.  There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….

The collective data suggest that, using the above below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.

The tumor criteria listed include:

  • The tumor should be 3 cm in diameter or less
  • The tumor should be 2 cm away from center of the nipple
  • Clinically negative axillae or sentinel node negative
  • No skin involvement, and no inflammatory breast cancer.
  • If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.

When the nipple can be spared then there is no need for nipple reconstruction.  When it can’t be, then the nipple sharing technique can be useful.  As with the above, the cancer risk is addressed:

Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.

The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.

Both articles are worth your time to read.


Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza

Unilateral Nipple Reconstruction with Nipple Sharing: Time for a Second Look; Plast & Reconstr Surg 123(6):1648-1653, June 2009; Zenn, Michael R.; Garofalo, Jo Ann

Related Posts

Breast Reconstruction – Part I

Breast Reconstruction – Part II

Integrating Radiation Therapy & Breast Reconstruction

*This blog post was originally published at Suture for a Living*

Weird Medical Problem Of The Week: Raynaud’s Phenomenon of the Nipple

This article would have been off my radar had it not been for the interaction on twitter.

jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis (via @EllenRichter)

Granted I am not generally asked about nipple pain in pregnant women.  Those questions tend to go to folk like TBTAM or ER’s Mom.

The article describes a case report of a 25 yo woman in her 2nd trimester with “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.”

The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us.  The text with the photo:

Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.

As with Raynaud’s of the hand (which I am more familiar with), the phenomenon tends to occur when the ambient temperature drops below a certain threshold that is specific to each individual.  Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors, and tobacco.

Additional treatment for Raynaud’s of the nipple:

Women with persistent pain require immediate relief to continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond within two weeks.


An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe

Vasospasm of the Nipple–a manifestation of Raynaud’s phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith

*This blog post was originally published at Suture for a Living*

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