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Subcutaneous Mastectomy With Conservation of the Nipple-Areola Skin: Broadening the Indications

Paepke, Stefan MD; Schmid, Rainer MD; Fleckner, Stefanie; Paepke, Daniela MD; Niemeyer, Markus MD; Schmalfeldt, Barbara MD; Jacobs, Volker R. MD; Kiechle, Marion MD

doi: 10.1097/SLA.0b013e3181b0c7d8
Original Articles

Background: Numerous authors take multiple predictive factors into account to decide whether or not the nipple-areola complex (NAC) can be conserved during mastectomy. These factors include the tumor-nipple distance, tumor size, axillary lymph node status, and lymphovascular invasion. Thus only a very limited percentage of patients can keep their NAC. If the breast gland tissue and all milk ducts can be separated completely from the nipple-areola skin (NA-skin) during subcutaneous mastectomy (SCM), conservation of the NA-skin is feasible even in the case of large, central, and retroareolar tumors.

Patients and Methods: From July 2003 to May 2006, we performed 109 SCMs on 96 patients. Total mastectomy was indicated in 94 of these breasts, in 16 because of extensive ductal carcinoma in situ, and 78 breasts with invasive carcinoma required additional axillary dissection resulting in indication for modified radical mastectomy. At least 33 of the breasts had malignancy underneath the skin within the areolar margin (centrally located tumors). After dissection of all the breast tissue, the skin envelope with the areola is turned inside out and all milk ducts and any tissue beneath the areola are precisely dissected under the surgeon’s visual control. Frozen sections and HE histopathologic examination of this retroareolar tissue next to the skin are requested to decide whether the NA-skin can be preserved or not. This study was registered on the website and has the following identification number ID: NCT00641628.

Results: We found it necessary to dissect the NA-skin in 13 of 109 breasts (12%), altering the procedure to a skin sparing mastectomy. Necrosis of the NA-skin requiring surgical intervention occurred in only 1 of the conserved 96 breasts. After follow-up of 20 to 54 months (median: 34 months), no recurrence within the nipple-areola region was observed. One local recurrence on the chest wall and 1 axillary recurrence were detected. Of 96 patients, 2 developed distant metastases. One death was recorded. Occasionally, partial necrosis of the nipple occurred, with residual depigmentation of the skin but a good or excellent cosmetic result was maintained in most cases.

Conclusion: SCM with NAC-skin conservation may be performed according to total mastectomy indications if an intraoperative frozen section (and the corresponding HE histopathology) of the tissue next to the nipple-areola skin is free of tumor. The remaining contraindications for SCM are: extensive tumor involvement of the skin, inflammatory breast cancer, and a clinically suspicious nipple.

Subcutaneous mastectomy with conservation of the nipple-areola skin can be performed in an oncologically safe manner in breast cancer patients who would usually undergo total mastectomy. We clear the retroareolar region precisely from any milk ducts and breast gland tissue. Necrosis of the mammilla is surprisingly rare.

From the Department of Obstetrics and Gynecology, Technical University of Munich, Munich, Germany.

The study was carried out by the department of obstetrics and gynecology, Technical University of Munich in terms of finance, facilities, and manpower. The color photograph was taken by Feile Andreas free of charge.

Duties: Paepke Stefan: main surgeon; Schmid Rainer: text author, data investigator, surgeons′ assistant, corresponding author; Fleckner Stefanie: data investigator; Paepke Daniela: surgeons′ assistant; Niemeyer Markus: literature investigator; Schmalfeldt Barbara: surgeons assistant; Jacobs Volker R: data investigator; Kiechle Marion: surgeon, head of department.

Reprints will not be available from the authors.

Corresponding author: Rainer Schmid, MD, Department of Obstetrics and Gynecology, Technical, University of Munich, Ismaninger Str., 22, 81675 Munich, Germany. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.