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Reply: Nipple Loss following Nipple-Sparing Mastectomy

Colwell, Amy S. M.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 795e
doi: 10.1097/PRS.0000000000003090

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street WACC 435, Boston, Mass. 02114,

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I would like to thank the authors for the opportunity to clarify our study.1 In this article, we reviewed 775 consecutive nipple-sparing mastectomies with immediate reconstruction. The purpose of the article was to analyze reconstructions that suffered nipple loss to determine the incidence of cancer in the nipple specimen, the incidence of nipple removal for cosmesis or symmetry, and whether patients pursued further nipple reconstruction. This article was intended to guide plastic surgery discussions and counseling with patients. Our oncology group is actively following recurrence and disease-free survival, and thus these data were specifically omitted from the article.

Of the 775 mastectomies, 381 were performed for breast cancer and 394 had unilateral or bilateral prophylactic procedures. Fifty-one mastectomies had nipple loss. The incidence of total loss versus partial loss is shown in Figure 1. The cause of nipple loss is shown in Figure 2. Pathology reports from excised nipples are shown in Figure 3. These figures were included as part of the original article submission; however, the reviewers felt the figures did not contribute to the article.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Our study was conducted on consecutive mastectomy procedures and was not based on specific surgeons. Including data from several surgeons increases the generalizability of the study to the population at large as opposed to single-surgeon series. Arguably, the incidence of nipple loss secondary to ischemia is likely related to surgical technique, among other factors; however, ischemia-related complications were not the primary focus of this article and are better addressed in our article “Breast Reconstruction following Nipple-Sparing Mastectomy: Predictors of Complications, Reconstruction Outcomes, and 5-Year Trends.”2

In the latter article, we used multivariate logistic regression to determine predictors of ischemic complications. We found that preoperative radiotherapy (OR, 4.8; p = 0.047; 96 percent CI, 1.0197 to 23.169) and a periareolar incision (OR, 22.4; p < 0.001; 96 percent CI, 4.471 to 112.26) were positive predictors for nipple necrosis when controlling for other confounding variables. We agree that the outcomes from nipple-sparing mastectomy and reconstruction are worthy of continued analysis and study.

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The author is a consultant for Acelity and a recent advisory board member for Allergan.

Amy S. Colwell, M.D.

Division of Plastic and Reconstructive Surgery

Massachusetts General Hospital

Harvard Medical School

55 Fruit Street WACC 435

Boston, Mass. 02114

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1. Mastroianni M, Lin AM, Smith BL, Austen WG Jr, Colwell ASNipple loss following nipple-sparing mastectomy.Plast Reconstr Surg201613824e–30e
2. Colwell AS, Tessler O, Lin AM, et alBreast reconstruction following nipple-sparing mastectomy: Predictors of complications, reconstruction outcomes, and 5-year trends.Plast Reconstr Surg2014133496–506
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