Nipple malposition following nipple sparing mastectomy: Evaluation of secondary correction in prepectoral implant-based breast reconstruction

Ptosis can be a relative contraindication to nipple sparing mastectomy (NSM). Although a mastopexy-type approach can be performed during mastectomy, this requires very well perfused skin flaps and possibly intraoperative adjustments with the oncological breast surgeon. The purpose of this study is to assess risk factors that result in the nipple surgically raised secondarily in standard NSM with prepectoral tissue expander (TE) reconstruction to help guide surgical decision-making and patient counseling.

Patients at our center who underwent NSM and immediate prepectoral TE reconstruction were assessed. Patients who had immediate nipple position adjustment during the day of the mastectomy were excluded. Patients were divided into two groups: Group 1 (secondary nipple adjustment during the second stage) and Group 2 (no secondary nipple adjustment). Preoperative sternal notch-to-nipple distance, Regnault classification ptosis grade, brassiere size, and mastectomy weights were assessed.

The study included 158 patients: 33 patients in Group 1, 125 patients in Group 2. Grade II ptosis was present in 84.8% (28/33) of Group 1 compared to 58.4% (73/125) of Group 2 (p=0.0044). The average preoperative sternal notch-to-nipple distance for Group 1 was 26.2±2.6 cm compared to 24.7±3.9 cm for Group 2 (p=0.002). There was no difference in preoperative cup size between groups (p=1). The average mastectomy weight in Group 1 was 542.6±207.6 g compared to 449.4±264.3 g (p=0.03).

Patients with grade II ptosis, sternal notch-to-nipple >26 cm, and larger breast size who undergo standard NSM are more likely to require secondary nipple correction. The findings can improve patient counseling and expectations.