Staged breast reconstruction before nipple-sparing mastectomy with reconstruction

Since the introduction of the radical mastectomy, surgical treatment for breast cancer has evolved significantly including advancements in breast reconstruction, resulting in improvements in both oncologic and aesthetic outcomes. Nipple-sparing mastectomy (NSM), in which the nipple-areolar complex is preserved along with skin, has become an oncological option for several groups of patients including patients with low body mass index (BMI), minimal ptosis, small breasts and non-smokers. Recently, patients who were initially deemed poor candidates for this procedure—such as women with macromastia or highgrade ptosis—have undergone NSM and reconstruction with successful outcomes due to the utilization of staged surgical techniques. In this review, options for staging reconstruction after mastectomy are outlined for both therapeutic and prophylactic NSMs. For therapeutic mastectomies, patients may undergo breast envelope shaping with either reduction mammoplasty, mastopexy, or oncoplastic reconstruction in a first stage, followed later by NSM and definitive reconstruction. Alternatively, NSM can be completed in the initial stage either with or without immediate breast reconstruction, followed by breast envelope shaping in a later stage. For prophylactic mastectomies, similar strategies may be employed with either breast envelope shaping or NSM up-front. Here, strategies for the various staging approaches are reviewed along with several techniques for nipple delay, and an algorithm for treatment of these patients is proposed.