Women with a cup size of D – DD or larger and/or who have ptotic breasts, in which the nipple is facing downward or positioned lower than the inframammary (bottom of breast) fold due to nursing or the effects of gravity, are often not ideal candidates for nipple sparing mastectomies. The size of the implant required to fill the breast skin envelope and ensure proper positioning of the nipple after tissue removal would simply be too large, which is aesthetically undesirable for most women and places too much stress on the pectoralis (chest) muscle.
The new technique uses a two-stage approach to allow women with large or ptotic breasts to become suitable candidates for nipple sparing, direct to implant prophylactic mastectomy. The first stage consists of a breast reduction or lift, known as mastopexy, to make the breast shapelier and slightly smaller, correcting ptosis and placing the nipple into the correct, forward-facing position. Nipple sparing, direct to implant mastectomy and reconstruction surgery is performed in the second stage six months to one year later, to provide enough time for the nipple to re-establish an adequate blood supply to keep it viable.
"It's difficult enough for high-risk women to face removing their breasts to prevent cancer, and then many are informed they can't have the type of mastectomy procedure they prefer due to breast size or shape," said C. Andrew Salzberg, M.D., associate professor at NY Medical College, Chief of Plastic Surgery at Westchester Medical Center and St. John's Riverside Hospital at Dobbs Ferry Pavilion, and partner with the New York Group for Plastic Surgery, who pioneered the direct to implant breast reconstruction procedure 12 years ago and has performed more of the direct to implant procedures after reduction than any surgeon in the U.S. to date. "By performing an initial breast reduction or lift or both, depending on each woman's unique situation, we can reshape the breasts in preparation for a subsequent successful nipple sparing, direct to implant prophylactic mastectomy."
"Many women want to keep their own nipples for aesthetic reasons and because they'll feel more 'like themselves' after mastectomy," Dr. Salzberg added. "This two-step process significantly increases the number of women who can now choose a preventive mastectomy and reconstruction that lets them retain the external appearance of their natural breast."
About 2.3 million women in the United States may be at increased risk for breast cancer because of their family history, according to the nonprofit organization FORCE (Facing Our Risk of Cancer Empowered.) An estimated 940,000 people in the U.S. carry a BRCA (BReast CAncer) gene mutation, and women with a BRCA mutation have up to an 85% lifetime risk for breast cancer. More than one-third of high-risk women choose to significantly reduce their breast cancer risk with a prophylactic mastectomy.
Traditionally, post-mastectomy breast reconstruction requires tissue expanders to be placed in the breast immediately after the breast tissue is removed, followed by months of saline fills and a second surgery to insert the permanent implant. A nipple sparing mastectomy preserves the woman's original nipple areola complex (NAC), and the direct to implant, or one step, procedure provides an immediate breast reconstruction within one surgery.