Journal of Cancer Therapy, 2012, 3, 831-835
http://dx.doi.org/10.4236/jct.2012.325105 Published Online October 2012 (http://www.SciRP.org/journal/jct)
831
Nipple-Areola Sparing Mastectomy Followed by
Immediate Breast Reconstruction in 126 Patients
Xianming Wang, Min Wang, Jinkun Liu, Weicai Chen, Huisheng Wu, Shufeng Song
Center of Breast Diseases, Shenzhen Second People’s Hospital, Shenzhen, China.
Received August 27th, 2012; revised September 26th, 2012; accepted October 4th, 2012
ABSTRACT
This study is to explore the indications, procedures, effectiveness, and feasibility of nipple-areola sparing mastectomy
followed by immediate breast reconstruction. The nipple-areola sparing mastectomy followed by immediate breast re-
construction was performed in 126 patients with breast cancer from June 2005 to October 2011. The cosmetic outcomes
of the reconstructed breasts were evaluated according to objective and subjective criteria. Meanwhile, the postoperative
complications were observed and the therapeutic efficacies were followed up. All the operations were successful. Six
patients experienced mild complications early after surgery and were resolved after symptomatic treatment. Both the
subjective and objective evaluation for the aesthetic outcomes yielded a satisfactory rate of 97.62% during the 6 -
80-month follow-up. No recurrence or metastasis was found in 118 cases. Nipple-areola sparing mastectomy followed
by immediate breast reconstruction is a simple and effective option for significantly improving the cosmetic outcomes
and quality of life of patients, without serious complications or impact on the comprehensive treatment and long-term
effect against breast cancer.
Keywords: Breast Cancer; Nipple-Sparing Mastectomy; Breast Reconstruction
1. Introduction
In recent years, orthopedic techniques are being increas-
ingly applied in the surgical treatment of breast cancer
[1]. The St. Gallen 2011 Expert Consensus has recog-
nized the cosmetic outcomes following extensive tumor
resection aided by orthopedic techniques [2]. Not only
does the reconstructive plastic surgery for breast cancer
compensate the resected breast in mastectomy, but it also
improve the safety and cosmetic outcomes of breast-
conserving surgery, thus improving the quality of life for
patients. Evidence-based medicine has confirmed that
skin-sparing mastectomy (SSM), comparably effective to
traditional mastectomy in treating breast cancer, is asso-
ciated with better cosmetic outcomes [3]. The nipple-
areola complex is essential in breast aesthetics. Nip-
ple-sparing mastectomy (NSM) is subcutaneous mastec-
tomy with nipple-areola complex left. A mastectomy that
retains the nipple and areola does not only simplify
breast reconstruction surgery, but significantly improves
cosmetic outcomes. Although the technical improvement
from SSM to NSM has been initiated, further research is
required to determine the eligible population in view of
the few long-term follow-up reports available. From June
to 2005 to October 2010, 126 patients with breast cancer
underwent nipple-areola sparing mastectomy followed by
immediate breast reconstruction in our hospital, achiev-
ing satisfying outcomes. The cases are reported as fol-
lows.
2. Materials and Methods
2.1. Study Design
The trial was a prospective cohort study and was ap-
proved by the ethic committee review boards of Shen-
zhen Second People’s Hospital, and enrollment began in
June 2005. Patients signed the informed consent forms
before operations.
2.2. Participants
The cohort included 126 female patients (Table 1) with
breast cancer aged 28 to 56 years (mean 43 years). Based
on TNM staging, there were 48 patients with stage 0
breast cancer, 23 cases with stage I stage 0 breast cancer,
and 55 with stage II stage 0 breast cancer. Overall, there
were 43 patients with ductal carcinoma in situ (28 with
negative sentinel lymph node biopsy and 15 without
axillary lymph node treatment), five patients with lobular
carcinoma (two with negative sentinel lymph node bi-
opsy and three without axillary lymph node treatment),
19 patients with stage I invasive ductal carcinoma, 52

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients
832
patients with stage II invasive ductal carcinoma, four
patients with stage I invasive lobular carcinoma and
three patients with stage II invasive lobular carcinoma.
Ninety-four patients did not have axillary lymph node
metastasis (including 42 with negative sentinel lymph
node biopsy). Of the thirty-two who did, twenty-five had
1 to 3 lymph node metastases and seven had 4 or more.
The molecular subtypes of the 78 cases of invasive car-
cinoma included 35 cases of LUMINAL A, 24 cases of
LUMINAL B, 9 cases of HER-2 ENRICH and 10 cases
of BASAL-LIKE.
Inclusion Criteria
1) Patients with stage 0 breast cancer with suspected
multifocal lesions or extensive calcification range; resid-
ual tumor along the needle tract was suspected in 15 pa-
tients despite definite diagnosis via minimally invasive
biopsy; non-Paget’s disease; 2) Patients with stages I and
II breast cancer (except T3N0 stage II breast cancer) with
a margin between the tumor and the areola of >2 cm, and
negative findings of subcutaneous tissues superior to the
tumor and subareola tissues near the lesion through in-
traoperative rapid pathological examination; 3) Patients
who had good overall conditions without serious heart
disease or cerebrovascular disease, and could tolerate
surgery; 4) Patients who met the requirements for breast-
conserving surgery but postoperative cosmetic expecta-
tions were poor due to small breast sizes; 5) Patients who
chose mastectomy due to concerns about the risk of re-
currence after breast-conserving surgery or unwillingness
to receive postoperative radiation therapy; 6) Patients
undergoing mastectomy in combination with prosthetic
implantation, also known as breast reconstruction sur-
gery.
2.3. Surgical Methods
All of the 126 patients underwent nipple-areola sparing
breast cancer resection and primary reconstruction with
silicone gel-filled breast implants. Incisions were made
along the outer edge of the breast, the areola or folds
under the breast following a curved shape for complete
removal of the breast tissue from skin and the surface of
pectoralis major. For patients whose incision was not
located at the outer edge of the breast, an additional inci-
sion was made at the armpit for sentinel lymph node bi-
opsy or axillary lymph node dissection. During separa-
tion beneath the nipple and areola, excessive division of
tissues posterior to the nipple should be avoided to pre-
vent postoperative ischemia and necrosis of the nipple
and areola. The breast reconstruction should be termi-
nated if positive pathological findings of the subcutane-
ous tissues under the tumor or subareola tissues near the
lesion were present.
Table 1. Baseline characteristics of patients.
Characteristic Patients (N = 126)
Age
Average 43
Range 28 - 56
TNM Staging
Stage 0 48
Stage I 23
Stage II 55
Pathology
Ductal carcinoma in situ 43
Lobular carcinoma in situ 5
Stage I invasive ductal carcinoma 19
Stage II invasive ductal carcinoma 52
Stage I invasive lobular carcinoma 4
Stage II invasive lobular carcinoma 3
Axillary Lymph Node
Positive 94
Negative 32
Prosthesis was implanted in the posterior space of the
pectoral muscle. The implant volume was calculated
based on preoperative measurement of the contralateral
breast. According to the measured volume of the contra-
lateral breast, a selected water-filled balloon was placed
into the space between the two chest muscles ipsilaterally
during surgery. In the present cohort, 85% patients had
relatively smaller breasts, and the volumes of used pros-
theses ranged from 180 to 240 mL. The space between
pectoralis major and pectoralis minor muscles, particu-
larly the lower edges, was completely divided and part of
the attachment of the pectoralis major to ribs was de-
tached to prevent asymmetrical appearance of the breasts
due to shift up of the prosthesis. Sufficient pads should
be used to support the upper and lateral sides of the
prosthesis during fixed dressing, and elastic tape was
used to simultaneously fix both the upper and lower sides
of both breasts in an oval shape so that both breasts were
at the same level. Intense activity of the upper limbs was
restricted in two weeks following the operation.
2.4. Aesthetic Evaluation of Breast
Reconstruction
2.4.1. M orphological Assess ment of Reconstructe d
Breasts
The appearance was classified according to the standards
of a previous report [4] as: 1) Excellent: breasts were
symmetrical, horizontal difference between nipples ≤ 2

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients 833
cm; normal appearance without significant difference in
shape compared with the contralateral breast; no breast
lift or deformation due to scar tissues, feel was good and
skin was normal; 2) Good: breasts were symmetrical,
horizontal difference between nipples ≤ 3 cm; normal
appearance or slightly smaller shape than the contralat-
eral breast; feel was slightly odd; and skin color became
lighter and then glossy; 3) Poor: breasts were asymmetric;
horizontal difference between nipples > 3 cm; obviously
deformed appearance and significantly smaller compared
with the contralateral side; feel was bad; skin was thick
and rough with rubber-like texture.
2.4.2. Patient Sel f- Assessment
Questionnaires were distributed among the patients 6 and
12 months after surgery, respectively, to determine their
satisfaction with breast reconstruction.
2.5. Postoperative Adjuvant Therapy
According to the clinical staging and molecular biologi-
cal subtypes specified in NCCN guidelines, postoperative
adjuvant radiotherapy, chemotherapy, endocrine therapy
and anti-HER-2 therapy were prescribed for all 126 pa-
tients. Conventional radiotherapy was administered for
seven patients who had four or more lymph node metas-
tases, and postoperative radiotherapy was given to six out
of nine patients who had one to three lymph node metas-
tases. The presence of prostheses did not affect the ef-
fectiveness of chemotherapy. Conformal radiotherapy of
the clavicle region could be prescribed for patients with
three or more lymph node metastases found in patho-
logical examination without affecting the prostheses [5].
3. Results
3.1. Postoperative Evaluation of Appearance
The satisfaction survey from six to twelve months after
surgery revealed that, of the 126 patients, 89 reported an
“excellent” morphological assessment of breast recon-
struction (70.63%), while 34 reported a “good” result
(26.98%). Both subjective and objective evaluation meas-
ures were at a satisfactory level (97.62%). Three patients
reported a “bad” outcome (2.38%), of which one experi-
enced significant prosthetic displacement at the early
stage of surgery and two developed prosthetic capsular
contracture during postoperative radiotherapy.
3.2. Postoperative Complications
Early after surgery, a slightly dry, solid and black ap-
pearance of the nipples was observed in three patients
due to poor blood supply. Although the wounds were
healed spontaneously without special treatment, they
were slightly smaller compared with the contralateral
ones. Subcutaneous hematoma was observed at the skin
folds under the nipples of two patients, and the wounds
were closed after removal of hematoma and pressure
bandage. One patient presented prosthesis displacement.
None of the remaining patients experienced flap necrosis,
effusion, wound dehiscence or other complications; pri-
mary closure of the wounds was achieved.
3.3. Follow-Up
The patients were followed up for 6 to 12 months and
97.62% of them were satisfied with the breast recon-
struction outcomes following surgery. In the follow-up
for 6 to 80 months, 15 patients (11.9%) had recurrence or
distant metastases, of which eight were regional recur-
rence (6.34%, including six cases of HER-2 ENRICH
and two of BASAL-LIKE) and seven were distant me-
tastases in 36 months after surgery (5.55%, including
five cases of HER-2 ENRICH and two of BASAL-LIKE).
Five of those patients died.
Another follow-up of 132 patients with stages 0, I and
II breast cancer who underwent breast-sparing surgery
over the same period revealed 17 patients (12.9%) of
recurrence or distant metastases, of which nine were re-
gional recurrence (6.81%, including seven cases of
HER-2 ENRICH and two of BASAL-LIKE) six seven
were distant metastases in 36 months after surgery
(4.54%, including four cases of HER-2 ENRICH and one
of BASAL-LIKE). Four of those patients died.
4. Discussion
The development of breast cancer therapy in the 21st
century has been steered by the important role of mo-
lecular spectra. The current consensus is also built upon
multi-disciplinary treatment by various means aided by
molecular classification of breast cancer. In recent years,
breast-conserving surgery has gradually been applied
across China, whereas the incidence of this technique
witnesses a decline in Europe and the United States [6,7].
This could be mainly explained by the following aspects:
1) The increasing application of BRCA genetic testing
has increased public awareness of prevention against this
condition; and preventive mastectomy with reconstruc-
tion has been used in clinical settings; 2) The universal
application of MRI and other imaging techniques has
increased the detection rate of many previously occult
lesions; 3) The addition of reconstructive plastic tech-
niques in the surgical treatment of breast cancer does not
only compensate the resected breast in mastectomy, but it
also improves the safety and cosmetic outcomes of
breast-conserving surgery, thus improving the quality of
life for patients.
Evidence-based medicine has confirmed that skin-
sparing mastectomy is comparably effective to traditional

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients
834
mastectomy in treating breast cancer, and there is con-
sensus that the extension of skin excision is independent
of local recurrence, so the skin-sparing technique is not
associated with an increased risk of local recurrence of
breast cancer [8,9]. The study of Fersis et al. [3] has
shown that postoperative local recurrence is mainly
caused by residual breast ductal epithelium cells rather
than breast skin tissues. Therefore, both approaches have
a comparable local recurrence rate after operation. The
nipple-areola complex (NAC) is an important part of the
female breasts, and salvage of the NAC is vital for the
cosmetic outcomes of breast reconstruction and postop-
erative quality of life. Laronga et al. [10] suggested a
correlation between the involvement of the nipple-areola
complex and lymph node metastasis, as well as the dis-
tance from the tumor to the edge of the areola, inde-
pendent of tumor size, histological type and receptors.
Therefore, nipple-areola sparing mastectomy is possible
in some breast cancer patients for whom the resection of
breast skin and the complex is unnecessary. In a clinical
trial, Gerber et al. [11] have shown that the retention of
the nipple-areola complex does not increase the risk of
relapse if the margin of lesions is farther than 2 cm from
the nipples. In a retrospective cohort study evaluating the
onset age, tumor size, axillary lymph node status, hor-
mone receptor status and HER-2 expression status of 47
patients undergoing the nipple-areola sparing modified
radical surgery, Wang Shengying et al. [12] found no
significant difference between the two groups in terms of
overall survival (OS), disease-free survival (DFS) and
local recurrence rate. This is consistent with the findings
in our follow-up comparison between the present cohort
and patients undergoing breast-conserving surgery over
the same period.
Breast reconstruction following mastectomy can be
divided into immediate (primary) and secondary opera-
tions. Compared with the secondary approach, imme-
diate breast reconstruction is advantageous [13,14] in: 1)
achieving mastectomy and breast reconstruction simul-
taneously so that patients will not “feel a loss” after the
initial operation; 2) reducing the required number of op-
erations and overall cost and avoiding pain from a second
surgery by accomplishing two procedures at one blow;
and 3) having no interference with postoperative radio-
therapy, chemotherapy and endocrine therapy. Based on
the source of materials used for reconstruction, the sur-
gery can be completed with either autogenous tissues or
prosthetic implants. While autologous tissue reconstruc-
tion is usually associated with large wounds, difficult
operations, high cost, obvious scars and high risk of
postoperative complications, prosthesis is a safe, fast and
simple option with little injury and short recovery period.
Studies have confirmed that the implantation of prosthe-
sis does not increase the risk of recurrence or develop-
ment of breast cancer, and thus silicone gel prosthesis
implantation is feasible and safe [11].
In the present study, we performed subcutaneous mas-
tectomy sparing the nipple, areola and skin of breasts in
strict compliance with the indication, and did not conduct
primary prosthetic implantation until it was confirmed
that no residual tumor cells were present beneath the nip-
ple-areola complex. The subjective and objective evalua-
tion of postoperative cosmetic outcomes was good in
97.62% of patients, which demonstrated the unique ad-
vantages of the technique in improving both aesthetic
effects and the quality of life of patients. Moreover, the
procedure did not affect the performance of postoperative
adjuvant therapy. The key to breast reconstruction is the
maintenance of symmetrical alignment of the skin folds
posterior to both breasts. When the folds are stripped
during mastectomy, the skin and the underlying tissues
should be sutured and fixed to form an alternative struc-
ture. The breast folds should be such fixed that the dis-
tance from the areola to the folds is equal to the contra-
lateral counterpart, otherwise the nipple may be prone to
skew and the lower half of the breast may lack fullness
[15]. Postoperative complications are common in patients
undergoing traditional mastectomy. Three patients had
compromised blood flow to the nipples, leading to partial
atrophy, which could be due to improper retention of the
vascular network in the subareolar layer. Crowe et al.
[16] noted that improper operation was a major cause of
necrosis of the retained nipple-areola complex. The blood
supply of the nipple-areola complex is mainly derived
from two circulatory networks—deep blood vessels in
the mammary gland and capillary network at the su-
bareolar layer. During operation of nipple-areola sparing
mastectomy, the deeper supply is interrupted and all
blood supply comes from the capillary network at the
layer 3 - 5 mm from the areola epidermis, which should
be protected [17]. Prosthesis displacement, a major risk
factor of poor cosmetic outcomes, was present in one
patient in the present cohort, as a result of excessive di-
vision of the posterior space to the pectoralis major and
improper postoperative fixation. Such displacement can
be effectively prevented by cutting off a part of the rib
attachment points of the pectoralis major to place the
lower edge of the prosthesis in the pectoralis major fis-
sures, so that the lower half of breasts can appear to be
nice and full. Postoperative radiotherapy has a certain
negative impact on breast reconstruction (two patients
experienced capsular contracture of the prosthesis). Hence,
tissue spacers may be implanted for patients with a clear
indication for radiotherapy, and replaced by the prosthe-
sis through secondary operation after the completion of
radiotherapy.
5. Conclusion
Based on the experience of the 126 patients undergoing

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients
835
nipple-areola sparing mastectomy (NSM) with primary
prosthesis implantation, we have found this technique
to be a simple and effective option for significantly im-
proving the cosmetic outcomes and quality of life of pa-
tients, without serious complications or impact on the
comprehensive treatment and long-term effect against
breast cancer. It is an effective option for surgical treat-
ment of breast cancer under clinical settings.
6. Acknowledgements
The study was supported by funds from Shenzhen Mu-
nicipal Bureau of Science and Technology (200801004).
REFERENCES
[1] F. Fitzal and P. Schrenk, “Oncoplastic Breast Surgery: A
Guide to Clinic Practice,” Springer Wien, New York,
2010. doi:10.1007/978-3-211-99317-0
[2] A. Goldhirsch, J. N. Ingle and R. D. Gelber, “Thresholds
for Therapies: Highlights of the St Gallen International
Expert Consensus on the Primary Therapy of Early Breast
Cancer 2009,” Annals of Oncology, Vol. 20, No. 8, 2009,
pp. 1319-1329.
[3] N. Fersis, A. Hoenig, K. Relakis, et al., “Skin Sparing
Mastectomy and Immediate Breast Reconstruction: Inci-
dence of Recurrence in Patients with Invasive Breast
Cancer,” Breast, Vol. 13, No. 6, 2004, pp. 488-493.
doi:10.1016/j.breast.2004.06.009
[4] B. N. Zhang, T. Zhang, W. G. Hu, et al., “The Breast-
Preserving Surgery for Breast Cancer,” Zhong Liu Xue Za
Zhi, Vol. 8, No. 6, 2002, pp. 311-314.
[5] H. C. Jiang, F. C. Li and J. Li, “Skin-Sparing Incision
Mastectomy and Immediate Implanting Breast Recon-
struction,” Zhong Guo Shi Yong Wai Ke Za Zhi, Vol. 25,
No. 2, 2005, pp. 84-85.
[6] M. Morrow, “More Mastectomies: Is This What Patients
Really Want?” Journal of Clinical Oncology, Vol. 27, No.
25, 2009, pp. 4038-4040. doi:10.1200/JCO.2009.23.0078
[7] Balch, Jacobs: “Mastectomies on the Rise for Breast
Cancer: The Tide Is Changing,” Annals of Surgical On-
cology, Vol. 16, No. 10, 2009, pp. 2669-2672
doi:10.1245/s10434-009-0634-y
[8] H. Y. Wang, R. S. Ali, S. C. Chen, et al., “One-Stage
Immediate Breast Reconstruction with Implant Following
Skin-Sparing Mastectomy in Asian Patients,” Annals of
Plastic Surgery, Vol. 60, No. 4, 2008, pp. 362-366.
doi:10.1097/SAP.0b013e318063ef70
[9] H. Medina-Franco, L. O. Vasconez, R. J. Fix, et al.,
“Factors Associated with Local Recurrence after
Skin-Sparing Mastectomy and Immediate Breast Recon-
struction for Invasive Breast Cancer,” Annals of Surgery,
Vol. 235, No. 6, 2002, pp. 814-819.
doi:10.1097/00000658-200206000-00008
[10] C. Laronga, B. Kemp, D. Johnston, et al., “The Incidence
of Occult Nipple-Areola Complex Involvement in Breast
Cancer Patients Receiving a Skin-Sparing Mastectomy,”
Annals of Surgical Oncology, Vol. 6, No. 6, 1999, pp.
609-613．doi:10.1007/s10434-999-0609-z
[11] B. Gerber, A. Krause, T. Reimer, et al., “Skin-Sparing
Mastectomy with Conservation of the Nipple-Areola
Complex and Autologous Reconstruction Is an On-
cologically Safe Procedure,” Annals of Surgery, Vol. 238,
No. 1, 2003, pp. 120-127.
doi:10.1097/00000658-200307000-00016
[12] S. Y. Wang, Z. Z. Zhu, D. F. Peng, et al., “Efficacy of
Modified Radical Operation of Preserving Nipple-Areolar
Complex on Early Stage Breast Cancer,” Ai Zheng, Vol.
28, No. 3, 2009, pp. 41-45.
[13] N. Fersis, A. Hoenig, K. Relakis, et al., “Skin-Paring
Mastectomy and Immediate Breast Reconstruction: Inci-
dence of Reurrence in Patients with Invasive Breast Can-
cer,” Breast, Vol. 13, No. 6, 2004, pp. 488-493.
doi:10.1016/j.breast.2004.06.009
[14] K. J. Downes, B. S. Glatt, S. K. Kanchwala, et al.,
“Skin-Paring Mastectomy and Immediate Breast Recon-
struction Is an Acceptable Treatment Option for Patients
with High-Risk Breast Carcinoma,” Cancer, Vol. 103, No.
5, 2005, pp. 906-913. doi:10.1002/cncr.20851
[15] J. H. Fu, B. Ke, C. X. Yang, et al., “Modified Radical
Mastectomy by Reserving Skin and Nipple Combined
with Breast Reconstruction: A Report of 32 Cases,”
Zhong Guo Shi Yong Wai Ke Za Zhi, Vol. 25, No. 1, 2005,
pp. 54-55.
[16] J. P. Crowe, J. A. Kim, R. Yetman, et al., “Nip-
ple-Sparing Mastectomy: Technique and Results of 54
Procedures,” Archives of Surgery, Vol. 139, No. 2, 2004,
pp. 148-150. doi:10.1001/archsurg.139.2.148
[17] D. Z. Gao, J. Z. Sun, Q. S. Yin, et al., “A Study of the
Blood Supply Relevant to Prevention of Nipple-Areola
Necrosis in Female Breast Operation,” Zhong Guo Pu
Tong Wai Ke Za Zhi, Vol. 14, No. 4, 2005, pp. 269-272