The utilization of intraoperative vs final pathology assessment of the sub-areolar tissue specimen as well as management of pathology results was assessed [7]. This analysis was done after 320 NSMs had been performed on 207 patients by 37 investigators at 35 institutions. Indications included: invasive carcinoma 83 (26 %), DCIS 46 (14 %), and prophylactic 191 (60 %). An intraoperative sub-areolar (SA) pathology assessment was requested on 104 (33 %) of NSMs at the surgeon’s preference. Tumor size ranged from 1 to 7 cm. Distance from tumor to NAC ranged from 1.6 to 4.1 cm (measured by physical exam, ultrasound (US), mammogram (MMG), or breast MRI).

Two NACs were unnecessarily excised secondary to intraoperative pathology results (one indeterminant and one suspicious) (Table 23.2). Of the 216 NSMs that did not undergo an intraoperative SA path assessment, one positive SA final pathology (DCIS) resulted in NAC resection . None of the final SA pathology specimens yielded invasive carcinoma. The risk of obtaining an intraoperative SA pathology appears to outweigh the benefit of finding a positive intraoperative SA pathology and avoiding an unnecessary NAC excision.

Breast characteristics (cup size and degree of ptosis), type of reconstruction, and incision placement in NSMs were assessed [8] after 386 NSMs performed by 39 surgeons from 36 sites for cancer (163) or prophylaxis (223) on 225 patients had been entered in the registry. All patients underwent immediate reconstruction with tissue expander, direct to implant (DTI), DIEP flap, TRAM flap, or latissimus dorsi flap. Breast size included cup sizes A, B, C, D, or ≥E. Degree of ptosis was; grade 1, 2, 3, none, or pseudoptosis. Incisions utilized included inframammary, peri-areolar, ellipse/hemibatwing, radial, radial with peri-areolar extension, previous lumpectomy scar, previous mastopexy scar, or Weiss pattern.

Cup size , degree of ptosis, incision placement, and type of reconstruction were assessed (Table 23.3). Free nipple transfer was performed on seven mastectomies.

One (0.2 %) NAC was excised secondary to full thickness necrosis . Four NACs (1 %) required debridement. Five (1 %) tissue expanders/implants were removed/exchanged secondary to flap infection. Cosmetic outcome as evaluated by 169 patients was excellent (58 %), good (36 %), or fair (7 %).

Patients undergoing an NSM had a wide variety of reconstruction techniques. The technique was not dependent on breast size or the degree of ptosis. The complication rate was low and there were too few complications to differentiate any differences based on size, ptosis, technique, or incision placement.

The incidence of postoperative infections in nipple sparing mastectomies was analyzed [9]. At the time of this analysis, 52 investigators from 41 institutions had performed 631 mastectomies. Indications included risk-reduction (365), cancer (248), and unknown (18) on 373 patients. A sub group of 449 mastectomies, with indications of risk-reduction (253) and cancer (196) that had all data sets completed was assessed.

An analysis of infection rates in the entire group as well as by indication (cancer vs. prophylaxis) was completed. Factors analyzed were smoking history, previous radiation therapy, previous surgery, incision type, reconstruction technique, and flap dissection technique were analyzed.

Infections were characterized as: treatment with oral antibiotics alone, treatment with I.V. antibiotics alone, IV antibiotics with washout or debridement, or antibiotics and implant/tissue expander removal.

Postoperative infections were reported in 4.9 % (n = 22) of patients: 3.6 % (7) of NSMs with an indication of cancer and 5.9 % (15) of prophylactic NSMs (p-value 0.3140). No correlation was found with infection and: smoking status (p-value 1.000); previous breast surgery (p-value 0.1277); previous radiation therapy (p-value 0.6024); reconstruction technique, incision placement, or dissection technique (Table 23.4).

The rate of postoperative infections in nipple-sparing mastectomies is comparable if not lower than non-nipple sparing mastectomies. No statistically significant difference in infection rate was found between mastectomies completed for risk-reduction or cancer. Improved aesthetics with a nipple-sparing approach (technically more demanding and typically through a smaller incision) does not come at the cost of a higher rate of infectious complications.

A preliminary data analysis of the ASBS NSMR 32 months into accrual was performed to specifically look at the degree of preoperative ptosis in patients undergoing a nipple-sparing mastectomy and its effect on outcomes [10]. A comparison was made of incision type, reconstruction type, infection rate, cup size, patient satisfaction, and cosmetic outcome as they related to degree of preoperative ptosis. This assessment comprised a total of 471 patients who underwent 780 mastectomies with indications of cancer (339), risk-reduction (440), and unknown (10) by 55 surgeons at 44 institutions.

Degree of ptosis was defined as: none (n = 301), pseudoptosis (n = 9), Grade I (n = 261), Grade 2 (n = 105), or Grade 3 (n = 44). Types of reconstruction included: DIEP Flap (n = 49), latissimus dorsi Flap (n = 2), DTI (n = 253), TRAM flap (n = 5), and tissue expander (n = 451).

Incision types utilized included: inframammary (n = 301), peri-areolar or hemibatwing (n = 17), previous lumpectomy scar (n = 9), previous mastopexy scar (n = 5), radial (n = 133), radial with periareolar extension (n = 172), Wise mastopexy incision (n = 7), other (n = 64), and unknown (n = 72) (Table 23.5).