The emotional benefits of breast reconstruction include: (1) Reduction of a patient’s preoccupation with her breast cancer, (2) Facilitation of wardrobe flexibility restricted by wearing an external prosthesis, (3) Elevation of mood and less anxiety, (4) Enhancement of body image, and (5) Improvement of sexual responsiveness. Including the nipple (reconstructed or natural) as part of breast reconstruction gives a patient a sense of completeness, not present with breast contour reconstruction alone [3]. The sense of completeness allows a patient to experience herself as “like herself,” meaning close to her preoperative state [1].

Didier and colleagues showed in their study of NSM patients a very high level of satisfaction for having preserved their nipples, and less feelings of being mutilated by their mastectomies. They also found that NSM had impacted positively on patient satisfaction with cosmetic results, with femininity and body image, especially related to nakedness [2].

Despite the pushback against Hinton’s concept of SCM for breast cancer treatment, institutions in Japan, the United States, Germany, and Croatia began performing NSMs for both prevention and treatment from 1985 to 1998 [9–16].

The most pivotal early publication on the results of NSM was in 2003 by Gerber and colleagues from Rostock, Germany [12]. They reported on 61 patients who underwent skin-sparing mastectomy (SSM) with NAC conservation, 51 patients who had SSM without NAC conservation, and 134 patients who had a standard modified radical mastectomy (MRM) . The SSM patients, with or without NAC conservation, were younger, averaging around 49 years of age. With a mean follow-up of 59 months, only one patient had a recurrence in the preserved NAC. The minimum distance from tumor to NAC was 2 cm in those who underwent SSM with NAC conservation [12].

In 2009, Gerber then reported on the same group of patients, now with a mean follow-up of 101 months [13]. There was no difference in local regional recurrence rates or deaths in all three groups. There were no additional recurrences in the NAC-preserved SSM group, other than the one case originally reported in 2003. Their conclusion was that preservation of the NAC was oncologically safe [13].

The first American group to publish on NSM for cancer was Dr. Joseph P. Crowe and colleagues from the Cleveland Clinic [17]. Their 2004 publication reported on 54 NSMs attempted among 44 patients. Six NAC core specimens found neoplastic involvement on frozen section analysis, resulting in conversion to total mastectomies. Forty-five of the 48 completed NSMs maintained postoperative viability of the NAC; three NACs had partial necrosis. This small series covered the time period from September 2001 to June 2003 [17].

A follow-up paper from Crowe and colleagues reported on their experience with 110 consecutive patients undergoing 149 NSMs from 2001 to 2007 [18]. There were no NAC recurrences in their series. They primarily utilized lateral incisions for the performance of their NSMs. The incidents of NAC neoplastic involvement at the time of mastectomy remained at 11 % in the larger series, which was the same as their initial report in 2004 [17, 18]. Sixty-four of the 154 NSMs were for prevention, and 85 were for breast cancer treatment. Exclusion criteria for performing NSMs included patients whose tumors were larger than 3.5 cm, centrally located tumors, lymph node involvement, inflammatory breast cancer, clinical involvement of the NAC, and patients who underwent neoadjuvant chemotherapy [18].

Contributing to the interest in NSM was a series of papers by Dr. Rachel M. Simmons and coworkers on areolar-sparing mastectomy, published between 2002 and 2004 [19–21]. Their initial report in 2002 was a retrospective analysis of 217 mastectomy patients conducted to determine the frequency of malignant nipple or areolar involvement with tumor. They also analyzed the association between nipple and/or areolar involvement and prognostic factors, including tumor size, pathologic stage, nuclear-grade, axillary nodal status, and tumor location. The overall frequency of malignant nipple involvement was 10.6 %. In a subgroup of patients with tumors less than 2 cm, peripheral tumors, and two positive nodes or less, the incidence of nipple involvement was 6.7 % [19]. When the nipple and areola involvement were analyzed separately, only 2 of 217 patients (0.9 %) had involvement of the areola. All patients with areolar involvement had Stage III breast cancers that were centrally located. They concluded that the preservation of the areola with skin-sparing mastectomy, in selected patients, warranted further study.

In 2003, Simmons and her coworkers reported on a small series of 12 patients who underwent 17 areola-sparing mastectomies (ASM) [20]. The study period was only 20 months. Ten mastectomies were for prophylaxis, four for ductal carcinoma in-situ (DCIS) , and three were for peripheral infiltrating carcinomas, less than 2 cm in size. In 2004, they reported on the 2-year follow-up. They had no recurrences, one postoperative infection, and excellent cosmetic results. They concluded that ASM would be offered to selected patients, including those desiring surgical breast cancer prophylaxis , as well as those with DCIS or small peripheral infiltrating ductal carcinomas [21].

Starting in the late 1990s, multiple academic institutions in the United States, Italy, and other locations around the world began to seriously consider NSM as an alternative to SSM. From 2000 to 2010, multiple reports from these academic institutions began to appear in the surgical literature, summarizing their individual institutional experiences [10–13, 17, 18, 22–34]. There were multiple issues that these reports analyzed. In general, the issues focused on patient selection, operative techniques, complications, oncologic safety, and cosmetic outcomes. Most of the institutional series were small, with short-term follow-ups averaging around a mean of 20 months.

In these initial series, much of the patient selection focused on patients wanting prophylactic mastectomies for risk-reduction. Several series were predominantly preventative mastectomies as a safe way to venture into the arena of NSM.

With breast cancer patients, various safe criteria were created for patient selection . Clearly, no patients would be eligible for NSM with clinical involvement of the NAC or bloody nipple discharge. Past literature analyzing NAC involvement with cancer in mastectomy specimens found the incidence of nipple–areolar involvement ranging from 5.9 to 50 % [10, 29]. Factors that have been associated with occult nipple involvement have been tumor size, subareolar location, tumor-to-nipple distance, positive axillary nodal status, multicentric tumors, and angiolymphatic invasion [29]. As a result, most institutions chose conservative inclusion criteria for selecting patients for NSM.

A good example of this approach is the initial criteria used by Dr. Scott Spear and colleagues. Tumor size less than 3 cm, tumor location greater than 2 cm from the NAC, clinically negative axillary nodes, no skin involvement, no inflammatory cancer, or Paget’s disease were key components of their selection criteria. In addition, preoperative MRI to exclude nipple involvement and possible preoperative ultrasound-guided core biopsy of the nipple base could also be used to rule out occult involvement of the nipple. With their initial criteria, they also excluded excessively large and ptotic breasts [11].

In these early institutional reports, various types of mastectomy incisions for NSM emerged. Incision designs included: radial (lateral or 6 o’clock axis), inframammary, circumareolar, NAC-crossing, lateral/inferolateral, mastopexy-type incision, and omega/areolar incisions [11, 22, 25].

The major complication that concerned everyone was partial or full loss of the NAC. What also emerged from the early literature was that there was a “learning curve” needed for incision selection and the tedious performance of NSM. As experience grew, complication rates fell [25]. The early literature also suggested that lateral (3 and 9 o’clock), vertical (6 o’clock), and inframammary incisions had lower ischemic complications with the NAC ranging from 0 to 5 % [11, 22, 25].

The oncologic safety of preserving the NAC in cancer patients is difficult to evaluate in the early institutional series because of the short mean follow-up times. Most series reported no NAC recurrences, and low regional recurrence rates were comparable to SSM, with reconstruction [11, 25, 30]. Three series with long-term follow-up of over 5 years have reported NAC recurrence rates of 3.7 %, 1.2 % and 0 %, respectively [9, 14, 15]. If the results of all series on NSM are combined, the NAC recurrence rate averages around 0.6 %.

Why would NAC recurrences rates be so low? One important reason could be the fact that terminal ductal lobular units (TDLUs) are demonstrated in only 25 % of nipples. More importantly, the TDLUs are always found at the base of the nipple, not within the nipple proper [22]. As a result, it is likely not important to core out the nipple as part of the NSM operative technique.

Cosmetic outcomes reported by these early institutional reports found that the majority of patients had excellent to good outcomes at least 70 % of the time [12, 13, 22, 25, 28, 29].