Nipple Sparing Mastectomies


Nipple Sparing Mastectomies (NSM) & Reconstruction


Women considering mastectomy to treat breast cancer or for risk reduction (prophylactic mastectomy) may be candidates for innovative reconstructive procedures that can significantly improve the appearance of their breasts. Nipple-sparing mastectomy (NSM) or as it is also known, nipple-preserving mastectomy, is the most cutting-edge technique of mastectomy presently available. NSM removes the breast gland, but allows a woman to keep her nipple and areola (the areola is the pigmented area surrounding the nipple) in place. NSM is intended to improve cosmetic outcomes following mastectomy without compromising cancer care or the effectiveness of risk reduction surgery. When appropriate oncologic and aesthetic criteria are strictly applied, NSM allows women to preserve their nipples and areolas and attain the best possible cosmetic results following mastectomy and immediate breast reconstruction.


While there is some debate about NSM in the medical community, an ever growing number of studies published in peer-reviewed journals including the Annals of Surgery, Annals of Surgical Oncology, The Breast Journal, Journal of Clinical Oncology, and Plastic and Reconstructive Surgery suggest that NSM can be safely performed in carefully selected patients. While not all women are candidates for NSM, the procedure may be appropriate for the treatment of certain breast cancers as well as for women undergoing prophylactic mastectomy.


Nipple-sparing mastectomy, is more difficult to perform than skin-sparing mastectomy because the ductal tissue directly behind the nipple must be removed, yet sufficient blood supply to the skin and nipple must be preserved while no breast tissue is left behind. For this reason, it is important that women considering nipple-sparing mastectomy choose a breast surgeon with experience in this cutting-edge procedure in order to assure both oncologic and cosmetic success.


Like all surgical procedures, NSM has benefits and risks. A woman considering this procedure must discuss it carefully with the members of her breast management team and make a choice that best suits her needs. Though the cosmetic benefits of keeping one’s own nipple and areola are readily apparent, women who are considering NSM must be aware of the potential risks of the procedure. In situations where NSM is either not recommended or desired, a Skin-Sparing Mastectomy is almost always an excellent option that can provide excellent cosmetic results.







Dr. Theresa Wang and Dr. Samuel Shih are amongst only a handful of surgeons in Georgia that routinely utilize the DIEP and SIEA flaps in breast reconstruction. These techniques utilize the patients’ own abdominal skin and fat to recreate the breasts while sparing the abdominal muscles.




The DIEP flap is the latest modification of the traditional pedicled TRAM procedure. The TRAM was pioneered by Dr. Carl Hartrampf in 1981 and actually originated in Atlanta, Georgia. Since then, there have been several modifications such as free TRAM and muscle sparing TRAM. These modifications have resulted in a flap with a more robust blood supply and less abdominal wall morbidity.


The DIEP flap is a free flap where the abdominal muscles are preserved. Only the skin and fat is utilized in the breast reconstruction thus causing even less abdominal wall morbidity.


The skin and fat is removed from the abdomen via a tummy tuck incision while keeping the blood supply attached via the Deep Inferior Epigastric Vessels. The skin/fat flap is then transplanted to the chest where it is connected to blood vessels using a microscope. The skin and fat is then molded into the shape of a breast.




The Stacked DIEP Flap is where both sides of the abdomen (two DIEP flaps) are used to reconstruct one breast. It is an option for unilateral breast reconstruction in woman who do not have sufficient fatty tissue for a single DIEP flap breast reconstruction.


This technique provides the opportunity for woman, who usually are not candidates for abdominally based breast reconstruction, to receive DIEP flap reconstruction.


Dr. Theresa Wang and Dr. Samuel Shih are amongst the most experienced in Georgia in Stacked DIEP Flap breast reconstruction. This allows women with insufficient fatty tissue, who need reconstruction of only one breast, the option of DIEP flap reconstruction. 




The SIEA flap does not violate the abdominal fascia or muscle at all. It is essentially a tummy tuck, with preservation of the blood supply to the abdominal skin and fat. The blood supply, Superficial Inferior Epigastric Artery, does not run through the abdominal musculature like the DIEP flap and therefore no violation of the abdominal fascia and muscle is needed at all. While this would make this the ideal flap, the SIEA is frequently too small to provide robust bloody supply to the flap. Given the potential benefits, the SIEA and SIEV is dissected out and examined in every patient undergoing abdominally based free flap reconstruction of the breasts. The SIEA flap will be offered to our patients based on our intra-operative findings.




There are women who require a little more fatty tissue, that cannot be provided by DIEP flaps alone, to achieve their desired size.  These women may have the option of a DIEP flap with DCIA extension. This is where the DIEP flap is extended to another zone supplied by the Deep Circumflex Iliac Artery. This adds an additional microvascular connection thus allowing for more blood flow to the larger flap.



Abdominally based free flap breast reconstruction is dependent on the availability of skin and fat from the abdomen.  Some woman are not candidates given their prior surgical history such previous abdominoplasty “tummy tuck” or major abdominal surgery. Others, simply do not have enough fatty tissue to reconstruct the breast.

There are other donor sites that can be considered for some patients:



BRCA Reconstruction


What do we know about heredity and breast cancer?


Each year, approximately 200,000 women in the United States are diagnosed with breast cancer, and one in nine American women will develop breast cancer in her lifetime. However, hereditary breast cancer — caused by a mutant gene passed from parents to their children — is rare. Estimates of the incidence of hereditary breast cancer range from between 5 to 10 percent to as many as 27 percent of all breast cancers.


In 1994, the first gene associated with breast cancer — BRCA1 (for BReast CAncer1) was identified on chromosome 17. A year later, a second gene associated with breast cancer — BRCA2 — was discovered on chromosome 13. When individuals carry a mutated form of either BRCA1 or BRCA2, they have an increased risk of developing breast or ovarian cancer at some point in their lives. Children of parents with a BRCA1 or BRCA2 mutation have a 50 percent chance of inheriting the gene mutation.  If a patient carries BRCA gene, they can have a lifetime risk of 50-70% of developing breast cancer.


BRCA Reconstruction


In the event you are diagnosed with a BRCA1 or BRCA2 mutation and have been referred for prophylactic, or risk-reducing  mastectomies, you have several options in breast reconstruction:

-DIEP flap reconstruction

-Direct to implant reconstruction

-Implant-based reconstruction with tissue expanders


© 2014 ATL DIEP

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