Primary Nipple-Repositioning Surgery Before Nipple-sparing Mastectomy in Large or Ptotic Breasts: A Multicenter...

Nipple-sparing mastectomy (NSM) after nipple-repositioning surgery (mastopexy or breast reduction) is increasingly used in patients with large or ptotic breasts to improve vascularity to the nipple-areolar complex (NAC) and decrease the risk of necrosis. This systematic review aimed to evaluate the safety and optimal timing of this approach.

Preferred reporting items of systematic reviews and meta-analyses guidelines were followed. PubMed, Scopus, and Web of Science databases were searched on February 24, 2024. All observational studies reporting complication outcomes and/or timing between staged NSM after breast reduction or mastopexy were included.

Thirteen studies met the inclusion criteria, with a combined sample of 591 breasts. The incidence of partial and complete NAC necrosis across the 13 studies was 4.06% (24 of 591), whereas skin flap necrosis occurred in 15 out of 591 breasts (2.54%), as reported in 8 studies. The mean follow-up time was 436.35 days, and the mean interval between mastopexy and NSM was 288.2 days. A correlation was observed between longer intervals and lower rates of skin flap necrosis and NAC necrosis; subgroup analysis for intervals greater than 5 months showed only 1 case of complete NAC necrosis across the combined sample of all studies.

Although data suggest that a 4- to 6-month interval may minimize complications, further research with larger sample sizes, longer follow-up times, and randomized controlled trials comparing staged and nonstaged approaches is necessary to establish definitive guidelines, especially with regard to high-risk patients requiring radiotherapy or undergoing therapeutic rather than prophylactic NSM.