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Keeping Your Nipples with a Mastectomy

Nipple Sparing and Nipple Delay Surgeries

Laura Frese PA-C: Laura Frese PA-C is a Physician Assistant at Cedars-Sinai Medical Center in the department of Plastic and Reconstructive Surgery. She received her Masters in the Physician Assistant program at St. Louis University followed by a surgical residency at Johns Hopkins. For the past 15 years, her practice as a PA has had a strong focus in breast reconstruction.

Holly is a writer, performer, and health advocate, sharing her personal experience as a breast cancer survivor and carrier of the BRCA1 gene mutation to raise awareness, and support women as they navigate their own cancer journey - practically, spiritually, and emotionally. With training and background in Reiki, spirituality, and holistic health/wellness, her writing runs the gamut from being a regular contributor at The Huffington Post, to produced playwright, to Senior Writer for a global non-profit.

If you are going to have a mastectomy, and the cancer is not in your nipple or tissue underneath the nipple, then you may be able to keep your real nipples. During what’s called a nipple-sparing mastectomy, all of the breast glandular tissue is removed from beneath the overlying skin and nipple, leaving the nipple and full breast skin envelope (including areola) intact.

The goal of this type of surgery — which is appropriate for all breast sizes — is to preserve the nipple and areola area without compromising the success of cancer treatment. It can only be performed, however, when breast reconstruction immediately follows the mastectomy; this includes placement of tissue expanders or saline or silicone implants, or the DIEP procedure, which uses the body’s own tissue to form a new breast.

The effects of nipple sparing are purely aesthetic; just because you still have your real nipples, does not mean you have any feeling in them, although on rare occasions if enough of the nerves stay connected, some sensations will remain. The crazy thing is that even though you can’t feel it, your nipples will still respond to external forces, like cold temperatures and touch. Personally, I find that mine have a mind of their own, constantly standing at attention for seemingly no reason! For some women, feeling may start to return to the region up to 18 months post-surgery. While that isn’t the case for me, I am able to feel any sort of pressure applied to that region.

 There are, however, two relatively new different types of re-nervation procedures  - axogen or patient’s donor nerve -  through which sensation can be restored, so check with your physician to see if you are a candidate for either. Currently, however, this is only an option for those doing autologous tissue reconstruction (such as DIEP flap).

The main concern with keeping the nipples is recurrence of cancer in the nipple or areola tissue that remains. However, the National Comprehensive Cancer Network guidelines state this technique is appropriate for those women who qualify for nipple sparing, and multiple studies have proven its safety. Of course, it is scary to think about the possibility of having any breast tissue left where cancer could potentially recur, but discuss it with your care team. My oncologist, breast surgeon, and cosmetic surgeon all told me in my case it was totally safe to do the nipple sparing, I trusted them; when the breast cancer is smaller than 3 cm and over 2 cm from the nipple itself, nipple sparing is typically the only option.

Another concern, or risk, with nipple-sparing mastectomy is of the blood supply to the nipple and areola region being cut off, which causes necrosis (tissue death), resulting in the nipple “dying.” Sometimes, to prevent this, a surgeon might recommend nipple delay, which is an outpatient surgery performed around two weeks prior to nipple-sparing mastectomy, with the intention of improving blood flow and circulation to the nipple. There are specific instances, however, when a nipple delay procedure is essential to perform before mastectomy, and that is for those who have previously had a breast lift, breast reduction, or any sort of incision previously made circumferentially around the nipple.

Essentially, this surgery disconnects the blood vessels that normally provide circulation to your nipple, drawing extra blood flow to the area as a means of keeping the nipple and areola “alive.” Approximately half of the breast skin is lifted off the fatty and glandular parts of the breast, releasing the undersurface of the nipple and surrounding skin from the breast. This is done so that over the next few weeks leading up to the nipple-sparing mastectomy, the blood flow to the nipple/areola from the surrounding skin increases, and the nipple gets used to receiving its blood supply from the skin around it rather than the breast tissue underneath, making it no longer dependent on that underlying breast tissue for its blood supply.

Usually this is done via the same incision planned for your upcoming mastectomy, which may be in the crease under your breast or under your areola; there will be no extra scars. Your surgeon may also take a tissue biopsy for pathology to confirm there are no cancer cells, reassuring the safety of keeping your nipples.

While the nipple-sparing procedure adds yet another surgery, has with it the standard surgery risks including pain and bruising, and does have a very low risk of the nipple not surviving, the chances of it saving the nipple are high, and therefore extremely worth it for many women who would like to keep their natural nipple. Every woman’s body and situation, however, is different. I did not need to have nipple-delay surgery, and my nipples have not died, while a “breastie” of mine did have the nipple-delay surgery, per her surgeon’s recommendation, and her nipples are also still alive. Yet another “breastie” had nipple delay and did get partial necrosis; during the subsequent mastectomy, her surgeon removed the dead portion of the nipple. As a result, the nipple on that side is flatter than the other, but did survive and is still alive today.

If you have questions about keeping your nipples, talk to your doctors and surgeons, but remember that at the end of the day, the most important thing, and the goal, is to be healthy and cancer-free.

For more information on breast reconstruction options, visit the other articles in this series:

Breast Reconstruction After Mastectomy: Implants and Tissue Expanders
Breast Reconstruction: Implants Under vs. Over the Muscle
Nipple Reconstruction After Mastectomy Yes, it’s a thing!

“Having a mastectomy and have questions about keeping your nipples? Talk to your doctors and surgeons. If the cancer is not in your nipple or the tissue underneath the nipple, there may be options.”

- Holly Sidell


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