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Hello, this is Dr. C. Andrew Salzberg. Many large-breasted women with a BRCA mutation or family history of breast cancer seeking prophylactic surgery have been told they are not candidates for a nipple sparing, direct to implant (“one step”) mastectomy. This has typically been true in the past, but there are now steps we can take to prepare the breasts for a successful nipple sparing procedure; let me explain:

Women with large (usually D – DD or larger) and/or ptotic breasts—where the nipple is facing downward or is in a position that is lower than the inframammary (bottom of breast) fold — are often not ideal candidates for nipple sparing mastectomies. This is because after the breast tissue is removed (mastectomy), the size of the implant needed to fill the skin envelope so that the nipple is positioned properly would just be too large — most women wouldn’t want such a large implant, and in fact implants aren’t typically made to those sizes. Plus, an implant that large can place too much stress on a woman’s pectoralis (chest) muscle.

A newer technique we perform to enable women with large or ptotic breasts to have a nipple sparing mastectomy is done in two stages. First, we give you a breast reduction or a breast lift (mastopexy) to make the breast shapelier and slightly smaller; this corrects ptosis and places the nipple into the correct (forward-facing) position.

After breast lift or reduction, you’ll wait six months to one year while your nipple areola complex (NAC) adjusts to its new blood supply. This is because the nipple sparing mastectomy is going to remove a large portion of the blood supply to your nipple and areola, which learn to survive from the blood flow provided by the breast skin left behind; the scar around the nipple areola complex from your reduction/lift can be an additional challenge to the post-mastectomy blood supply. Waiting six months to one year will reduce this challenge as much as possible, and your nipples are likely to do well with a nipple sparing mastectomy despite having the reduction/lift surgery scars.

In general, breast reduction scars heal very well. The scar around the nipple complex is almost completely hidden — it fades nicely and is positioned in the boundary between the dark skin of the areola and the light skin of the breast. The lower scar along the inframammary fold is hidden in the creases of the lower pole of the breast. The only scar that is really visible is the vertical component of the “inverted T” through which the reduction was done, and which fades to an almost indiscernible white line in nine months to a year. We encourage patients to use silicone scar sheeting and massage to speed the process of scar maturation and make the scars as minimal as possible. Physical recovery time is two weeks off from strenuous activity and heavy lifting, then resumption of all normal activities. Most women who work at desk jobs or those that don’t involve heavy lifting return to work in three to four days. A drain is used but typically comes out 24 hours after surgery.

Once the breast has been reduced and/or lifted — the breast is smaller, the nipple is in the correct position and the important waiting period for nipple blood supply recovery has passed — we proceed with a nipple sparing mastectomy and direct to implant breast reconstruction. You will wake from surgery with breast mounds from implants and with your own nipples and areolae intact.

Many women want to keep their own nipples for aesthetic reasons and because they feel more whole or “like themselves” afterwards. We’ve performed this two-stage nipple sparing process successfully for many large-breasted women, and we’re happy to discuss this option with you and answer any of your questions and concerns during a consultation. Please feel free to reach out to us here as well.

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