Nipple-Sparing Mastectomy in Irradiated Breasts: Selecting Patients to Minimize Complications

Background: Nipple-sparing mastectomies (NSM) are increasingly common because of their cosmetic advantage. Radiotherapy (RT) has been a relative contraindication to immediate reconstruction because of concerns about increased complications. We aimed to evaluate outcomes of NSM plus immediate reconstruction in irradiated breasts and to determine additional risk factors for complications. Methods: We retrospectively reviewed NSM with immediate reconstruction from 2007 to 2013 at our institution. Complications were broken down into several categories. Potential risk factors for complications were evaluated. Results: There were 982 NSM: 816 had no RT, 67 had prior RT, and 97 had postmastectomy radiotherapy (PMRT). Compared to breasts with no RT, both prior RT and PMRT increased overall complications (10.2 vs. 21.7 and 17.5 %, p = 0.003, 0.03, respectively) and nipple loss (0.9 vs. 4.3 and 4.1 %, p = 0.04, 0.02, respectively), while PMRT increased rate of reconstruction failure (2.2 vs. 8.2 %, p = 0.003). On multivariate regression analysis, prior RT [odds ratio (OR) 2.53, p = 0.006], PMRT (OR 2.29, p = 0.015), age >55 years (OR 2.03, p = 0.04), breast volume ≥800 cm³ (OR 1.96, p = 0.04), smoking (OR 2.62, p = 0.001), and periareolar incision (OR 1.74, p = 0.03) were independent risk factors for complications requiring surgical revision. In irradiated breasts, complication rates were 13.4 % without further risk factors and 17.5, 50, and 66.7 % when 1, 2, and ≥3 additional independent risk factors were present, respectively (p < 0.001). Conclusions: Although complication rates were higher in irradiated breasts, reconstruction failure and nipple/areola necrosis was infrequent. RT should not be a contraindication to NSM. Preoperative identification of risk factors and appropriate patient selection may reduce complication rates.