Advanced techniques for mastopexy in patients with ptotic breasts requiring nipple-sparing mastectomy: a narrative review

Introduction

Nipple-sparing mastectomy (NSM) has become an increasingly preferred surgical option due to its potential for superior cosmetic outcomes and its significant positive impact on women’s psychosocial well-being (1-4). Previous studies considering treatment goals and preferences in women undergoing breast cancer treatment have demonstrated that patients, particularly those with early-stage disease or younger age, increasingly prioritize functional well-being, body image, and quality of life alongside survival (5). In women with breast ptosis, preserving the nipple-areola complex (NAC) during NSM is a highly desirable aesthetic goal, yet it presents a significant technical challenge (6).

The need to address nipple-sparing breast lift techniques is crucial as the proportion of females with any level of breast ptosis ranges from 22.8–72% in the literature, depending on various factors such as ethnicity and obesity (7,8). Considering that one in eight women in the United States will be diagnosed with breast cancer during their lifetime, improving the quality of life for this large subset of patients with ptotic breasts who require mastectomy is essential (9). However, achieving safe and effective NSM in this population poses significant technical challenges for reconstructive surgeons.

As patient-driven demand for personalized medical care grows, surgeons have developed a range of techniques to preserve the NAC in patients with ptosis. These approaches include: (I) nipple-preserving skin-reducing mastectomy (SRM) and mastopexy with concomitant reconstruction, a single-stage procedure in which NSM, immediate implant-based reconstruction, and mastopexy are performed simultaneously; (II) a two-stage approach with NSM and immediate tissue expander placement followed by mastopexy with implant exchange; (III) NSM with immediate implant-based reconstruction followed by a secondary mastopexy; (IV) NSM with immediate deep inferior epigastric perforator (DIEP) flap reconstruction followed by a secondary mastopexy; and (V) staged nipple-sparing mastectomy (SNSM) with prior breast reduction and/or mastopexy, a staged strategy beginning with mastopexy or reduction, followed by NSM with either direct-to-implant or DIEP flap reconstruction (10-12). Collectively, these techniques aim to broaden NSM eligibility for patient groups who were traditionally considered poor candidates.

Despite advancements in surgical techniques, variability in surgeon experience and persistent misconceptions regarding absolute contraindications to NSM in patients with breast ptosis have resulted in inconsistent patient care. This narrative review aims to summarize current surgical techniques for addressing breast ptosis in the context of NSM, with emphasis on technical considerations, oncologic safety, complication profiles, and impact on patient outcomes, to provide evidence-based guidance for surgeons in selecting approaches that optimize both aesthetic results and oncologic care. We present this article in accordance with the Narrative Review reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-566/rc).

Methods

A comprehensive literature search of PubMed and Embase was conducted to identify studies reporting surgical techniques, outcomes, and considerations for mastopexy in patients undergoing NSM with ptotic breasts. Search terms included “nipple-sparing mastectomy”, “mastopexy”, “breast lift”, “skin-reducing mastectomy”, and “nipple-areola complex”. Searches spanned database inception through October 2025, and reference lists of relevant articles were manually reviewed to identify additional studies.

Studies were included if they described NSM approaches in ptotic breasts, mastopexy techniques, or outcomes, and excluded if they were case reports, reviews, editorials, focused solely on nipple grafting, or lacked sufficient technical or outcome data.

Two authors (O.D. and K.J.) independently extracted data on study characteristics, patient demographics, surgical approach, reconstruction type, and reported outcomes, including NAC necrosis, skin flap compromise, wound healing issues, and revisions. Discrepancies were resolved by consensus with a third author (R.G.). Data were synthesized qualitatively to summarize current surgical strategies, technical considerations, and patient outcomes in NSM for ptotic breasts. A summary of the search strategy is presented in Table 1.

Oncologic considerations for NSM in ptotic breasts

The ultimate goal of NSM is to ensure negative margins of breast cancer while preserving the native skin envelope and NAC to optimize aesthetic outcomes. Historically, ptotic breasts were not considered candidates for NSM and were instead offered skin-sparing mastectomy, however, with improved surgical techniques, NSM has become a possibility for patients with large or ptotic breasts.

At present, the only true absolute contraindications for NSM include inflammatory breast cancer, presence of pathologic discharge, Paget disease of the nipple, and confirmed NAC involvement (13). These conditions can be excluded through standard breast cancer staging and diagnostic evaluation, including mammography, ultrasound, and magnetic resonance imaging (MRI), in conjunction with tissue biopsy when indicated. Preoperative MRI should demonstrate a clear dissection plane between the tumor and NAC. Cases in which the tumor-to-nipple distance is <2 cm have been shown to predict occult nipple involvement and may warrant closer margin inspection intraoperatively or reconsideration of nipple preservation (14).

If preoperative imaging indicates tumor proximity to the NAC or if there is clinical suspicion of NAC involvement, a biopsy of nipple margins should be performed. The reported incidence of occult NAC involvement in mastectomy specimens varies widely in the literature, ranging from 0 to 58%, reflecting differences in patient selection and pathologic selection.

The decision between intra-operative frozen section versus permanent section analysis should align with the planned reconstructive strategy. Frozen sectioning permits real-time decision-making, with results typically available within minutes. However, in staged procedures utilizing a dermoglandular pedicle, retroareolar frozen sampling may not be feasible during the first stage because biopsy of the NAC-bearing pedicle could compromise its vascularity. In such cases, margin assessment is deferred to the second stage or evaluated using permanent pathology. Permanent sectioning provides more definitive histologic assessment but requires longer processing time, often necessitating a staged reconstructive approach if nipple excision becomes necessary.

Positive nipple margins indicate involvement of the NAC and therefore preclude preservation of the NAC. Nevertheless, management can be individualized. In selected patients who strongly prefer nipple preservation, subareolar shave biopsy has been described as an intermediate step. In one study of 40 patients with positive nipple margins, 16 underwent subareolar shave biopsy rather than immediate nipple excision. On final pathology, only one patient had a persistently positive margin (ductal carcinoma in situ within 1 mm of the margin), and no cases of subsequent NAC necrosis were reported (13). If the shave biopsy remains positive, definitive nipple or NAC excision is required for oncologic safety. The authors do not utilize this approach, instead preferring a conservative route of fully removing the NAC if nipple margins return positive or if the tumor-to-nipple distance is <2 cm.

This approach is supported by a study by Brachtel et al. that demonstrated that a positive subareolar margin predicts nipple involvement by tumor with a sensitivity of 0.8 and a negative predictive value of 0.96, reinforcing that a truly positive subareolar margin should prompt resection of the nipple (15). After removal of the nipple or NAC complex, the rate of local tumor recurrence is typically low. In a study that observed NSM performed on 1,326 breasts across 766 patients, 43 of 642 (6.7%) of therapeutic NSM and 3 of 684 (0.4%) of prophylactic NSM had positive nipple margins for malignant lesions. Of the breasts with positive nipple margins, 39 of 46 (85%) of breasts underwent nipple or NAC excision. The remaining seven breasts were managed with observation alone due to patient preference or anatomical distance of the tumor from the nipple margin (16). No recurrences were observed at the nipple/NAC excision site in either patients who underwent nipple/NAC excision or patients managed with observation alone.

One additional option for preserving the NAC in patients with ptotic or large breasts is a nipple delay procedure. First described in 2005 by Palmieri et al., this technique separates the NAC from the underlying breast parenchyma approximately 2 weeks before the NSM procedure to invoke collateral vascularization of the NAC before the mastectomy (17). In this way, the risk of partial or total NAC necrosis is reduced. This technique has further been shown to increase NAC salvage in patients with risk factors for necrosis, such as preexisting breast scars, active smoking, BMI >30 kg/m², and prior radiation (18,19). Of course, this procedure requires an interim period between the delay procedure and the mastectomy, this is not feasible in cases with aggressive breast cancers.

Sentinel lymph node biopsy (SLNB) is typically performed at the time of SNM. If a patient has opted to undergo a staged approach, such as with SNSM preceded by mastopexy, then axillary staging is deferred to the mastectomy stage to avoid disrupting lymphatic mapping. In the event that disease pathology is upstaged due to nodal positivity or identification of invasive disease, adjuvant therapies may interfere with the initial reconstructive timeline. This is particularly true when postmastectomy radiation is warranted.

Together, these data underscore the importance of careful preoperative imaging, appropriate intraoperative margin assessment, and individualized management of positive nipple margins to safely expand NSM to patients with larger or ptotic breasts while maintaining oncologic integrity. A flow chart detailing key treatment considerations for reconstructive strategies may be found in Figure 1.

Figure 1 Algorithm demonstrating a decision-making framework for oncologic eligibility and reconstructive planning in NSM among patients with macromastia or breast ptosis. *, for patients who are non-smokers or diabetic patients with an HbA1c <8%. **, for patients who smoke or diabetic patients with an HbA1c >8%. 1, nipple-preserving skin-reducing mastectomy and mastopexy with concomitant reconstruction; 2, NSM tissue expander; 3, NSM with direct-to-implant reconstruction; 4, NSM with autologous reconstruction. High BMI is not an absolute contraindication to NSM. BMI, body mass index; HbA1c, glycated hemoglobin; ICG, indocyanine green; MRI, magnetic resonance imaging; NAC, nipple-areola complex; NSM, nipple-sparing mastectomy.

The following sections detail the major techniques and key clinical considerations for addressing breast ptosis through mastopexy in the context of NSM.

Nipple-preserving SRM and mastopexy with concomitant reconstruction

Efforts to simultaneously address ptotic breasts at the time of NSM began in the 1970s when Weiner et al. reported that the NAC could survive on a superiorly based dermal pedicle. This technique was first introduced in 1973, demonstrating that the NAC could remain viable while allowing mobility without distortion. Although the authors noted diminished sensation in some patients, they observed the potential preservation of nipple erectile function. In their series of 32 patients, only one case of partial NAC necrosis was reported (20).

Subsequent refinements in surgical technique led Bayram et al. to present an SRM approach that employed a vertical incision positioned laterally and inferior to the NAC, while preserving the dermal pedicle supporting the nipple. This allowed the mastectomy to be performed with sustained perfusion to the NAC, resulting in a reported 15% incidence of NAC necrosis (21).

In general, surgical techniques for SRM can be categorized into three primary approaches. The first method is the bipedicle technique, which preserves both superior and inferior dermal flaps to maintain vascularity to the NAC. Modifications of this approach include medial pedicle preservation and diagonal dermal incisions designed to create a broader proximal dermal pedicle base that gradually tapers distally toward the NAC (21-25).

The second approach utilizes a superior dermal pedicle, which may range from a periareolar sling to a broader flap extending inferior to the NAC, as described by Patzelt et al. This technique typically involves advancing the dermal flap superiorly to reduce the distance from the nipple-to-suprasternal notch distance and optimize nipple position (26-29).

A third approach, as reported by Mosharrafa et al., involves an inferiorly based pedicle with a triangular dermal flap covering the NAC and its surrounding region. In this technique, the mastectomy is performed in the plane between the inferior dermal flap and the superior skin flap, creating a relatively wide operative field that facilitates dissection and implant placement (30-33).

Patient-reported outcomes following SRM, as noted by Sahin et al., indicate high satisfaction rates concerning breast shape, symmetry, and projection, with 90–100% of patients expressing satisfaction in various aspects of the Michigan Breast Satisfaction Questionnaire (29,34). However, a primary concern with SRM is the extent of breast tissue undermining, which may increase the risk of ischemic complications compared to SNSM. Therefore, a crucial element of SRM surgery is ensuring the viability of the skin mastectomy flap and NAC post-procedure. In cases where clinical evaluation of perfusion is uncertain, indocyanine green (ICG) angiography has been utilized to assess tissue viability (22,25,28,30,31,35,36). The authors routinely utilize ICG angiography if a patient is at higher risk for NAC necrosis or if there is concern for ischemia. An additional hypothesis is that a vertical mastectomy skin incision, as opposed to an exclusive buttonhole technique, could increase the risk of tissue ischemia by compromising perforators that support flap perfusion (37,38).

In a systematic review and meta-analysis conducted by the authors, 28 papers reporting SRM techniques and outcomes were evaluated (39). This review confirmed that SRM is an established approach for nipple-preserving breast reconstruction, with skin flap and NAC necrosis rates remaining within acceptable limits. Nonetheless, our results demonstrated a higher rate of NAC necrosis for SRM compared to SNSM. Interestingly, when the analysis was restricted to SRM performed with a superior dermal pedicle, no significant difference in NAC complication rates was observed compared with SNSM.

Ultimately, the primary advantage of SRM lies in its ability to eliminate the need for an additional surgical intervention to address breast ptosis. This procedure effectively combines the surgical excision of breast tissue with a breast lift, thereby accomplishing both objectives in a single operation (Figure 2).

Figure 2 Nipple-preserving skin-reducing mastectomy and mastopexy with concomitant reconstruction. (A) Preoperative breasts with bilateral ptosis. (B) Wise-pattern excision for single stage nipple-preserving, skin-reducing mastectomy with immediate reconstruction and mastopexy. (C) Immediate postoperative result of the reconstructed breast. (D) Six-month postoperative outcome demonstrating stable nipple position.

There are multiple published papers discussing immediate breast reconstruction with a direct-to-implant approach combined with SRM as a single procedure. Schwartz et al. reported a bipedicle mastopexy technique utilizing superior and inferior dermal pedicles combined with direct-to-implant reconstruction (24). In this study, 43% of included patients underwent mastectomy for risk reduction. Out of 105 breasts analyzed, partial NAC necrosis occurred in two breasts, and no cases of total NAC necrosis were reported. Wound dehiscence, infection, and seroma rates were 6%, 8% and 8%, respectively. Sahin et al. reported another technique with a superior pedicle dermal approach to preserve the nipple (29). Their study included 42 breasts undergoing risk-reducing SRM, of which three developed seromas and four experienced NAC congestion; all complications were managed nonoperatively.

Despite the perceived efficiency and convenience of performing NSM, reconstruction, and mastopexy in a single procedure, this approach is suitable only for select patients. A sufficiently thick skin flap with adequate perfusion is essential to ensure reconstructive success with this technique. Patients with very thin, poorly perfused, or otherwise tenuous flaps may not be optimal candidates as the risk of ischemic complications, wound dehiscence and implant exposure may be increased. Alternatively, patients with significant macromastia or grade III ptosis may not be optimal candidates for this single-stage approach due to increased risk for ischemic complications and poor aesthetic outcomes, such as NAC malposition (40).

NSM with immediate tissue expander placement followed by secondary mastopexy with implant exchange

A common two-stage strategy for ptotic breasts combines NSM with immediate subcutaneous or submuscular tissue-expander placement as the index operation, followed by a secondary mastopexy with exchange to a permanent implant (Figure 3). Use of a temporary tissue expander after mastectomy was first described by Radovan as a staged approach to regaining lost tissue (41). Tissue expanders offer the advantage of gradually stretching the retained skin envelope while counteracting the wound contraction that often follows NSM. In patients with ptosis, the second-stage implant exchange provides an opportunity to correct asymmetry and refine NAC position. This staged approach also accommodates variations in skin quality and mastectomy flap thickness, making it particularly valuable for patients with grade II–III ptosis, borderline flap perfusion, or preexisting breast asymmetry (42).

Figure 3 Nipple-sparing mastectomy with immediate tissue expander placement followed by mastopexy and implant exchange. (A) Preoperative appearance of ptotic breasts. (B) Postoperative view after bilateral nipple-sparing mastectomy with immediate placement of saline tissue expanders and acellular dermal matrix. (C) Six months after final reconstruction with silicone implants and mastopexy.

At the second stage, mastopexy can be safely performed, provided that capsular integrity is preserved. The ability to adjust the implant pocket at this stage allows further refinement of breast contour and symmetry. This may involve conversion from subpectoral to prepectoral placement or addition of acellular dermal matrix (ADM) for support. As with implant-based mastopexy, intraoperative ICG angiography may be used to objectively confirm NAC perfusion (43).

Salibian et al. conducted an institutional review study that included 10 breasts undergoing wise-pattern mastopexy after NSM with an implant/expander-based reconstruction (44). Their findings supported the feasibility of performing mastopexy without capsule undermining, thereby minimizing the risk of implant contamination. No complications were reported in their series.

The timing of the mastopexy stage is determined by the rate of expansion, flap quality, the desired breast size, and the administration of adjuvant therapy. Patients whose cancer is upstaged on final pathology diagnoses and subsequently require chemotherapy or radiation may require alterations to the planned reconstructive timeline. In patients receiving radiation, mastopexy is often delayed or modified because of reduced skin mobility, compromised perfusion, and increased risk of ischemic and wound-healing complications.

In the case of patients who are at risk for necrosis, the authors will typically delay placement of the tissue expander and instead utilize a Goldilocks approach with NAC preservation. A tissue expander can be placed later if the patient still desires eventual implant placement, or a flap-based construction can be pursued.

NSM with direct-to-implant reconstruction followed by secondary mastopexy

Direct-to-implant breast reconstruction at the time of NSM aims to reduce the number of surgeries for patients (Figure 4). This reconstruction option is typically recommended for patients with grade I–II ptosis and those who intend to maintain a similar breast size (45). For patients with grade III ptosis and above, a staged approach is generally recommended to optimize NAC position (42).

Figure 4 Nipple-sparing mastectomy with direct-to-implant reconstruction followed by secondary mastopexy. (A) Postoperative results of left-sided nipple-sparing mastectomy with radial incision. (B) Preoperative marking before secondary mastopexy. (C) Incision for mastopexy made using previous radial scar. (D) Six-month postoperative results after secondary mastopexy.

Following immediate reconstruction, residual or progressive ptosis after NSM may still require secondary mastopexy. This issue can occur whether the reconstruction is implant-based or autologous. In implant-based reconstruction, asymmetry is typically due to draping of the NAC and skin envelope over the prosthesis during the first surgical stage (40). This issue is more pronounced in patients with ptosis, even if proper positioning against the chest was initially achieved.

While it is feasible to perform a secondary mastopexy after either autologous or implant-based reconstruction, this procedure carries a greater risk in implant-based reconstruction due to the potential for implant exposure, which may result in infection or explantation. Nonetheless, multiple studies support the safety of this intervention, reporting favorable outcomes following implant-based secondary mastopexy (44,46,47). The main technique involves performing a breast lift without undermining the capsule, thereby protecting the implant from exposure (Figure 4B-4D). Additional strategies include confirming NAC vascularity intraoperatively using ICG angiography (43).

Direct-to-implant NSM with the intention of secondary mastopexy requires high confidence in preoperative staging and intraoperative margin assessment, as immediate reconstruction limits flexibility if re-excision is needed due to positive biopsy margins. Frozen section analysis of retroareolar tissue is particularly valuable in this setting to avoid delayed nipple excision after definitive implant placement. Of note, this delayed approach utilizing secondary mastopexy may be less suitable for patients with borderline imaging findings or anticipated need for postmastectomy radiation.

NSM with immediate DIEP flap reconstruction and secondary mastopexy

An alternative approach to breast reconstruction is DIEP flap reconstruction at the time of NSM (Figure 5). Similar to immediate implant-based reconstruction, patients may benefit from a secondary mastopexy to address aesthetic concerns or to remove the free-flap skin island. Additional refinements, such as lipofilling to correct contour irregularities, scar revision, and excision of fat necrosis, may also be performed during the second stage.

Figure 5 Nipple-sparing mastectomy with immediate DIEP flap reconstruction and secondary mastopexy. (A) Preoperative view. (B) Intraoperative image depicting superior and inferior dermal flaps utilized in a bipedicled mastopexy. (C) Six months after bilateral DIEP flap reconstruction and secondary mastopexy. DIEP, deep inferior epigastric perforator.

In contrast to implant-based reconstruction preceding mastopexy, autologous flap reconstruction confers a distinct advantage by providing direct microvascular perfusion from the free flap to the NAC. This vascular supply ensures more reliable perfusion of the NAC, thereby significantly reducing the risk of necrosis and subsequent wound-healing complications (48-50). Furthermore, this revascularization phenomenon has enabled mastopexy to be performed without preservation of an intact dermal pedicle to the NAC while avoiding NAC necrosis, as demonstrated by DellaCroce et al. This expanded operative flexibility allows for greater freedom in repositioning the NAC, ultimately facilitating improved aesthetic outcomes, and provides a reliable reconstructive option for patients with grade II or III ptosis (48).

The authors previously described a nipple-preserving Wise-pattern mastopexy for patients with ptosis who desired a smaller breast size after DIEP flap reconstruction (11). This approach removes excess fat from the lateral and superior flap volume. Although the superior vascular attachments to the NAC were divided to accommodate the incision pattern, perfusion was preserved through the combined vascular support of the DIEP flap and the inferior dermal mastectomy flap. In our patient cohort, the surgeries were conducted as outpatient procedures under general anesthesia. As with mastopexy following implant-based reconstruction, NAC perfusion may be confirmed through intraoperative use of ICG (51,52). The use of ICG in secondary mastopexy was also reported in the literature, providing an objective method for assessing the perfusion of the NAC during surgery (51-53). In cases where ICG findings are ambiguous or suggest borderline perfusion, topical nitroglycerin ointment may be applied intraoperatively to improve blood flow and reduce the risk of ischemia (54). The authors routinely utilize intraoperative and post-operative nitroglycerin paste to support NAC blood flow.

As with direct-to-implant reconstruction, performing a secondary mastopexy after immediate DIEP flap reconstruction requires thorough preoperative planning and confidence in oncologic staging. Immediate autologous reconstruction limits flexibility if re-excision is needed for positive retroareolar margins, making intraoperative frozen section analysis particularly valuable to guide safe NAC preservation.

SNSM and reconstruction with prior breast reduction and/or mastopexy

When Spear et al. initially reported on SNSM in 2009, they advised against performing the surgery in the setting of large or ptotic breasts (12). This was criticized by a letter by Dr. Jensen, which illustrated the feasibility of using the staged approach in macromastia to improve the perfusion of the NAC (55).

The surgical techniques for SNSM differ. For patients with minimal ptosis, a simple peri-areolar mastopexy is conducted to elevate the NAC (56). For higher grades of breast ptosis, a skin-only Wise-pattern mastopexy is utilized to raise the NAC and decrease the breast’s base diameter (57). In cases with excess breast tissue, a pedicle is combined with either a Wise-pattern or vertical skin incision (Figure 6). A critical maneuver affecting the NAC involves circumferentially incising the areola, which separates it from the surrounding skin and may induce mild ischemic changes. This triggers the “delay phenomenon”, enhancing NAC survival after NSM (58).

Figure 6 Staged nipple-sparing mastectomy. (A) Preoperative appearance of ptotic breasts. (B) Two months after bilateral breast reduction. (C) Three months following bilateral DIEP flap reconstruction. (D) Six months after secondary mastopexies with adjunctive fat grafting. DIEP, deep inferior epigastric perforator.

This phenomenon has prompted increased research into SNSM outcomes, particularly to assess the feasibility of this technique in patients with ptotic or large breasts. Studies have varied in the reconstructive techniques utilized, the time intervals between mastopexy and definitive mastectomy, and inclusion criteria based on patient history and surgeon preference.

The delay period varied in the literature. Some studies supported a short minimum period between both surgeries with promising outcomes. Economides et al. reported a minimum of three to four weeks before NSM (57). This was also reported by Momeni et al., who included a patient who underwent definitive surgery after 3 weeks (59). Hammond and Little reported a patient who had the definitive NSM after 39 days from the staged mastopexy (56). In a large institutional case series involving 387 patients who underwent SNSM, Momeni et al. reported using a 6-month interval between the first and second stages of surgery (59). However, the rationale for selecting this specific cutoff was not explained.

In patients who previously underwent cosmetic mastopexy or breast reduction years before their cancer diagnosis, a subsequent nipple-sparing mastectomy is considered unplanned SNSM. In this cohort, the interval between the prior breast surgery and NSM may be substantial, often spanning several years. These patients are frequently considered higher risk due to prior disruption of dermal and subdermal vascular networks supplying the NAC, which may theoretically increase the likelihood of ischemic complications following NSM. Studies including patients with a mean interval of greater than 50 months between the two surgeries have supported the safety of unplanned SNSM and successfully maintained NAC viability (60,61). Rose et al. also reported the safety of this technique and supported the use of ICG angiography as an adjunctive tool if there is concern about tissue viability (62).

Immediate reconstructive techniques performed at the time of definitive mastectomy vary across the literature. Autologous free-flap reconstruction is commonly used in studies evaluating SNSM. Daly et al. primarily utilized muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps in 30 breasts, reporting minor skin-flap necrosis in five cases and NAC necrosis in two (63). Varnava et al. described the use of 11 DIEP flaps following SNSM, none of which resulted in NAC necrosis (64).

Implant-based reconstruction included tissue expander implantation, followed by delayed implant insertion, and a direct-to-implant approach. A study by Tondu et al. included 41 breasts undergoing a planned delayed secondary NSM and simultaneous expander to implant reconstruction (65). Three breasts developed epidermolysis of the skin flap and two breasts had epidermolysis of the NAC; however, none of the breasts experienced NAC necrosis. The authors concluded that expander to implant reconstruction at the time of delayed secondary NSM was a safe technique in ptotic breasts. Awaida et al. used a direct-to-implant approach in most of their patients, and their complication rate was relatively low (66).

SNSM has been used for both therapeutic and risk-reducing indications. Vicini et al. included 334 breasts that underwent a staged oncoplastic approach followed by definitive NSM (67). They confirm the safety of this technique following previous breast surgery. In a systematic review conducted by the authors, 18 papers reporting on SNSM were included, 17 of which included both risk-reduction and therapeutic patients (68). The only study that exclusively included risk-reducing SNSM patients was by Daly et al., who noted this as a limitation (63).

SNSM has been found to have a relatively low incidence of NAC necrosis, making it a favorable option for patients at high risk of developing this complication, including patients with diabetes mellitus or obesity (68-73).

It is important to emphasize that a planned staged or delayed reconstructive approach is not appropriate for patients with aggressive or large tumors, or for those who require the timely initiation of adjuvant therapy (13). When postmastectomy radiation is anticipated, the sequencing of surgery must avoid delaying definitive oncologic treatment or altering the recommended radiation timeline. In general, patients receive some mode of preoperative imaging, such as MRI, to evaluate tumor extent, assess tumor-nipple distance, and identify occult invasive cancers and lymph node involvement. Imaging findings, in conjunction with clinical examination and biopsy results, help guide patient selection for NSM and inform reconstructive planning, such that reconstructive strategies do not compromise oncologic safety.

Future directions of nipple-sparing mastectomy techniques

As surgical technology advances, endoscopic and robotic techniques have been increasingly adapted into breast cancer treatment. Recent studies have demonstrated that the surgical safety and postoperative complication rates of endoscopic and robotic NSMs were comparable or even superior to conventional NSM (74,75). Advantages of these minimally invasive approaches include improved aesthetic outcomes, with concealed scars and higher patient satisfaction. In a systematic review by Maes-Carballo et al., oncologic safety was found to be equivalent across NSM techniques, with no significant differences in positive margins, recurrence rates, or survival rates (76). Until recently, these minimally invasive approaches were avoided in patients with ptotic breasts or cup size D and above due to technical challenges and concerns over aesthetic outcomes (77). However, recent studies have begun to challenge this view, demonstrating that endoscopic NSM and direct-to-implant placement can be safely and effectively performed in patients with large or ptotic breasts. Dai et al. described an endoscopic NSM technique incorporating an air inflation adjustment method, performed through a 3–5 cm incision in the axillary skin fold (78). This single access point allows for axillary lymph node surgery, NSM, and direct-to-implant breast reconstruction to be completed efficiently. After performing endoscopic NSM and reconstruction in 98 patients with ptosis and 464 without, they reported that overall and major complication rates were similar between the two groups. Although outcomes of robotic and endoscopic techniques are encouraging for patients with breast ptosis, this surgical approach adds significantly longer operative time and increased costs, and requires additional surgeon training for successful procedure outcomes (79). Currently, efforts are underway to develop a structured training curriculum for these advanced minimally invasive NSM techniques; however, further work is needed to expand patient eligibility criteria and establish national accreditation guidelines (80). At the present time, mastopexy procedures in patients undergoing endoscopic NSM remain underreported in the literature, particularly in those with breast ptosis.

Conclusions

Preserving the nipple in patients with larger or ptotic breasts undergoing NSM and breast reconstruction presents significant technical challenges, particularly with maintaining NAC viability and achieving optimal aesthetic outcomes. This article outlines several safe and effective mastopexy-based strategies for patients requiring NSM, each designed to address breast ptosis while preserving nipple position and vascular integrity. The timing of mastopexy relative to NSM and reconstruction varies based on patient-specific factors such as oncologic urgency and comorbidities, availability of experienced surgeons skilled in combined oncologic and reconstructive procedures. Proper planning and multidisciplinary collaboration can enhance aesthetic outcomes and improve quality of life without compromising oncologic safety.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery for the series “Aesthetic Breast Reconstruction”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-566/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-566/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-566/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. S.N.B. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Gland Surgery from March 2025 to February 2027. As of 10-27-2025, S.N.B. receives fees of $5,000 or more per year as a paid consultant, speaker, or member of an advisory committee for BD Healthcare Ventures, LLC. She is also a speaker for MMI (Symani). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent for publication of this article and accompanying images was obtained from the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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