Nipple-sparing mastectomy

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Woman after nipple-sparing mastectomy and implant reconstruction. Breast reconstruction 14.jpg
Woman after nipple-sparing mastectomy and implant reconstruction.

Nipple-sparing mastectomy (NSM), also known as nipple delay, is one of the surgical approaches for treating or preventing breast cancer. It involves the removal of all breast tissue, except the nipple-areolar complex (NAC), and the creation of new circulatory connections from the breast skin to NAC. [1] By preserving the NAC, NSM has provided patients with higher cosmetic expectations and the opportunity to undergo a mastectomy while maintaining a more natural appearance. [2]

Contents

The concept and technique of NSM were originally introduced by Freeman in the 1960s. [3] This technique has offered a viable alternative for patients who prioritize cosmetic outcomes, taking into consideration factors such as tumour size, breast size, and the presence of inflammatory signs. [4] [5]

At the beginning of the surgery, various incision methods can be performed. [6] Followed by flap dissection for removal of the breast tissue, NAC is preserved during the whole procedure. [7] Breast reconstruction options, such as implant-based or flap-based reconstruction, can be pursued at last. After the surgery, proper monitoring of blood pressure and psychological support are needed. [8]

NSM is generally safe involving a low risk of necrosis of the NAC or surrounding skin due to interruptions of blood supply to it. [9] Necrosis has been reported from 6%-30% of patients. [10] The increased rates have an association with risk factors, including ptotic breasts, periareolar scars, large cup size, and previous radiation. [10]

History

The concept and technique of NSM were first described by Freeman in 1962. [3] The procedure was fraught with complications, unsatisfying cosmetic outcomes, and concerns about its oncologic safety. [3] It was thus not widely accepted by surgeons. After the identification of the BRCA gene in the 1990s, [11] together with the reintroduction by Hartmann et al. in their published research, [12] the procedure regained popularity. The bulk of the study's patients had undergone NSM, and only 1% of them went on to acquire breast cancer subsequently. [12] Whether the nipple was removed or kept, there was no difference in risk reduction. [13] [12]

However, the suitability of NSM for individuals with excessively large or ptotic breasts has been a topic of debate. In 2009, Spear et al. conducted an initial study and concluded that NSM should not be offered to such patients. [14] Nevertheless, in the same year, a critique of Spear challenged this conclusion by presenting a case of a patient with macromastia who underwent NSM safely following a pre-mastectomy delay procedure. [15]

In 2020, Jay Arthur Jensen presented a new strategy that combines NSM with subtotal mastectomy. [16] This approach not only achieves post-mastectomy nipple positioning but also avoids the potential drawbacks associated with a separate reduction mammoplasty followed by NSM or a specialized delay procedure. [16] Importantly, all patients undergo full oncologic mastectomies, ensuring that nipple sparing can be achieved in this high-risk group within two procedures without compromising oncologic safety. [16]

Indication

Therapeutic Candidate

Patients suffering from benign or malignant breast cancer can receive NSM treatment. The goal of NSM is to obtain negative margins and achieve a satisfying cosmetic outcome at the same time. NSM was ideally aimed at small breast cancer where the location of tumour is far away from the Nipple Areolar Complex (NAC), and without clinical lymph node involvement. [4] [5] Selection of NSM candidates is based on preoperative and intraoperative assessment.

Preoperative Assessment [4] [5]

Patients who have
  • undergone tumour margin evaluation by using radiological distance (mammogram or MRI)
  • a tumour size smaller than 3 cm
  • a distance between tumour and NAC farther than 2 cm
  • tumour located outside of the areola area
  • no nipple retraction
  • no blood discharge from the nipple
  • no inflammatory signs
  • no previous irradiation and no micro calcifications on radiologic assessment
  • no or minimal ptosis (grade 0 or 1)
  • A or B cup breast size
  • a BMI < 30 kg/m2
Patients with
Patients who are not an active smoker

are recommended to receive this surgery.

Nonetheless, patients with contraindications have shown positive results when using some of the more recent approaches to these difficult cases. NSM is now feasible even for patients with different contraindications. Currently, only women with inflammatory signs and nipple involvement are the absolute contraindications for conducting an NSM. [17]

Intraoperative Assessment

Patients will undergo a frozen section examination of retroareolar tissue during the operation. [4] The intraoperative frozen section is highly specific and moderately sensitive for identifying positive sub-areolar biopsies in NSM. The examination can act as a guide for intraoperative reconstructive planning. [18] The importance of conducting sub-areolar biopsies in all nipple-sparing mastectomies can be shown by the existence of positive sub-areolar biopsies in contralateral and high-risk prophylactic mastectomy specimens. [18]

Prophylactic Candidate

High risk genetic mutations BRCA1 and BRCA2 carriers can receive preventative mastectomy as a risk-reduction treatment. The operation can reduce their overall risk of developing future breast cancer by more than 90%. [19]

Technique

There are various ways of incision. The selection of incision methods depends on the skin perfusion and cosmetic factors. [20]

Incisions in nipple-sparing mastectomy (A: periareolar, B: radial, C: inframammary fold). Incision of breast.jpg
Incisions in nipple-sparing mastectomy (A: periareolar, B: radial, C: inframammary fold).

Inframammary fold (IMF) incision

This is the most common incision approach. [21] An approximately 9 cm incision is performed inferiorly to the nipple. [22] It then extends laterally along the IMF. [22] The incision can be displaced 4 cm medially if the internal mammary arteries are desired as the recipient vessel for autologous reconstruction. [22]

Vertical radial incision

A vertical radial incision extends from the bottom of the areola border to the inframammary fold. [6] This incision is preferable by plastic surgeons as it allows upward positioning of the nipple for ptosis correction. [23]

Circumareolar with lateral extension incision

The incision is performed around the button half portion of the areolar border to the inframammary fold laterally. [6] This approach is preferred by surgeons who routinely perform skin-sparing mastectomies via circumareolar incision.

Preexisting scars incision

NSM can be performed through preexisting incision for prevention of additional scarring.  

After incision, mastectomy flap dissection is performed. [7] Exposure is created by retraction of the skin flap with counter-tension by countertraction of the breast gland. [7] This technique allows better visualization and access to the underlying breast tissue. [24] Breast and ductal tissues are removed from the chest wall and the pectoralis muscle, including the pectoralis fascia. [7] Through the whole procedure, the NAC is preserved by dissecting the tissues away from the underlying structures to maintain the blood supply and nerve connections to the nipple. [6]

Any breast reconstruction approaches, including implant-based reconstruction and flap-based reconstruction, may be done after the surgery. [6] Implant-based reconstructions are most commonly selected as they allow the rebuilding of a moderate size of breast. [25] Flap-based reconstruction utilizes autologous tissue, such as muscle or subcutaneous from alternative body regions for reconstructing the breast mound. [26]

Postoperative management

Physical

Monitoring of blood pressure is vital after the surgery. [8] If any hypotensive situation occurs in patients, intravascular fluid injection is required for replenishment of blood pressure. [8] Drugs containing epinephrine should be avoided to prevent vasoconstriction and reduced blood flow through the anastomosis. [27] Physical assessment, such as skin colour, capillary refill time, skin turgor, skin temperature, and sensation of the breast, are used for blood pressure examination at NAC. [8]

Psychological

Patients often suffer from depression and anxiety due to the stress of surgery and loss of breast tissue. [27] Mental health education and self-compassion are important as a protective mechanism for body image disturbance and psychological distress. [28] However, this surgical approach provides greater psychological benefits than other mastectomy due to the preservation of the NAC and women’s body image. [8]

Risk and complication

NSM has the same perioperative complications as skin-sparing mastectomy and breast reconstruction. [29] One of the most common risks would be necrosis of the NAC and the surrounding skin tissues. [30] This is affected by the oxygenating ability of the breast skin, which relates to the blood supply. [31] The blood supply to the NAC particularly may be interfered with by the NSM. The average rate of partial or full skin flap necrosis is 9.5%. [31] This is likely due to the surgical techniques and patient selection. BMI, breast mass, and sternal notch to nipple length are more adversely affecting the risk of necrosis. [31]

Although breast reconstruction is known to be safe, there might still be some complications, including infection, seroma, hematoma, and capsule contracture. [32]

The risk of NAC necrosis can be reduced by the ‘delayed’ procedure. [10] It consists of the creation of new circulatory connections from the breast skin to the NAC. [10] In this way, the NAC may no longer be completely dependent on the breast tissue underneath for its blood supply. [33]

As the NAC is preserved, patients may encounter a higher risk of occult NAC tumour. [34] The retroareolar tissue is not removed completely and thus more terminal duct lobular units are left in patient’ s body, which induces higher oncological risk. [34]

Significance

The difference between NSM and skin-sparing mastectomy (SSM) is that NSM allows preservation of the NAC but SSM does not. [35] One of the main reasons to preserve the NAC is for patients’ satisfaction and psychological benefits. [36] It is a crucial component of the breast, given its aesthetics and contribution to sexual pleasure. [37] Even though the NAC can be reconstructed after performing SSM, the reconstruction is difficult due to the unique appearance of every NAC. Overall, NSM can result in higher sexual and psychosocial well-being. [38]

Related Research Articles

<span class="mw-page-title-main">Breast reconstruction</span> Surgical rebuilding of a breast

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Plastic surgery</span> Medical surgical specialty

Plastic surgery is a surgical specialty involving the restoration, reconstruction, or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery covers a wide range of specialties, including craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. This category of surgery focuses on restoring a body part or improving its function. In contrast, cosmetic surgery focuses solely on improving the physical appearance of the body. A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills.

<span class="mw-page-title-main">Nipple</span> Part of the breast

The nipple is a raised region of tissue on the surface of the breast from which, in lactating females, milk from the mammary gland leaves the body through the lactiferous ducts to nurse an infant. The milk can flow through the nipple passively, or it can be ejected by smooth muscle contractions that occur along with the ductal system. The nipple is surrounded by the areola, which is often a darker colour than the surrounding skin.

<span class="mw-page-title-main">Mammaplasty</span> Surgically modifying the appearance of the breast

Mammaplasty refers to a group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast. There are three main types of mammoplasty:

  1. Augmentation mammaplasty is commonly performed to increase the size, change the shape, and/or alter the texture of the breasts. This usually involves the surgical implantation of breast implants.
  2. Reduction mammaplasty is commonly performed to reduce the size, change the shape, and/or alter the texture of the breasts. This involves the removal of breast tissue.
  3. Reconstructive mammoplasty is breast reconstruction that is done after mastectomy to give the breasts an appearance that is more normal/familiar.

Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Breast augmentation</span> Surgical procedure

Breast augmentation and augmentation mammoplasty is a cosmetic surgery procedure, which uses breast-implants and/ or fat-graft mammoplasty technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall in other cases it is performed purely for cosmetic reasons.

<span class="mw-page-title-main">Breast reduction</span> Plastic surgery procedure

Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.

<span class="mw-page-title-main">Chest reconstruction</span> Surgical procedure

Chest reconstruction refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. People may pursue chest reconstruction, also known as top surgery, as part of transitioning.

<span class="mw-page-title-main">Breast implant</span> Prosthesis used to change the size, shape, and contour of a persons breast

A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenital defects and deformities of the chest wall or, cosmetically, to enlarge the appearance of the breast through breast augmentation surgery.

Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.

A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.

<span class="mw-page-title-main">Liposuction</span> Surgery to remove unwanted fat

Liposuction, or simply lipo, is a type of fat-removal procedure used in plastic surgery. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect obesity-related problems. In the United States, liposuction is the most common cosmetic surgery.

Trans-umbilical breast augmentation (TUBA) is a type of breast augmentation in which breast implants are placed through an incision at the navel rather than the chest.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

<span class="mw-page-title-main">Nipple prosthesis</span>

Nipple/Areola prostheses are made of silicone by breast prosthesis manufacturers and anaplastologists for breast cancer survivors who were treated for breast cancer with a mastectomy. Prostheses can be worn weeks after a mastectomy, breast reconstruction, or even nipple reconstruction. As an inexpensive and convenient alternative to surgery, patients may choose to wear them anytime during treatment. Patients who ultimately find nipple prostheses thought that they should be informed of them during the consultation prior to mastectomy.

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.

Aesthetic flat closure after mastectomy is contouring of the chest wall after mastectomy without traditional breast reconstruction. Vernacular synonyms and related vernacular and technical terms include "going flat", "flat closure", "optimal flat closure", "nonreconstructive mastectomy", "oncoplastic mastectomy", "non-skin sparing mastectomy", "mastectomy without reconstruction", and "aesthetic primary closure post-mastectomy".

<span class="mw-page-title-main">Nipple reconstruction surgery</span>

Nipple reconstruction, specifically nipple-areola complex (NAC) reconstruction, is a procedure commonly done for patients who had part or all of their nipple removed for medical reasons. For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development.

Rebecca Aft is an American surgical oncologist and breast cancer researcher. Holds the inaugural title of Moley Professor of Endocrine and Oncologic Surgery at Washington University School of Medicine in St. Louis. Aft studies the mechanisms of breast cancer metastasis and explores potential targets for treatment. Her work has identified the anti-metastatic effects of bisphosphonates in patients with breast cancer. 

References

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  15. ↑ Jensen, J. Arthur (2009). "Nipple-sparing mastectomy: what is the best evidence for safety?". Plastic and Reconstructive Surgery. 124 (6): 2195–2197. doi:10.1097/PRS.0b013e3181bcf654. ISSN   1529-4242. PMID   19952691.
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  17. ↑ Brzezinska, Monika; Dixon, J. Michael (2018). "Inflammatory breast cancer: no longer an absolute contraindication for breast conservation surgery following good response to neoadjuvant therapy". Gland Surgery. 7 (6): 52024–52524. doi: 10.21037/gs.2018.08.04 . ISSN   2227-8575. PMC   6323256 . PMID   30687625.
  18. 1 2 Alperovich, Michael; Choi, Mihye; Karp, Nolan S.; Singh, Baljit; Ayo, Diego; Frey, Jordan D.; Roses, Daniel F.; Schnabel, Freya R.; Axelrod, Deborah M.; Shapiro, Richard L.; Guth, Amber A. (2016). "Nipple-sparing Mastectomy and Sub-areolar Biopsy: To Freeze or not to Freeze? Evaluating the Role of Sub-areolar Intraoperative Frozen Section". The Breast Journal. 22 (1): 18–23. doi: 10.1111/tbj.12517 . PMID   26510917.
  19. ↑ Thepjatri, Nate (2007). "Surgery of the Breast: Principles and Art, 2nd ed". Annals of Surgery. 245 (4): 661. doi:10.1097/01.sla.0000259049.76053.05. ISSN   0003-4932. PMC   1877050 .
  20. ↑ Lotan, Adi Maisel; Tongson, Krystina C.; Police, Alice M.; Dec, Wojciech (2020). "Mastectomy Incision Design to Optimize Aesthetic Outcomes in Breast Reconstruction". Plastic and Reconstructive Surgery Global Open. 8 (9): e3086. doi:10.1097/GOX.0000000000003086. ISSN   2169-7574. PMC   7544272 . PMID   33133941.
  21. ↑ Go, Ju Young; Jeong, Dae Kyun; Han, Daniel Seungyoul; Bae, Seong Hwan (2018). "Inframammary Flap Excision Method in Breast Augmentation: Improving Symmetry of NAC and IMF". Plastic and Reconstructive Surgery Global Open. 6 (12): e2052. doi:10.1097/GOX.0000000000002052. ISSN   2169-7574. PMC   6326606 . PMID   30656124.
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  25. ↑ Malekpour, Mahdi; Malekpour, Fatemeh; Wang, Howard Tz-Ho (2023). "Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome". World Journal of Clinical Cases. 11 (10): 2201–2212. doi: 10.12998/wjcc.v11.i10.2201 . ISSN   2307-8960. PMC   10131028 . PMID   37122510.
  26. ↑ Somogyi, Ron B.; Ziolkowski, Natalia; Osman, Fahima; Ginty, Alexandra; Brown, Mitchell (2018). "Breast reconstruction". Canadian Family Physician. 64 (6): 424–432. ISSN   0008-350X. PMC   5999246 . PMID   29898931.
  27. 1 2 Nahabedian, Maurice Y.; Nahabedian, Anissa G. (2016). "Autologous microvascular breast reconstruction: Postoperative strategies to improve outcomes". Nursing. 46 (12): 26–34. doi:10.1097/01.NURSE.0000504672.73356.8e. ISSN   1538-8689. PMID   27824738.
  28. ↑ Sherman, K. A.; Woon, S.; French, J.; Elder, E. (2017). "Body image and psychological distress in nipple-sparing mastectomy: the roles of self-compassion and appearance investment". Psycho-Oncology. 26 (3): 337–345. doi:10.1002/pon.4138. ISSN   1099-1611. PMID   27167009.
  29. ↑ Piper, Merisa; Peled, Anne Warren; Foster, Robert D.; Moore, Dan H.; Esserman, Laura J. (2013). "Total Skin-Sparing Mastectomy: A Systematic Review of Oncologic Outcomes and Postoperative Complications". Annals of Plastic Surgery. 70 (4): 435–437. doi:10.1097/SAP.0b013e31827e5333. ISSN   0148-7043. PMID   23486127.
  30. ↑ Chirappapha, Prakasit; Petit, Jean-Yves; Rietjens, Mario; De Lorenzi, Francesca; Garusi, Cristina; Martella, Stefano; Barbieri, Benedetta; Gottardi, Alessandra; Andrea, Manconi; Giuseppe, Lomeo; Hamza, Alaa; Lohsiriwat, Visnu (2014). "Nipple Sparing Mastectomy: Does Breast Morphological Factor Related to Necrotic Complications?". Plastic and Reconstructive Surgery Global Open. 2 (1): e99. doi:10.1097/GOX.0000000000000038. ISSN   2169-7574. PMC   4174220 . PMID   25289296.
  31. 1 2 3 Zenn, Michael R. (2018). "Evaluation of skin viability in nipple sparing mastectomy (NSM)". Gland Surgery. 7 (3): 301–307. doi: 10.21037/gs.2018.04.04 . PMC   6006020 . PMID   29998079.
  32. ↑ Toh, Uhi; Takenaka, Miki; Iwakuma, Nobutaka; Akagi, Yoshito (2021). "Clinical outcomes of patients after nipple-sparing mastectomy and reconstruction based on the expander/implant technique". Surgery Today. 51 (6): 862–871. doi:10.1007/s00595-020-02175-4. ISSN   0941-1291. PMC   8141482 . PMID   33185799.
  33. ↑ Davies, Kerry; Allan, Lyra; Roblin, Paul; Ross, David; Farhadi, Jian (2011). "Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction". The Breast. 20 (1): 21–25. doi: 10.1016/j.breast.2010.06.006 . ISSN   0960-9776. PMID   20619645.
  34. 1 2 Edge, Stephen B. (2009). "Nipple-sparing mastectomy: how often is the nipple involved?". Journal of Clinical Oncology. 27 (30): 4930–4932. doi:10.1200/JCO.2009.23.9996. ISSN   1527-7755. PMID   19720888.
  35. ↑ Galimberti, Viviana; Vicini, Elisa; Corso, Giovanni; Morigi, Consuelo; Fontana, Sabrina; Sacchini, V.; Veronesi, Paolo (2017). "Nipple-sparing and skin-sparing mastectomy: review of aims, oncological safety and contraindications". Breast (Edinburgh, Scotland). 34 (Suppl 1): S82–S84. doi:10.1016/j.breast.2017.06.034. ISSN   0960-9776. PMC   5837802 . PMID   28673535.
  36. ↑ Agha, R. A.; Al Omran, Y.; Wellstead, G.; Sagoo, H.; Barai, I.; Rajmohan, S.; Borrelli, M. R.; Vella-Baldacchino, M.; Orgill, D. P.; Rusby, J. E. (2019). "Systematic review of therapeutic nipple-sparing versus skin-sparing mastectomy". BJS Open. 3 (2): 135–145. doi:10.1002/bjs5.50119. ISSN   2474-9842. PMC   6433323 . PMID   30957059.
  37. ↑ Clarijs, Marloes E.; Peeters, Noelle J. M. C. Vrancken; van Dongen, Sophie A. F.; Koppert, Linetta B.; Pusic, Andrea L.; Mureau, Marc A. M.; Rijken, Bianca F. M. (2023). "Quality of Life and Complications after Nipple- versus Skin-Sparing Mastectomy followed by Immediate Breast Reconstruction: A Systematic Review and Meta-Analysis". Plastic and Reconstructive Surgery. 152 (1): 12–24. doi:10.1097/PRS.0000000000010155. ISSN   0032-1052. PMC   10298179 . PMID   36728484.
  38. ↑ Goh, S. C. J.; Martin, N. A.; Pandya, A. N.; Cutress, R. I. (2011). "Patient satisfaction following nipple-areolar complex reconstruction and tattooing". Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS. 64 (3): 360–363. doi:10.1016/j.bjps.2010.05.010. ISSN   1878-0539. PMID   20570584.
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