Nipple Delay Surgery

Angelina Jolie recently shared her BRCA+ diagnosis and brave decision to undergo prophylactic nipple-sparing mastectomy and immediate breast reconstruction. As part of her surgery, she underwent a nipple delay procedure.

So what is a "nipple delay"?

Most patients do not need a delay procedure. It's actually performed quite rarely. It can however be a good option for patients who want nipple-sparing mastectomy but are at high risk for nipple necrosis. High risk patients include smokers, patients with moderate to significant breast ptosis (sagging), and patients with a history of previous breast surgery (eg breast reduction or lift).

Nipple delay is usually performed 7-21 days before the nipple-sparing mastectomy. The nipple-areolar complex and a rim of surrounding breast skin is elevated off the underlying breast gland. This disconnects all the ducts connecting the breast tissue to the nipple and also cuts off the blood supply to the nipple and areola from the underlying breast tissue. At this point, the nipple-areolar complex is only kept alive by the blood supply from the surrounding skin.

Over the next 1 - 3 weeks, this remaining blood supply becomes much more robust and the blood flow to the nipple-areola from the surrounding skin increases. This improved blood supply makes the subsequent nipple-sparing mastectomy safer and decreases the risk of nipple-areolar necrosis (tissue death) and wound healing complications.

The procedure is combined with a subareolar biopsy to ensure there are no cancer cells involving the nipple-areolar complex. If the subareolar biopsy reveals malignancy, the nipple and areoala are removed at the time of mastectomy. Sentinel lymph node biopsy is also usually performed at the same time as the nipple delay procedure if it is indicated.

Nipple delay does not decrease the risk of future breast cancer. As long as the subareolar biopsy is negative, the risk of future breast cancer is very low and is the same as with standard nipple-sparing mastectomy.

Nipple delay is usually covered by insurance if it is medically justified and the mastectomy is covered.

I hope this info helps.

Dr C

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PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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Can Breast Cancer return in a Reconstructed Breast?

Some women are scared to consider breast reconstruction after a mastectomy because they think it will increase the risk of the breast cancer coming back. This is a common misconception. Thankfully, it's not the case.


Breast cancer can come back even after a mastectomy. However, the risk of recurrence after a mastectomy is very low and is the same whether you have breast reconstruction or not. Studies have compared patients with similar stage breast cancers and found no difference in recurrence between patients undergoing mastectomy alone (without reconstruction) and those having skin-sparing mastectomy and reconstruction.


When the patient's own tissue is used for the reconstruction (as in a "flap" procedure), only skin, fat, and/or muscle are used. This tissue is used to replace breast tissue and feels like a breast, but it never turns into real breast tissue.


While it is possible for breast cancer to recur after a mastectomy and breast reconstruction, breast reconstruction in itself (either with an implant or flap) does not increase the risk of breast cancer recurrence.


I hope this info helps.


Dr C


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PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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Considering Breast Reconstruction?

Are you considering breast reconstruction?

Would you like to know more about your reconstructive options?

Do you have questions about a specific procedure?

Two of my partners at PRMA, Dr Gary Arishita and Dr Oscar Ochoa will be available to answer your breast reconstruction questions live on Friday, April 5th from 10am-12pm central time.

You can submit your questions through Twitter, Facebook and our Google+ Hangout.

Mark your calendars and tune in to get your questions answered, live!

Dr C

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PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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Should I have Breast Reconstruction Now or Later?

With so much to think about after a breast cancer diagnosis, many patients facing mastectomy do not fully understand how the timing of breast reconstruction influences how the reconstructed breasts will ultimately look.

Breast reconstruction can be performed at the same time as the mastectomy ("immediate reconstruction") or a while after mastectomy ("delayed reconstruction").

When the mastectomy and reconstruction are performed at the same time, a skin-sparing mastectomy can usually be performed which saves the majority of the natural breast skin envelope (except for the nipple and areola). Only the actual breast tissue under the skin is removed. The reconstruction then "fills" this empty skin envelope. In some select cases the nipple and areola can also be saved. This is known as a nipple-sparing mastectomy.

Skin-sparing (or nipple-sparing) mastectomy and immediate breast reconstruction produce the most "natural" results with the least scarring. This should therefore be the goal for breast cancer patients with early disease (stage I or II) whenever possible.

Delayed reconstruction unfortunately leaves more scarring (typically) and the final breast is less likely to look like the breasts Mother Nature provided. Common reasons to delay reconstruction include advanced breast cancer (stage III or IV), inflammatory breast cancer, the plan for radiation therapy after mastectomy, and lack of access to a reconstructive surgeon.

The difference in scarring between immediate and delayed breast reconstruction can be seen in these breast reconstruction before and after photos.

Ultimately the priority must always be "life before breast" - obviously the breast cancer treatment comes first in terms of priority. However, all other things being equal, there will sometimes be a choice to be made between having the reconstruction performed with the mastectomy or some time after the mastectomy. Whenever possible, I encourage women to seek immediate reconstruction for the best cosmetic results.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques including the DIEP flap procedure. He and his partners perform over 500 DIEP flap procedures per year and are In-Network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

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Nipple-Sparing Mastectomy

Nipple-sparing mastectomy in conjunction with immediate breast reconstruction is becoming more and more popular so I thought a blog post about it was in order...

What is a nipple-sparing mastectomy?

A nipple-sparing mastectomy preserves the nipple,  areola and all the surrounding breast skin which is then used for the breast reconstruction. Unlike the traditional "modified radical mastectomy", nipple-sparing mastectomy only removes the breast tissue ("parenchyma") under the skin.

What are the benefits?

Studies show that nipple-sparing mastectomy provides the same level of surgical treatment as a modified radical mastectomy in appropriate candidates. Preserving the nipple-areola complex adds to the quality of the reconstruction making the results even more "natural". It also means the patient avoids having to go through the additional steps of nipple reconstruction and tattooing.

Who is a candidate?

Nipple-sparing mastectomy is an option for many patients with a small cancer located several centimeters away from the nipple-areola complex. Patients with ductal carcinoma in situ (DCIS) can also be candidates, again depending on the location and distance from the nipple-areola.

During the surgery, a biopsy ("frozen section") is taken from behind the nipple-areola complex and sent to pathology to make sure there is no cancer under the nipple or areola. If this biopsy is negative then the area can be preserved. If it is positive for cancer cells, the nipple and areola are obviously removed.

Patients at high risk of breast cancer (eg BRCA+, strong family history, Cowden's syndrome) choosing to undergo prophylactic (preventive) mastectomy and immediate breast reconstruction are the best candidates.

Patients who do not need a signficant breast lift will have the best cosmetic results.

What are the risks?

Nipple sensation is usually significantly reduced. Sometimes feeling is lost completely. Even in cases where some nipple-areola sensation is maintained, it is very unlikely the feeling will be as Mother Nature provided.

The underside of the nipple and areola is "shaved down" to remove as much of the breast tissue as possible. This can sometimes compromise the blood supply to the tissue which can then cause healing problems. If the blood supply is damaged too much by the mastectomy, part or all of the nipple-areola can die. Thankfully this is uncommon.

At PRMA we check the blood flow intra-operatively to ensure the nipple-areola will survive. In the unlikely event that the nipple-areola cannot be saved, it is removed to prevent wound healing complications and a new nipple and areola are reconstructed at a later time.

Where will the scars be?

This depends on the size and shape of the breast, whether a small "lift" is needed, patient preference and surgeon preference. Scars can be placed around part of the areola and extended outwards or downwards, or completely away from the areola at the breast crease ("inframmamary fold incision").


I hope this info helps!

Dr C

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Dr Chrysopoulo specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. He is in-Network for most US insurance plans. Patients are routinely welcomed from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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