Nipple Malposition after Nipple-sparing Mastectomy with Implant-based Reconstruction: Understanding Its Occurrence and Prevention

Objectives: The reasons for nipple malposition after nipple-sparing mastectomy with implant-based reconstruction are not well characterized, and nipple asymmetry remains a source of patient dissatisfaction. This study employed mathematical simulation to analyze the variables that affect nipple position, developed countermeasures to improve symmetry, and tested them in a case-control cohort. Methods: Patients who underwent nipple-sparing mastectomy followed by two-stage tissue expander and implant reconstruction were recruited and divided into two groups. The study group (N = 57) underwent reconstructive surgery guided by our mathematical simulations and countermeasures. The control group (N = 32) underwent reconstructive surgery using conventional methods. Results: Morphological simulation revealed that the fundamental reason for nipple malposition is inadequate superior pole expansion. Thus, we developed a countermeasure: fixing the nipple areolar complex in a more inferior position, combined with inferior expander placement. Good or excellent symmetry was obtained in 45/57 (79%) patients in the study group and only 8/32 (25%) patients in the control group. In the control group, poorer results were associated with mastectomy weight (ρ = 0.47, P < 0.006), preoperative ptosis grade (ρ = 0.38, P = 0.037), and the difference between the superior pole length (B) and sub-mid-clavicle-to-inframammary fold length (l) (B-l; ρ = 0.067, P < 0.0001). In the study group, the results had no relation with those variables. Conclusions: Morphological simulation found that inadequate superior pole expansion is the primary reason for nipple malposition. On the basis of this result and the patient's breast measurements, we recommend fixing the nipple areolar complex in a more inferior position and possibly pulling the nipple inferiorly, combined with inferior expander placement