Management of nipple malposition after breast implant removal following nipple sparing mastectomy: An algorithmic approach

Abstract

Background: Infection is problematic in implant-based breast reconstruction and can be particularly challenging with nipple-sparing mastectomy (NSM). Traditionally, infected tissue expanders (TEs)/implants are removed for several months resulting in nipple malposition. Negative pressure wound therapy with instillation and dwell (NPWTi-d) has been described to salvage infected TEs/implants. The effect of NPWTi-d on maintenance of skin envelope/nipple position with TE has not been well described. Surgical nipple correction in this group has not been well characterized. The purpose of this study is to evaluate correction of nipple malposition following implant removal with nipple-sparing mastectomy. Methods: A single-center retrospective review was performed for NSM patients who underwent implant-based breast reconstruction (2018-2024). Those who required TE/implant removal from surgical-site infection (SSI)/skin necrosis were included. SSI, skin necrosis, and adjusted nipple location were outcome variables. Results: The study included 192 NSM patients (342 TE/implants) who underwent implant-based reconstruction. Implant loss occurred in 8.5 % (29/342 TE/implants) with 5.0 % (17/342 TE/implants) from infection and 3.5 % (12/342 TE/implants) from skin necrosis. Secondary nipple adjustment was required in 41.2 % (7/17) who had infection and 41.7 % (5/12) who had skin necrosis. Salvage of TE/implants using NPWTi-d, and implant replacement while inpatient was performed in 7/17 patients with infection. No patients managed with NPWTi-d required secondary nipple correction. Conclusion: Nipple location may be preserved in nipple sparing mastectomy patients who receive NPWTi-d with faster reconstruction rates following infection compared to the control group. NPWTi-d may serve as a therapy adjunct in forming an algorithm following loss of a tissue expander.