Nipple Position and Clinical Outcomes Following Nipple-Sparing Mastectomy: An Examination of Prepectoral and Subpectoral Implant-Based Reconstruction Utilizing 3D Imaging

Background: Nipple-sparing mastectomy (NSM) has become increasingly popular in recent years. However, the impact of prepectoral vs subpectoral implant reconstruction on nipple position, clinical outcomes, and patient-reported outcomes (PROs) after NSM remains unknown. Objective: We hypothesized that prepectoral reconstruction would lead to a more anatomic nipple position and improved clinical outcomes and PROs when compared to subpectoral reconstruction following NSM. Methods: Surgical characteristics, complications, and PROs in NSM patients with implant-based reconstruction from 2018 to 2021 were prospectively collected. Nipple displacement from baseline was analyzed with 3-dimensional (3D) surface imaging. Results: In total 216 patients underwent 391 NSMs, separated into subpectoral (n = 96) and prepectoral (n = 120) cohorts. There were no differences in demographics or comorbidities between cohorts. Prepectoral placement showed a greater incidence of short-term return to the operating room (21% vs 10%, P = .026). Three-dimensional analysis of 96 patients and 175 nipple positions was conducted. Compared to preoperative baseline, 3D imaging at 12 months postoperatively showed that the subpectoral cohort had greater straight-line distance between the nipples (23.1 mm vs 17.3 mm, P < .001) and more lateral nipple displacement (9.2 mm vs 6.1 mm, P < .001) when compared to the prepectoral cohort. Regression analysis found no relationship between incision pattern and nipple displacement. No postoperative differences were seen in PROs. Conclusions: Subpectoral NSM reconstruction was found to have more lateralized nipple displacement when compared to prepectoral patients, regardless of the incision pattern employed. Nipple displacement after NSM can play a significant role in postoperative aesthetic appearance and should be considered when deciding implant plane.