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Predictors of Nipple Malposition After Nipple-Sparing Mastectomy
Carrie K. Chu, MD MS, Albert Losken, MD, Toncred Styblo, MD, Grant W. Carlson, MD.
Emory University School of Medicine, Atlanta, GA, USA.

PURPOSE:
Nipple malposition is a well-recognized problem following reconstruction after nipple-sparing mastectomy (NSM). We aim to identify variables associated with eventual malposition of the preserved nipple-areolar complex.
METHODS:
NSMs were identified from a prospectively-maintained institutional database. Pre- and post-operative photos following conclusion of reconstruction were judged for nipple malposition using several definitions: 1) deviation from the point of maximal implant projection, 2) lateral deviation from mid-clavicular line, or 3) excess/insufficient vertical height based on ratio of upper pole to total breast height. Pre-operative photos were reviewed for baseline deviation from ideal nipple position (intersection between mid-clavicular line and inframmary fold). Cases with and without malposition were compared; logistic regression modeling was used to evaluate predictors of malposition.
RESULTS:
93 breasts (58 patients) were analyzed. Inframammary fold incisions were predominant. 19% of nipples were malpositioned. Most common patterns were lateral displacement and high position. BMI (odds ratio 1.64, 95% confidence interval [1.02-7.55]), expander base width >13cm (7.75 [2.04-19.37-7.55]), radiation (9.34 [5.26-29.15]), nipple ischemia (4.12 [1.13-9.87]), and unilaterality (2.23 [1.12-5.49]) were predictors of malposition. A trend was observed towards malposition when increased mastectomy weight was combined with decreased initial expander fill. Patients with pre-existing discrepancy of the nipple from ideal position were also at risk for malposition (75%).
CONCLUSION:
Patients with wide-based breasts and higher BMI are predisposed to nipple malposition after NSM. Postoperative radiation is also an independent risk factor. Baseline variation in nipple position is accentuated following NSM. Technical precision in expander/implant placement is critical in patients with these features.


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