Optimal Strategies for the Management of Macromastia and Breast Ptosis for Patients Undergoing Nipple-sparing Mastectomy

Authors: Moreira AA, Kozorosky E, Coopey SB

Affiliation: University of Pittsburgh School of Medicine; Allegheny Health Network; St. Joseph’s University Medical Center

Journal: Journal of Reconstructive Microsurgery, 2026;42:80–90

PMID: 39947639.

Key takeaways

• For macromastia and ptosis, the authors favor staging when feasible (mastopexy/reduction first, then NSM) to optimize nipple–areolar complex viability and shape control.

• They describe a selective one-stage approach for active-cancer patients using skin-only mastopexy/skin reduction with NSM, emphasizing perfusion assessment and a low threshold to abandon NAC preservation.

• Their “extreme NSM” cohort (specimens >600 g) reports nipple necrosis 4.7%, seroma 16.3%, and implant extrusion 7.0% (43 patients, 64 breasts) – comparable to their patient cohort who underwent NSM  with specimens < 600g.

Background

Large, ptotic breasts have historically been considered higher risk for nipple-sparing mastectomy because long, thin mastectomy flaps and redundant skin can compromise perfusion and increase NAC necrosis.

Objective

Provide a practical algorithm and technical strategies to expand NAC preservation for patients with macromastia and ptosis undergoing NSM.

Methods

• Design: Narrative review with institutional algorithm and a retrospective outcome summary on patients who underwent NSM with >600g specimen

• Algorithm:

  • Stage reduction or mastopexy first, then NSM performed 1–3 months later when oncologically feasible

    • Primarily favored for prophylactic

    • Or highly selected early-stage cancers where short delay is acceptable (DCIS) – patients underwent lumpectomy at time of mastopexy/reduction. RTX withheld due to second stage NSM performed in 1-3 months

• In healthy, carefully selected patients with active cancer and grade 2 or 3 ptosis - consider one-stage NSM with immediate skin-only mastopexy/reduction.

1.      Breast surgeon performs NSM through an inferolateral incision to help preserve NAC perfusion via superficial branches of the 5th intercostal perforator.

2.      Intraoperative perfusion assessment of mastectomy flaps and NAC (clinical exam ± ICG); low threshold to excise the NAC or convert the plan if perfusion is marginal.

3.      If the NAC is well perfused, perform immediate skin-only mastopexy. 

§  There were a variety of pedicle patterns discussed: superior dermal pedicle with limited transposition; McKissock-type or tripedicle dermal flaps; extended inferior dermal pedicle when IMF-to-nipple distance is short.

• Patients who are not candidates for single stage (active disease, with higher comorbidities, and grade 2 ptosis) should undergo NSM with implant or DIEP flap reconstruction – the redundant tissue is then excised as a mastopexy 3 months later as a second stage. Or 6 months later if they require radiation.

Results

The author’s reviewed their results for their “Extreme NSM cohort” (>600 g specimen weight), and compared complication rates to their cohort tradition NSM (<600g specimen”

• n: 43 patients, 64 breasts; mean breast weight ~879 g (range 603–1658); mean BMI 31.5.

• Reconstruction mix: direct-to-implant 53.5%, tissue expander 27.9%, DIEP 18.6%.

• Complications: seroma 16.3%, hematoma 7.0%, skin flap necrosis 7.0%, nipple necrosis 4.7%, implant extrusion 7.0%, major complications 27.9%.

• Author’s report no statistically significant increase in risk of NAC necrosis between groups. 

Conclusion

With careful patient selection, incision planning, and real-time perfusion assessment, the authors argue NSM can be extended to macromastia/ptosis using staged approaches and selected one-stage techniques.

Strengths

• Clear pragmatic algorithm reflecting real multidisciplinary decision-making.

• Emphasizes perfusion-driven “stop rules,” the correct safety posture for high-risk NSM.

• Provides complication rates in a population many surgeons consider outside traditional NSM candidacy.

Limitations

• Primarily an experience-driven review and algorithm; no comparative evidence that one pathway is superior.

• No statistical analysis

• No analysis of cohorts based on degree of ptosis and/or mastopexy design (e.g. amount of dermal preservation around the NAC)

• Operative detail capture is incomplete; mastopexy pattern was not consistently recorded, limiting reproducibility.

• Outcomes are confounded by mixed reconstruction types and treatment contexts without stratified risk modeling.

Clinical relevance

This paper functions best as a technical and decision framework: stage when oncologically feasible; when one-stage is necessary, treat it as a perfusion-driven operation with a low threshold to convert plans (NAC sacrifice) based on intraoperative assessment.

Editorial notes

• The algorithm would be stronger with reproducible risk stratification (BMI, smoking, diabetes, prior radiation, breast size/measurements) tied to NAC loss and reconstructive failure rates. As well as the type of mastopexy designed and the degree of ptosis: 2 vs. 3.

• Perfusion assessment is emphasized, but quantitative ICG or other numeric thresholds were not provided; decisions are described qualitatively (clear ischemia vs borderline vs good perfusion).