It is hard to believe that we are only a generation away from the widespread use of the Halstead radical mastectomy. Indeed, breast surgery, as in other areas of surgery, has moved away from more invasive procedures toward minimally invasive techniques. This, coupled with the desire for improved cosmetic outcomes, has been the driving force behind innovation in breast surgery over the last 30 years. The success of the skin-sparing mastectomy (SSM) has emboldened surgeons to consider procedures that preserve the nipple and areola as well. Despite the fact that nipple and areola reconstructions generally have excellent satisfaction rates, the nipple remains the cornerstone of breast identity, and evidence of the psychological importance of the nipple-areola complex (NAC) abounds.1 Furthermore, preserving the nipple has the potential to salvage nipple sensation. There is a growing body of evidence on nipple-sparing (NSM) and areola-sparing (ASM) mastectomies. Nevertheless, the topic remains controversial amid concerns about oncologic safety, and there is consensus for neither selection criteria nor technique.
The NSM was first described by Freeman in 1962, who called it the subcutaneous mastectomy. The procedure involved removal of the breast through a submammary or thoracomammary incision while preserving NAC and was recommended for recurrent chronic or subacute mastitis.2 The surgery was plagued by complications, especially flap necrosis, and was eventually abandoned.3 Of note, patients who had the surgery, which removed the breast tissue from an inferior incision, reported a delayed return of sensation to the nipple with permanent loss in many. In 1978, Freeman went on to describe an areola-sparing procedure, called a total glandular mastectomy, for patients with noninvasive cancers.4 A year later Randall et al described an "apple coring" technique for a subcutaneous mastectomy in an effort to improve oncologic safety while preserving as much of the NAC as possible.5 Despite these early efforts, the procedure was abandoned in the proceeding decades amid concerns for oncologic safety.
Central to the debate over the oncologic safety of the NSM is the anatomy of the NAC and the risk of cancer developing in remaining tissue following surgery. Anatomic studies of the areola date back to Morgagni's work in the 1719. The first thorough description was undertaken by Montgomery in 1837. He described the raised areolar prominences that bear his name and established that lactiferous ducts indeed empty into the areola. In 1980, Smith et al looked at serial sections of Montgomery's tubercles from 12 mastectomy specimens. They found that the tubercles were associated with lactiferous ducts 97% of the time.6 Of note, they found focal atypia in 2 of the tubercles and ductal carcinoma in situ (DCIS) in 1. In 1992, Schnitt et al looked at 8 mastectomy specimens performed for invasive carcinoma.7 They found mammary ducts in the areola of all 8 cases and carcinoma in 2 of them.
Obviously, the nipple contains the ducts draining the breast parenchyma and this ductal tissue ...