Primary Nipple-Repositioning Surgery Before Nipple-sparing Mastectomy in Large or Ptotic Breasts: A Multicenter Cohort Analysis.

Background: Nipple-sparing mastectomy (NSM) after nipple-repositioning surgery (mastopexy or breast reduction) is increasingly used in patients with large or ptotic breasts to improve vascularity to the nipple-areolar complex (NAC) and decrease the risk of necrosis. This systematic review aimed to evaluate the safety and optimal timing of this approach. Methods: Preferred reporting items of systematic reviews and meta-analyses guidelines were followed. PubMed, Scopus, and Web of Science databases were searched on February 24, 2024. All observational studies reporting complication outcomes and/or timing between staged NSM after breast reduction or mastopexy were included. Results: Thirteen studies met the inclusion criteria, with a combined sample of 591 breasts. The incidence of partial and complete NAC necrosis across the 13 studies was 4.06% (24 of 591), whereas skin flap necrosis occurred in 15 out of 591 breasts (2.54%), as reported in 8 studies. The mean follow-up time was 436.35 days, and the mean interval between mastopexy and NSM was 288.2 days. A correlation was observed between longer intervals and lower rates of skin flap necrosis and NAC necrosis; subgroup analysis for intervals greater than 5 months showed only 1 case of complete NAC necrosis across the combined sample of all studies. Conclusions: Although data suggest that a 4- to 6-month interval may minimize complications, further research with larger sample sizes, longer follow-up times, and randomized controlled trials comparing staged and nonstaged approaches is necessary to establish definitive guidelines, especially with regard to high-risk patients requiring radiotherapy or undergoing therapeutic rather than prophylactic NSM.