Complications, patient satisfaction, clinical outcomes, and aesthetic outcomes of nipple-sparing

Background: Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are widely used conservative mastectomy techniques that preserve native breast skin, with NSM additionally maintaining the nipple-areola complex (NAC). This systematic review and meta-analysis aims to compare postoperative complications, patient satisfaction, and clinical and aesthetic outcomes between NSM and SSM in breast cancer patients. Methods: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Cochrane Library, Web of Science, and the Virtual Health Library (September 9, 2025) for original studies directly comparing NSM and SSM in women with breast cancer. Two reviewers independently screened records, extracted data, and assessed quality using STROBE and CARE checklists and the ROBINS-I tool. Crude pooled incidences were calculated for postoperative complications, and quantitative analyses were conducted using odds ratios with 95% confidence intervals where at least two comparative studies reported a given outcome. Results: Twenty-one studies, including 7,032 patients (1,195 NSM; 1,671 SSM), met inclusion criteria. NSM was associated with higher odds of skin-flap necrosis than SSM (odds ratio 2.20; 95% confidence interval: 1.07-4.55), whereas rates of surgical-site infection, hematoma, seroma, venous thromboembolism, and wound dehiscence were low and generally similar between techniques. Despite more ischemic complications, NSM did not show higher rates of implant or tissue-expander loss, reconstruction failure, or radiation-associated complications. Across most studies, NSM yielded superior aesthetic outcomes, better preservation of nipple sensation, and higher scores for psychosocial well-being, breast satisfaction, and reduced postoperative regret, although SSM sometimes achieved more favorable aesthetic ratings after postmastectomy radiotherapy. Conclusions: Compared with SSM, NSM offers advantages in patient-reported and sensory outcomes at the cost of an increased odds of skin-flap necrosis and delayed wound healing, without clear differences in other major complications or oncologic safety. NSM appears best suited for carefully selected, nonsmoking patients with low body mass index and minimal breast ptosis, while SSM remains an important option for patients with larger or ptotic breasts, NAC involvement, or anticipated radiotherapy. Procedure selection should be individualized based on anatomy, oncologic factors, and patient priorities. This review may be limited by the heterogeneity and retrospective nature of the included studies. Additionally, the descriptive nature of pooled incidences and the potential for manual data extraction errors should be considered when interpreting the results.