Complications, patient satisfaction, clinical outcomes, and aesthetic outcomes of nipple-sparing vs. skin-sparing mastectomies: a systematic review and meta-analysis

Introduction

Breast cancer is the most common malignancy in women worldwide, with more than 2.3 million cases and related deaths reported in 2022 alone (1). Mastectomy remains the definitive curative therapy for breast cancer patients at the cost of aesthetics and the breast itself (2). In recent decades, nipple-sparing (NSM) and skin-sparing (SSM) mastectomies were developed to conserve as much of the nipple-areola complex (NAC) or breast skin as possible (3). These techniques aim to conserve as much of the native breast architecture without compromising oncological outcomes or patient safety (4). This systematic review serves to compare NSM and SSM in breast cancer patients to assess differences in indications, surgical techniques, complication rates, and clinical outcomes.

SSM involves the removal of breast tissue in addition to the NAC, while the NSM preserves the NAC. However, in both procedures, it is crucial that the skin flaps of the breast be prepared in a fashion to minimize blood loss and necrosis (3). This can be achieved by utilizing Cooper’s ligaments as landmarks to dissect within an avascular region of the breast (3). These conservative options have become increasingly attractive as they provide superior aesthetic outcomes and quality of life compared to complete mastectomies, while remaining efficacious and safe (5). Appropriate patient selection is critical to NSM as they are recommended for women with low BMI, small breasts, and no ptosis (6). Regarding tumor location, early-stage tumors at least 2 cm (T1) from the nipple with no involvement are ideal (3). Patient preference is also important to consider they may often prioritize reducing treatment toxicity and adverse events, even at the cost of improvements in survival (7).

Both NSM and SSM are established mastectomies that are designed to preserve native breast architecture and improve aesthetic outcomes. While NSM is suitable for patients with low BMI and small breast size, SSM is often reserved for those with larger breast volumes or tumor involvement of the nipple. The increased adoption of conservative mastectomy options highlights the need to evaluate the practical advantages and potential complications of NSM and SSM. Although sparing the NAC may improve aesthetics and quality of life, it remains to be determined whether these benefits are consistent across the literature and ultimately outweigh any differences in clinical outcomes or risk of complications (8). These risks may include nipple necrosis, infection, or asymmetries (4). By reviewing the available literature, this systematic review seeks to provide an evidence-based comparison of NSM and SSM. We aim to guide future research to help inform clinical decision-making by providing an overview of the aesthetic outcomes, quality of life, and oncological safety of these conservative mastectomies. We present this article in accordance with the PRISMA reporting checklist (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2025-1-86/rc).

Methods

Search strategy

A comprehensive literature search was performed from database inception through September 9, 2025, using four electronic databases: PubMed, Cochrane Library, Web of Science, and Virtual Health Library.

The search strategy incorporated combinations of the primary keywords “nipple-sparing mastectomy, skin-sparing mastectomy”, and “breast cancer”, along with their respective synonyms and Medical Subject Headings (MeSH) terms when available in PubMed. The complete database-specific search strings are provided in Table S1.

Two independent reviewers screened all retrieved articles by title, abstract, and full text to determine eligibility based on relevance to the research question comparing NSM versus SSM in patients with breast cancer. Any discrepancies between reviewers were resolved through discussion and consensus; when disagreement persisted, a senior author adjudicated the final decision.

Eligibility criteria

Studies were included if they met the following criteria: (I) published in English, (II) conducted in humans, (III) presented original research, and (IV) directly compared NSM and SSM within the same study population. Only studies that reported outcomes for NSM and SSM separately were included to allow direct comparison between the two techniques.

Studies were excluded if they were non-English, animal-based, reviews, or if they did not include both NSM and SSM or combined their outcomes without distinction.

Data extraction

After completion of the search and screening process, all eligible studies were imported into Zotero for organization and reference management. Data extraction was performed using a single extraction with verification approach: each reviewer independently extracted data from an assigned subset of the included studies, and the extracted data were independently verified by a second reviewer. Any discrepancies were resolved through discussion between the two reviewers, with unresolved disagreements adjudicated by the senior author. The domains for data extraction were pre-determined by the senior authors prior to the extraction process. From each included study, the following data were extracted: design, total study population, relevant population (patients meeting inclusion criteria related to NSM and SSM comparison), mean age, and breast cancer staging.

Population characteristics were defined as the specific inclusion criteria used by each study to determine patient eligibility for NSM or SSM. Outcome-related data were also extracted, including indications, contraindications, surgical technique, oncological safety, post-operative complications, NAC/skin viability, aesthetic outcomes, nipple sensation, patient quality of life, and mortality (Table S2).

Crude pooled incidence and statistical analysis

For each postoperative complication, we identified all studies that reported that outcome with extractable data for NSM and SSM. Within each technique, for a given complication, we summed the number of events across all studies that reported that complication and divided by the total number of patients undergoing that technique in those same studies. Incidence was therefore expressed as the proportion of patients experiencing the complication among all patients in that surgical group. These crude pooled incidences were descriptive and were not adjusted for potential confounders. Each complication was analyzed independently, with no pooling across complication types.

Comparative analyses between NSM and SSM were performed using Review Manager (RevMan, Cochrane Collaboration, London, UK). For outcomes reported by at least two comparative studies, we conducted meta-analyses using odds ratios (ORs) with corresponding 95% confidence intervals (CIs) to compare the odds of each complication between NSM and SSM. Study-specific ORs were pooled primarily using an inverse-variance fixed-effects model. When there was evidence of substantial heterogeneity (I²≥50% or P<0.05 for Cochran’s Q), or when outcomes were judged to be clinically heterogeneous, a random-effects model was used instead. Statistical heterogeneity was assessed with Cochran’s Q (χ²) test and quantified using the I² statistic. The overall effect size was evaluated using a Z-test, with a two-sided P value <0.05 regarded as statistically significant. Results of these meta-analyses are presented as forest plots (Figures 1-5), with values <1 favoring NSM and values >1 favoring SSM.

Figure 1 Postoperative complications following nipple-sparing and skin-sparing mastectomy. Created in BioRender. Basson M. (2026) https://BioRender.com/d5fspnk. NAC, nipple-areola complex; NSM, nipple-sparing mastectomy; SSM, skin-sparing mastectomy.

Figure 2 Infection. Forest plot comparing infection rates between NSM and SSM using a fixed-effects model with inverse variance weighting. The pooled odds ratio showed no significant difference in infection rates between NSM and SSM (OR 1.31, 95% CI: 0.57–3.00, P=0.52). No heterogeneity was observed across studies (I²=0%, Chi²=0.03, df=3, P=1.00). CI, confidence interval; IV, inverse variance; NSM, nipple-sparing mastectomy; OR, odds ratio; SSM, skin-sparing mastectomy.

Figure 3 Hematoma and seroma. Forest plots comparing (A) hematoma and (B) seroma rates between NSM and SSM. (A) Hematoma analysis using a fixed-effects model with inverse variance weighting showed no significant difference between NSM and SSM (OR 0.72, 95% CI: 0.29–1.75, P=0.47). No heterogeneity was observed (I²=0%, Chi²=0.04, df=2, P=0.98). (B) Seroma analysis using a random-effects model with inverse variance weighting showed no significant difference between NSM and SSM (OR 0.53, 95% CI: 0.02–11.63, P=0.69). Heterogeneity was not applicable due to only one study providing estimable data. CI, confidence interval; IV, inverse variance; NSM, nipple-sparing mastectomy; OR, odds ratio; SSM, skin-sparing mastectomy.

Figure 4 Implant/tissue expander loss. Forest plot comparing implant or tissue expander loss rates between NSM and SSM using a random-effects with inverse variance weighting. The pooled odds ratio showed no significant difference in implant/tissue expander loss between NSM and SSM (OR 0.47, 95% CI: 0.12–1.78, P=0.27). No heterogeneity was observed across studies (I²=0%, Chi²=1.23, df=2, P=0.54). CI, confidence interval; IV, inverse variance; NSM, nipple-sparing mastectomy; OR, odds ratio; REML, restricted maximum likelihood method; SSM, skin-sparing mastectomy; Tau², between-study variance.

Figure 5 Wound dehiscence. Forest plot comparing wound dehiscence rates between NSM and SSM using a random-effects model with inverse variance weighting. The pooled odds ratio showed no significant difference in wound dehiscence between NSM and SSM (OR 1.09, 95% CI: 0.04–30.44, P=0.96). Moderate to substantial heterogeneity was observed (I²=63%, Tau²=3.67, Chi²=2.70, df=1, P=0.10). CI, confidence interval; IV, inverse variance; NSM, nipple-sparing mastectomy; OR, odds ratio; REML, restricted maximum likelihood method; SSM, skin-sparing mastectomy; Tau², between-study variance.

Certainty of evidence assessment

The certainty of evidence for each outcome was assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework (9). Certainty was evaluated across five domains: risk of bias, imprecision, inconsistency, indirectness, and publication bias.

Quality assessment and risk of bias

Reporting quality for each included study was assessed according to the Enhancing Quality and Transparency of Health Research (EQUATOR) guidelines based on study design. Observational studies were evaluated using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist, while case series were assessed using the CARE (Case Report) guidelines.

Risk of bias was assessed independently of reporting quality by two reviewers. For retrospective observational studies, bias was evaluated using the Cochrane ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) tool, which examines seven bias domains, including confounding, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and selective reporting. Studies were classified as having low, moderate, or high risk of bias.

Results

Search strategy

The initial database search yielded 1,014 records. After removal of 314 duplicates, 700 unique studies remained for screening. Following title and abstract review, 371 articles were selected for full-text assessment (table available at https://cdn.amegroups.cn/static/public/tbcr-2025-1-86-1.docx). Of these, 21 studies met all inclusion criteria and were included in the final qualitative synthesis (4,10-29) (Figure 6).

Figure 6 PRISMA flow diagram for study selection. NSM, nipple-sparing mastectomy; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SSM, skin-sparing mastectomy.

Characteristics and demographics

Twenty one studies, published between 2009 (18) and 2025 (4), were included in the analysis. Among these, nineteen were observational studies (4,10-22,25-29), and two were case series (23,24). Across all included studies, the combined study population comprised 7,032 patients, including 1,195 undergoing NSM and 1,671 undergoing SSM.

The smallest cohort included 1 NSM and 4 SSM patients (24), while the largest included 558 NSM and 477 SSM patients (15). The mean or median age of patients undergoing NSM ranged from 39.0 to 51.2 years, with an overall mean of 45.6 years, while for SSM, the mean age ranged from 40.0 to 55.0 years, with an overall mean of 47.6 years.

The lowest mean or median age for NSM was 39.0±9 years (12), and the highest was 51.2±10.2 years (13). For SSM, the lowest mean age was 40.0±7 years (12), and the highest was 55.0±14.5 years (26).

Twenty studies reported staging information (4,10,12-18,20,21,23-30). Among studies reporting Stage 0/DCIS, proportions ranged from 12.5% to 23.3% for NSM (21,26,27) and 8.5% to 22.2% for SSM (21,26,27). For Stage I disease, NSM ranged from 35.0% to 56.8% (13,14,21,26) while SSM ranged from 28.8% to 51.53% (13,14,21,26). Stage II disease was reported in 21.3% to 36.2% of NSM patients (14,21) and 31.0% to 36.4% of SSM patients (14,21). Stage III disease comprised 5.3% to 11.2% of NSM cases (14,18,21) and 2.0% to 22.9% of SSM cases (18,26). Stage IV disease was reported in four studies, ranging from 0% to 2.4% for NSM and 0% to 3.4% for SSM (14,26). One study focused specifically on locally advanced disease, with 71.8% of patients being node-positive (15) (Table 1).

Quantitative analysis

Among the outcomes formally analyzed across multiple studies, skin flap necrosis was the only complication to demonstrate a statistically significant difference: NSM was associated with significantly higher odds compared to SSM (OR 2.20, 95% CI: 1.07–4.55, P=0.03). No statistically significant differences were observed for surgical site infection (OR 1.31, 95% CI: 0.57–3.00, P=0.52), hematoma (OR 0.72, 95% CI: 0.29–1.75, P=0.47), seroma (OR 0.53, 95% CI: 0.02–11.63, P=0.69), implant or tissue expander loss (OR 0.47, 95% CI: 0.12–1.78, P=0.27), or wound dehiscence (OR 1.09, 95% CI: 0.04–30.44). For outcomes reported by a single study, no statistically significant differences were identified for venous thromboembolism (VTE) (OR 0.42, 95% CI: 0.14–1.29), delayed wound healing (OR 2.27, 95% CI: 1.03–5.02), radiation-associated complications (OR 1.03, 95% CI: 0.33–3.21), or reconstruction failure (OR 0.11, 95% CI: 0.01–2.00). NAC/nipple necrosis was reported in NSM patients only and could not be compared to SSM, with an incidence rate of 10.8% (73/678 patients). Postoperative complications were additionally classified using the Clavien-Dindo (CD) classification system to standardize severity grading across studies (Table 2). The certainty of evidence for each outcome was assessed using the GRADE framework. Because all included studies were observational and non-randomized, the baseline certainty started at Low and was further downgraded based on risk of bias, imprecision, inconsistency, indirectness, and publication bias where applicable (Table 3).

Quality assessment and risk of bias

Two independent reviewers assessed the quality and risk of bias for all 21 included studies. The 19 cohort studies were evaluated using the STROBE guideline (Table 4) and the ROBINS-I tool (Table 5), and the 2 case series were assessed using the CARE guidelines (Table S3).

Discussion

Applications of conservative mastectomies

Although conservative mastectomies have historically been reserved for prophylactic applications, recent advances in their safety profiles and techniques have resulted in their growing utilization as an alternative to traditional mastectomies (40,41). NSM and SSM are both considered to be conservative mastectomies, yet they vary in their specific patient population. The following outlines the indications and contraindications of NSM and SSM.

NSM indications and contraindications

For the purposes of NSM, it is crucial that the blood supply to the NAC is not compromised to minimize the risk of postoperative necrosis (42). For this reason, ideal NSM candidates include non-smoking patients with a BMI <30 kg/m², a breast cup size of A or B, and little to no breast ptosis (6). Excessive breast ptosis or high BMI may lengthen the distance of the skin flap between the thoracic wall and the NAC, thereby increasing the risk of necrosis following surgery (43,44). Smoking also predisposes patients to NAC necrosis, as cigarette smoking is strongly associated with vascular endothelial dysfunction and thus increased risk of ischemia (45). These indications reflect the considerably delicate nature of the NAC and its associated plexuses, which have been characterized as poorly vascularized, further illustrating the NAC’s susceptibility to ischemia and necrosis (46).

Indications for NSM include any carcinoma or ductal carcinoma in situ (DCIS) no less than 2 cm from the NAC (47). Absolute contraindications include tumor involvement of the nipple, positive tumor margins, and microcalcifications near the subareolar region, which may increase the risk of tumor recurrence (3,6). Inflammatory breast cancer is also a relevant contraindication as it includes involvement of the skin and lymphatics of the affected tissue; as such, preserving any breast tissue would be deemed an oncological risk in this patient population (48).

SSM indications and contraindications

SSM is commonly indicated for patients who are ineligible for NSM due to tumor involvement of NAC or large breast volume and excessive ptosis (3). Indications for SSM include patients requiring mastectomy for DCIS, stage I-II infiltrating breast cancer, or tumor recurrence following previous treatment (49). Similar to NSM, contraindications for SSM include patients with inflammatory breast cancer, advanced or late-stage carcinoma, and smoking (49).

Surgical techniques for nipple-sparing mastectomies

The defining technical challenge of NSM is the “coring” of tissue within the nipple papillae, which involves elevation of the areola and removal of the ductal bundle (50). The nipple must also be everted to accomplish successful dissection, leaving a rim of tissue at the base of the ducts no thicker than 2–3 mm (50). Frozen retro-areolar biopsies should be taken intraoperatively to be evaluated for carcinoma. If the sample tests positive, the NAC must be removed (42).

Regarding incision placement, common approaches may include inframammary fold (IMF), radial, or peri-areolar incisions (51). Radial and peri-areolar incisions involve a lateral incision that extends to the axilla, with the latter of the two including portions of the areola (52). Unlike radial or peri-areolar incisions, the IMF incision achieves breast access from the lower outer arc of the breast area (52). A review of over 290 NSM cases found that peri-areolar incisions are associated with an increased incidence of NAC necrosis and post-operative complications (52) (Figure 7). The success of such a technically demanding procedure may be influenced by physician comfort. Specialized training in NSM, especially for advanced endoscopic techniques, can help increase technical confidence and attenuate the steep learning curve of such a procedure (53).

Figure 7 Incision patterns and classification schemes for nipple-sparing and skin-sparing mastectomy. Created in BioRender. Basson M. (2026) https://BioRender.com/imd9nvm.

Surgical techniques for skin-sparing mastectomies

Similar to NSM, techniques for SSM may also involve several approaches for incision placement. There are five classifications of SSM: type I employs a circular peri-areolar incision, type II utilizes a similar incision with the addition of lateral or medial extension, type III is characterized by additional incisions to remove pre-existing biopsy scars, type IV utilizes a wide elliptical excision reserved for ptotic breasts, and type V involves resection of the chest wall with an “inverted T” pattern, also intended for ptotic breasts (54).

As a result of these incisions, a central aperture is essentially created, which allows for the breast flaps to be visualized and the mastectomy to be performed (49). Since the NAC complex is excised in this approach, one advantage of SSM is the removal of tissue at risk for necrosis (55). Following a mastectomy, the breast must be reconstructed. This involves filling the resulting skin envelope and closure of the aperture with transverse rectus abdominus muscle flaps, implants, and anatomical expanders (54) (Figure 7).

Postoperative complications quantitative analysis

Necrosis of the NAC or skin flap

Of all the reported adverse events, necrosis is the most significant complication of conservative mastectomies. Necrosis of the skin or flap can apply to both NSM and SSM, while NAC necrosis is naturally exclusive to NSM. In the eight studies that reported NAC or nipple necrosis, 73 of 678 (10.77%) NSM cases reported this complication (4,14,19-21,23,25,29). Furthermore, skin flap necrosis was reported in 26 of 456 (5.7%) NSM and 40 of 574 (2.6%) SSM cases (OR: 2.20; 95% CI: 1.07–4.55; P=0.03) (4,12,14,17,20,29) (Figure 8).

Figure 8 Skin flap necrosis. Forest plot comparing skin flap necrosis rates between NSM and SSM using a fixed-effects model with inverse variance weighting. The pooled odds ratio demonstrates significantly higher odds of skin flap necrosis in NSM compared to SSM (OR 2.20, 95% CI: 1.07–4.55, P=0.03). Heterogeneity was low to moderate (I²=39%, Chi²=6.53, df=4, P=0.16). CI, confidence interval; IV, inverse variance; NSM, nipple-sparing mastectomy; OR, odds ratio; SSM, skin-sparing mastectomy.

These findings suggest that NSM carries more than a two-fold increase in the odds of skin flap necrosis compared to SSM. The difficulty in maintaining adequate perfusion during the NSM procedure is likely attributable to several factors, including incisions exceeding 30% of the areolar circumference and insufficient thickness of the resulting peripheral rim, which preserves less of the native NAC, and thus, may predispose patients to post-operative necrosis (42,56).

Necrosis is more common in patients with higher mastectomy specimen weight, high BMI, diabetes, smoking, prior radiation, and more extensive skin-reducing patterns in NSM/SSM cohorts with immediate reconstruction (57-59). Techniques that better preserve microvascular perfusion, including tumescent infiltration with sharp dissection instead of routine electrocautery in NSM, and minimal-access NSM with standardized tumescent sharp dissection, have been shown to significantly reduce rates of partial and full-thickness skin-flap necrosis and other early complications (60,61). Additional device-related strategies, such as the use of bipolar scissors and vessel sealing systems in NSM and SSM, have been shown to shorten operative time, reduce intraoperative bleeding and drainage, and lower the rate of postoperative complications, supporting their role as perfusion-sparing instruments (31,62). In the NSM and SSM studies that reported management, skin-flap necrosis was treated with surgical debridement or resection in the operating room; accordingly, skin-flap necrosis is classified as a Clavien-Dindo 3B complication (Figure 1).

Surgical site infections

Postoperative infections are a significant adverse event following any surgical procedure and may necessitate the removal of implanted prostheses. Five of the reviewed studies evaluated surgical site infections, revealing a 31% increased odds of surgical site infections associated with NSM (OR: 1.31; 95% CI: 0.57–3.00; P=0.52) (4,12,14,17,29) (Figure 2). Although not statistically significant, this observed trend may be due to necrotic tissue serving as a risk factor for developing wound site infection, since NSM was found to be associated with a more than two-fold increase in skin flap necrosis (63). Although a significant increase in infection rate was not associated with NSM despite higher rates of skin flap necrosis, this complication should be further investigated with larger cohort analyses to fully characterize the extent of postoperative infection risk with these conservative mastectomies.

In the NSM series with immediate implant-based reconstruction, higher BMI, active smoking, preoperative radiotherapy, and peri-areolar incisions have been identified as important risk factors for postoperative complications, including infection (64,65). Broader implant-based breast reconstruction literature likewise highlights smoking, obesity, large breast size, and adjuvant radiotherapy or chemotherapy as modifiable risk factors for infection and emphasizes preoperative optimization of these factors (66). To mitigate infection risk, recommended strategies focus on perioperative prophylactic antibiotics with adequate coverage of skin flora and on optimization of modifiable patient factors such as preoperative smoking cessation, weight management, and careful planning of radiotherapy (35,66). In the NSM and SSM studies included in our review, infections were managed with systemic antibiotics alone or with operative implant removal, corresponding to Clavien-Dindo 2-3B complications (Figure 1).

Hematoma and seroma

Fluid collections such as hematomas and seromas may accumulate postoperatively, preventing adequate adhesion to the chest wall and thereby compromising flap viability (67). Hematomas and seromas were evaluated between the NSM and SSM cohorts across four (12,14,17,29) and two (17,29) studies, respectively. Regarding hematomas, it was found that 6/275 (2.18%) and 17/447 (3.80%) cases of NSM and SSM reported this complication, respectively (OR: 0.72; 95% CI: 0.29–1.75; P=0.47) (Figure 3A). Furthermore, none of the 63 NSM cases reported any incidences of seroma, while 2/68 (2.94%) of the SSM cases were found with this complication (OR: 0.53; 95% CI: 0.02–11.63; P=0.69) (Figure 3B).

While the overall incidence rates of hematoma and seroma were marginal, the resection of larger volumes of breast tissue during SSM procedures may increase the likelihood of lymphatic channel disruption, thereby enabling postoperative fluid collection (68).

Hematoma and seroma were uncommon but clinically meaningful early complications after NSM and SSM. Identified risk factors for seroma in breast surgeries, including mastectomies, include age, smoking, implant reconstruction, axillary lymph node dissection, and prior radiation (69). In studies that reported management, these fluid collections were of sufficient volume to require return to the operating room for evacuation or washout. Tranexamic acid has been investigated in patients undergoing SSM and NSM with immediate reconstruction to reduce perioperative bleeding and postoperative drain output (32), while flap fixation sutures that close the mastectomy dead space have been shown to decrease seroma formation and its sequelae (37). These strategies may therefore help mitigate the risk and severity of hematoma and seroma after NSM and SSM. On this basis, hematoma and seroma in our review are classified as Clavien-Dindo 3B complications (Figure 1).

Prosthesis loss

Breast implants, such as silicone and saline implants, in addition to tissue expanders, are commonly deployed prostheses following mastectomy (70,71). Loss of a prosthetic device is an undesirable outcome for any breast reconstruction or mastectomy, and signifies procedural failure given the primary outcomes of these procedures. Among the three studies that assessed implant or tissue expander loss, 2/88 (2.27%) and 14/167 (8.38%) of NSM and SSM cases resulted in prosthetic failure (OR: 0.47; 95% CI: 0.12–1.78; P=0.27) (12,22,25) (Figure 4).

Although not statistically significant, this trend suggests that SSM patients may be at increased risk of prosthesis loss relative to NSM, despite lower rates of skin flap necrosis and delayed wound healing. Prosthetic device loss represents one of the most severe complications after NSM and SSM with immediate prosthetic reconstruction. Post-mastectomy radiotherapy has repeatedly been associated with increased rates of implant exposure, capsular contracture, and reconstruction failure in patients undergoing SSM or NSM with implant-based reconstruction, identifying it as a major risk factor in this setting (72-74). Smoking also independently increases the risk of major complications and device loss after immediate implant reconstruction, supporting perioperative smoking cessation as a key mitigation strategy (34). Since prosthesis loss invariably requires operative removal or replacement of the device under general anesthesia, it is classified as a Clavien-Dindo 3B complication (Figure 1).

Wound dehiscence

Wound dehiscence following mastectomy was observed in 2/75 (2.67%) and 2/68 (2.94%) of NSM and SSM cases, respectively (OR: 1.09; 95% CI: 0.04–30.44; P=0.96) (4,12) (Figure 5). The rates of wound dehiscence were comparable between NSM and SSM, with no significant difference observed between the two mastectomy types. Although varying incisions are used in NSM and SSM, they both employ the use of implants or expanders during subsequent breast reconstruction, which may put additional stress on the wound site, potentially leading to complications like wound dehiscence, irrespective of mastectomy type (75).

Wound dehiscence commonly occurs at high-tension junctions such as Wise- or tennis-racquet-pattern closures. Higher BMI, increased breast weight, and greater sternal-notch-to-nipple distance have been associated with higher rates of flap-related wound dehiscence and necrosis following SSM with immediate reconstruction (39). Noninfectious wound-complication data from large mastectomy cohorts show that dehiscence frequently requires surgical wound care (76). Incision planning to avoid high-tension patterns in large or ptotic breasts and the use of closed-incision negative pressure therapy in high-risk oncologic breast and reconstruction patients have been reported to reduce overall surgical-site complications, including dehiscence (77-79). Small separations treated with local dressings alone correspond to CD1; dehiscence treated with oral or intravenous antibiotics or negative-pressure wound therapy corresponds to CD2; and dehiscence requiring surgical debridement or reclosure without general anesthesia corresponds to CD3A. Accordingly, wound dehiscence is classified as a Clavien-Dindo 1-3A complication (Figure 1).

VTE

VTE was reported in 4/195 (2.05%) and 16/340 (4.71%) of NSM and SSM cases (14). Although only reported in one study, there appeared to be no notable difference in VTE incidence between NSM and SSM. This finding is to be expected, as the risk of developing VTE is known to be increased during any period of surgical recovery, as patients are in a hypercoagulable state, which can be further heightened by longer operation times (80).

The risk of VTE following NSM and SSM is increased in patients undergoing SSM or NSM with immediate reconstruction, prolonged operative time (>4 hours), higher BMI, recent surgery, and longer hospital stay (38,81,82). Risk-reduction strategies include Caprini-based risk stratification, routine mechanical prophylaxis with sequential compression devices and early ambulation for most mastectomy patients, and pharmacologic prophylaxis with low-molecular-weight heparin for higher-risk patients or those undergoing mastectomy with immediate reconstruction (82). Standard management consists of systemic anticoagulation without routine surgical intervention; therefore, based on the breast-surgery literature, VTE is classified as a Clavien-Dindo 2 complication (38,81) (Figure 1).

Delayed wound healing

A delay in wound healing may present as prolonged scar formation or incomplete closure at the incision site, which can predispose the surgical wound to subsequent infection. One study reported delayed wound healing and found that 18/55 (32.73%) and 15/85 (17.65%) of NSM and SSM cases presented with this complication, respectively (22). These findings are consistent with the previously discussed incidence rates of skin flap necrosis, reinforcing the notion that NSM is associated with an increased risk of ischemia, which may manifest as postoperative delays in wound healing. It has been well described that inadequate perfusion may increase the burden of oxidative stress as a result of prolonged inflammation, further contributing to tissue damage, which can delay wound healing (83). Delayed wound healing reflects wound disruption, necrosis of the skin flap or NAC, or ulceration, often in areas where perfusion is already limited. This risk is heightened when the tumor lies close to the NAC or skin envelope, necessitating more aggressive dissection around the nipple or very thin mastectomy flaps that further compromise microvascular supply (22).

Low-dose topical nitroglycerin ointment applied to the mastectomy skin flaps has been shown in NSM/SSM cohorts to significantly reduce rates of skin-flap necrosis without increasing systemic side effects, and multiple studies in immediate breast reconstruction and mastectomy flaps more broadly support nitroglycerin as an effective adjunct to improve flap survival and reduce full-thickness necrosis (33,84,85). Accordingly, minor delays in epithelialization managed with local wound care alone correspond to Clavien-Dindo 1, wounds requiring pharmacologic therapy such as topical or oral agents correspond to Clavien-Dindo 2, and more extensive necrosis requiring surgical debridement or revision under general anesthesia correspond to Clavien-Dindo 3B (22), such that delayed wound healing ranges from Clavien-Dindo 1-3B (Figure 1).

Radiation associated complications

Radiation-associated complications occurred in 12/31 (38.71%) and 8/21 (38.1%) NSM and SSM cases, respectively (15). This finding suggests that preservation of the NAC following NSM procedures does not appear to act as an independent risk factor for complications following subsequent radiation. These findings are reflected by the findings of a study that found no significant differences in complication rates between NSM and SSM cohorts following post-mastectomy radiotherapy (12) (Figure 1).

Reconstruction failure

Reconstruction failure was not reported in any of the 55 NSM cases, but was found in 6/85 (7.06%) of the SSM cases (22). Although NSM was associated with significantly increased odds of skin flap necrosis, this did not necessarily translate to total reconstructive failure. This may be attributed to the extent and nature of the observed necrosis, as partial necrosis has consistently been reported more frequently than total necrosis in studies evaluating complications following NSM (19,44). This suggests that the extent of necrosis typically observed following NSM is not severe enough to result in postoperative breast reconstruction failure.

Aesthetic outcomes

Seven studies from the reviewed literature assessed post-operative aesthetic outcomes of both NSM and SSM (4,10,12,18,22,24,27). Although two studies found no difference between NSM and SSM (18,22), when evaluating BREAST-Q scores, overall aesthetics, and scar appearance, patient satisfaction was found to be higher in those having undergone NSM (4,86). Furthermore, a case series utilizing objective evaluations of breast contour with 3D surface imaging found higher symmetry scores in NSM patients when compared to SSM (24).

These findings, however, are reversed in the context of post-mastectomy radiation, where SSM was found to yield higher scores in blinded aesthetic ratings following radiation (12). This may be due to the removal of the NAC, permitting more precise adjustments to overall breast symmetry following the onset of radiation-induced fibrosis (12). Finally, SSM was found to score higher on investigator-generated questionnaires assessing appearance satisfaction, which may be explained by the nature of the NSM cohort, which included younger, premenopausal patients, with lower exposure to radiation and chemotherapy (27). Such a cohort may experience much more dramatic, and thus unpleasant, changes in their breast aesthetics and even function following NSM, which may not be as drastic as a change in the older SSM cohort, which was also included more postmenopausal females (27).

Nipple sensation

Review of patient satisfaction with sensory outcomes following NSM revealed retention of nipple sensation and light touch preservation, specifically in the upper medial and lower lateral quadrants (11,16). Furthermore, when the NAC was reconstructed in SSM patients, nipple sensitivity was still found to be higher in the NSM cohort (22). This may be explained by the fact that although the NAC is eventually reconstructed, the nerves providing nipple sensation have been severed during the SSM procedure along with the NAC, leading to diminished nipple sensation (54).

These findings, however, do not always translate to patient satisfaction, as a majority of NSM patients in a study were unsatisfied with nipple sensitivity despite its preservation (29). This phenomenon demonstrates that although retained, nipple sensation was ultimately impaired and essentially altered from before the operation (29).

Patient well-being and quality of life

Studies utilizing the BREAST-Q questionnaire found that NSM patients reported higher scores of psychosocial well-being and lower levels of postoperative regret (4,22,29). Additionally, a study utilizing an institutional breast reconstruction satisfaction questionnaire reported higher self-confidence and sexual attraction scores in the NSM cohort when compared to the SSM (10). These findings underscore the impact of nipple preservation on the overall psychological recovery and perception of body image that can be achieved with NSM, which may be a relevant factor to consider for patients assessing mastectomy options.

Limitations

This study is not without its limitations. It is important to consider the heterogeneity of the study populations and studies included in this review, as they must not be presumed to be identical demographics. As discussed previously, the ideal NSM patient is one with a low BMI and minimally ptotic breasts. Furthermore, it is not uncommon for patients to undergo SSM for not meeting the inclusion criteria for NSM, which may result in the real-world population of the two cohorts varying significantly. Additionally, almost all included studies within this review are observational and retrospective, which inhibits our ability to determine the absolute causality of our results. Variable definitions and operationalization across institutions may vary widely across the reviewed studies, which should be considered. Also, the crude pooled incidences are descriptive summaries only, with no inferential statistics applied, and should not be interpreted as formally pooled effect estimates given variability in follow-up, baseline risk factors, and outcome definitions across studies. Subgroup and sensitivity analyses were not feasible given the limited number of studies and patients per individual complication outcome. Finally, the potential for human error during study screening and subsequent data extraction must be acknowledged, as these manual tasks are susceptible to potential oversight.

Conclusions

This systematic review aimed to assess the oncological outcomes, safety profiles, and quality of life of NSM and SSM to help guide clinical decision-making and future study directions. It was found that NSM offers favorable patient outcomes and satisfaction with the risk of ischemic complications due to challenges in the preservation of NAC vasculature. NSM is best suited for non-smoking patients with low BMIs and minimal breast ptosis who would like to maintain their breast aesthetics and natural body image. SSM remains a robust standard in conservative mastectomy, indicated for patients with greater breast volume and ptosis or those requiring radiation post-mastectomy. Although the NAC is not preserved in SSM, it is associated with lower rates of skin flap necrosis and may still achieve satisfactory aesthetic results given the capabilities of modern breast reconstruction techniques. Selection of conservative mastectomies should be individualized from patient to patient, depending on indications, patient preferences, and relevant risk factors that may complicate clinical outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2025-1-86/rc

Peer Review File: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2025-1-86/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-2025-1-86/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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