Advanced techniques for mastopexy in patients with ptotic breasts requiring nipple-sparing mastectomy: a narrative review

Background and Objective: Achieving aesthetically pleasing results in patients with ptotic breasts who require nipple-sparing mastectomy (NSM) is crucial for an enhanced quality of life, however, preservation of the nipple-areola complex (NAC) introduces significant technical challenges. To address this, various surgical approaches and reconstructive timelines have been developed to expand NSM eligibility in patients with breast ptosis. This narrative review aims to synthesize current evidence on these approaches to guide surgical decision-making and patient counseling. Methods: A literature search of PubMed and Embase was conducted to identify studies describing nipple-preserving mastopexy techniques in NSM. Articles detailing surgical approaches, outcomes, and patient selection considerations were reviewed and analyzed to summarize practical guidance for each approach. Key Content and Findings: Five primary surgical strategies for NSM in ptotic breasts were identified. (I) Single-stage nipple-preserving skin-reducing mastectomy (SRM) with concomitant mastopexy and simultaneous reconstruction offers a single operation but increases technical demands. Two-stage approaches with NSM and (II) tissue expander, (III) immediate implant-based reconstruction, or (IV) flap-based reconstruction, followed by secondary mastopexy, offer greater flexibility in NAC positioning and improved vascular safety. Finally, (V) staged nipple-sparing mastectomy (SNSM) utilizes initial mastopexy to optimize nipple position and expand candidacy for NSM and concomitant reconstruction. Understanding these approaches enables tailored surgical planning based on patient anatomy, oncologic safety, and aesthetic goals. Conclusions: Multiple surgical strategies allow safe NAC preservation in patients with ptotic breasts undergoing NSM, improving aesthetic outcomes and expanding eligibility for breast reconstruction. Tailoring the approach to patient anatomy, oncologic considerations, and surgical expertise, combined with careful preoperative planning and multidisciplinary collaboration, can enhance quality of life without compromising oncologic safety.