title: Delay techniques for nipple-sparing mastectomy: A systematic review.
abstract: BACKGROUND
  Rare but serious complications of nipple-sparing mastectomy (NSM) include necrosis of the nipple-areolar complex (NAC) and mastectomy skin flaps. NAC and mastectomy flap delay procedures are novel techniques designed to avoid these complications and may be combined with retroareolar biopsy as a first-stage procedure. We performed a systematic review of the literature to evaluate various techniques for NAC and mastectomy flap delay.
  
  
  METHODS
  PubMed and Cochrane databases were searched from January 1975 through April 15, 2016. The following search terms were used for both titles and key words: 'nipple sparing mastectomy' AND ('delay' OR 'stage' OR 'staged'). Two independent reviewers determined the study eligibility, only accepting studies involving patients who underwent a delay procedure prior to NSM and studies with objective results including specific outcomes of NAC and mastectomy flap necrosis.
  
  
  RESULTS
  The literature search yielded 242 studies, of which five studies met the inclusion criteria, with a total of 101 patients. Various techniques for NSM delay have been described, all of which involve undermining the nipple and surrounding mastectomy skin to some degree. Partial NAC necrosis was reported in a total of 9 patients (8.9%). Mastectomy flap necrosis was reported in a total of 8 patients (7.9%). Three of five studies reported positive retroareolar biopsy findings in a total of 7 patients (6.9%).
  
  
  CONCLUSIONS
  Delay procedures for NSM have a good safety profile and may be considered in patients at risk for NAC or mastectomy flap necrosis, such as patients with pre-existing breast scars, active smoking, prior radiation, or ptosis. These procedures have the added benefit of allowing a retroareolar biopsy to be sent for permanent sections prior to mastectomy, allowing the surgical team to plan for the removal of the NAC at the time of mastectomy if indicated and eliminating the risk of a false-negative result on frozen section analysis.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA. Electronic address: laurel.karian@gmail.com.
authors.forename: Laurel S
authors.initials: LS
authors.lastname: Karian
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Therattil
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
authors.forename: Philip D
authors.initials: PD
authors.lastname: Wey
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
authors.forename: Kevin T
authors.initials: KT
authors.lastname: Nini
mesh_terms: D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D015414:Mastectomy, Subcutaneous / Q000379:methods*; D009558:Nipples / Q000601:surgery*; D013524:Surgical Flaps
keywords: Breast reconstruction; Delay phenomenon; Nipple-areola perfusion; Nipple–areola complex-sparing mastectomy