Determinants of Nipple–Areola Complex Reconstruction After Breast Reconstruction: A Preference-Sensitive Decision Rather Than a Predictable Final Step

Background Nipple–areola complex reconstruction (NACR) is commonly regarded as the final stage of breast reconstruction, yet a substantial proportion of patients do not pursue NACR despite technically successful breast mound reconstruction. The factors influencing this decision remain incompletely understood. Methods This retrospective cohort study included patients who underwent skin-sparing mastectomy followed by immediate breast reconstruction at a single university-affiliated hospital between January 2020 and December 2024, with a minimum postoperative follow-up of 12 months. Clinical and treatment-related factors associated with the decision to undergo NACR were analyzed using Firth penalized logistic regression. Results Among 57 eligible patients, 19 (33.3%) underwent NACR. Increasing age (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.65–0.89; p = 0.001), receipt of adjuvant radiotherapy (adjusted OR, 0.02; 95% CI, 0.00–0.33; p = 0.006), and postoperative complications (adjusted OR, 0.03; 95% CI, 0.00–0.37; p = 0.007) were independently associated with a decreased likelihood of NACR. The primary model demonstrated good apparent discrimination (AUROC, 0.939; 95% CI, 0.848–1.000). Reconstruction modality, patient-reported aesthetic satisfaction, and follow-up duration were not independently associated with NACR. Conclusion Cumulative treatment burden and postoperative recovery experiences, rather than reconstructive technique or satisfaction, appear to shape patient decisions regarding NACR, supporting its conceptualization as a preference-sensitive decision within the broader context of survivorship. Given the small sample, the model performance reflects apparent performance and should be regarded as exploratory and hypothesis-generating. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .