Abstract Background: Nipple-sparing mastectomy (NSM) is increasingly utilized in breast cancer surgery due to its superior cosmetic outcomes and patient satisfaction. However, ischemic complications, particularly necrosis of the nipple-areolar complex (NAC), remain a significant concern, with reported incidence ranging from 6% to 30%. Several patient- and surgery-related factors such as large breast volume, periareolar incisions, prior breast surgery, radiation exposure, and smoking have been identified as contributors to NAC necrosis. Nipple delay (ND) is a surgical technique performed approximately 1-2 weeks prior to NSM, designed to improve NAC perfusion and reduce ischemic complications in patients considered high risk. While the efficacy of ND has been demonstrated in Western populations, there are no published studies evaluating this technique in an Asian population. To our knowledge, this is the first report from Japan to assess the impact of ND in a cohort of Japanese patients undergoing NSM with immediate autologous reconstruction. Methods: We conducted a retrospective review of patients who underwent either ND followed by NSM (ND-NSM) or NSM alone between January 2020 and March 2025 at a single high-volume breast cancer center in Japan. All patients underwent one-stage autologous breast reconstruction using abdominal flaps. ND was performed approximately 14 days prior to NSM under local or general anesthesia, using a semicircular periareolar incision and skin undermining to precondition the NAC. Baseline characteristics, including body mass index (BMI), history of breast surgery, radiation therapy, and smoking status, were collected. Surgical variables such as incision type, mastectomy specimen weight, and postoperative complications were analyzed. NAC necrosis was graded by severity, and statistical comparisons were performed using Fisher’s exact test or Mann-Whitney U test, as appropriate. Results: A total of 100 patients were included, with 31 in the ND-NSM group and 69 in the NSM-only group. There were no significant differences between the two groups in terms of BMI, prior breast surgery, radiation exposure, or smoking history. The ND-NSM group had a significantly higher frequency of periareolar incisions (73.5% vs. 33.3%, p 0.01) and larger mastectomy weights (median 350g vs. 275g, p = 0.02), indicating higher surgical risk. The overall incidence of NAC necrosis did not differ significantly between groups (22.6% in ND-NSM vs. 23.2% in NSM-only). However, when stratified by necrosis grade, the ND-NSM group demonstrated a significantly lower rate of grade ≥2 necrosis (p = 0.0276). Importantly, no cases of grade ≥2 necrosis were observed in the ND group. Other complications such as skin necrosis, infection, thrombosis, and flap-related events were similar between groups. Conclusion: Despite higher-risk features, the ND-NSM group showed a markedly reduced severity of NAC necrosis. Our findings suggest that the nipple delay procedure may allow patients with traditionally high-risk characteristics to safely undergo NSM with complication rates comparable to lower-risk patients. This is the first study from Japan to evaluate the clinical utility of ND, and our results indicate that this approach is both feasible and beneficial in the Japanese population. ND should be considered a valuable adjunct to NSM in patients at elevated risk for ischemic complications, particularly when immediate autologous reconstruction is planned. Citation Format: K. Matsui, S. Nagasawa, E. Kanaya, M. Araki, S. Sekine, T. Fujii. Nipple Delay Improves Nipple-Areolar Complex Viability in High-Risk NSM Patients abstract. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS2-03-01.
Matsui et al. (Tue,) studied this question.