The Use of Neoadjuvant Systemic Therapy to Facilitate Nipple-sparing Mastectomy and Immediate Reconstruction

Background: Neoadjuvant systemic therapy (NST) is a well-established strategy to convert patients initially requiring a mastectomy to breast-conserving surgery, but has not been studied for its efficacy in facilitating total skin-sparing mastectomy (TSSM) and reconstruction in patients with tumors that encroach on the skin- and/or nipple–areola complex (NAC). Methods: The author reviewed his experience from August 2010 through July 2024 with the use of NST to facilitate TSSM and the immediate implant-based reconstruction in patients who were initially not candidates for this approach because of tumor encroachment on the NAC and/or skin envelope. Results: Between 2010 and 2024, the author identified 1425 patients who underwent TSSM with immediate implant reconstructions in his surgical practice. Of these, 160 patients initially presented with disease that precluded preservation of the skin and/or NAC and underwent NST, allowing for TSSM and immediate reconstruction in 138 (86.3%) patients. Conclusions: The use of NST in patients with tumors that encroach on the NAC and/or skin envelope can be used to facilitate TSSM and reconstruction in patients who otherwise would not be candidates for this approach. Reconstructive surgeons should familiarize themselves with the principles of and indications for NST and play an active role in the multidisciplinary treatment planning of these complex patients.