Breast cancer surgeons are cautious about offering nipple-sparing mastectomies to women who have had breast radiation. Radiation damages the skin, making it more prone to infection, scarring, and fibrosis, so surgeons generally opt for the safer strategy of skin-sparing mastectomy.

However, with reassuring data on oncologic outcomes, nipple-sparing mastectomy after breast radiation is becoming more widely accepted, said Anastasia Tousimis, MD, breast surgical oncologist and expert in the technique at Baptist Health South Florida in Miami.

Tousimis shared her insights with Medscape Medical News after her presentation on the topic at the Miami Breast Cancer Conference 2026. The following Q&A has been edited for clarity and length.

If it’s riskier, why offer nipple-sparing mastectomy after breast radiation?

A lot of patients will request it because they want to save their nipple, [and] they’re willing to take the risk for a higher complication rate for that trade-off. It also depends on age. The older patient may say, “I already had my kids, I breastfed, the nipple’s not important to me.” But for younger patients especially, saving the nipple is part of their body image.

We did a survey of women who had previous radiation and underwent nipple-sparing mastectomy. The survey results showed that even if their nipple was a little bit uneven or they had some scarring and it wasn’t completely perfect, they were just happy keeping as much of their body as possible.

Also, aesthetically, saving the nipple is much better than removing and reconstructing it. Reconstructed nipples look good, but they never look as good as your natural nipple.

However, when you save the nipple in a radiated breast, there’s a chance of a side effect called a high-riding nipple, where over time it can rise unevenly compared with the other side. So it’s very important patients understand that complication rates are higher and that a second surgery for revision to make them more symmetrical may be necessary.

Which patients are not appropriate candidates?

If the nipple is below the bra line, the patient is not a good candidate because the nipple is going to be in the wrong place after surgery.

Active smoking is a contraindication. Nicotine causes vasoconstriction, which decreases blood flow to the skin and increases the risk for ischemia and skin necrosis. Most surgeons will require patients to stop smoking for at least a month before surgery.

How do you increase the likelihood of success?

The most important thing is to save the blood flow to the skin to prevent the skin from dying after surgery. The second intercostal perforator provides the largest blood flow to the chest wall skin. As surgeons, we do everything we can to save that blood vessel and the venous plexus. [The same is true] with skin-sparing mastectomy, but with nipple-sparing, you have more tissue that you're saving, so it’s even more important to preserve that vasculature.

Most of the time, the surgeon does the incision at the bra line to keep the incision as far from the nipple as possible. If you place it near the nipple, the nipple can pull toward the scar. Bra-line incisions are also hidden and cosmetically look better.

A longer incision — 13 cm vs 10 cm — helps get better exposure and reduces tension on the skin, so you don’t get skin necrosis or ischemia.

We also try to be as gentle as possible with the tissues, with the least amount of retraction and manipulation of the nipple to preserve blood flow.

We usually do immediate reconstruction.

The choice between free-flap and implant reconstruction depends on the patient’s body habitus and comorbidities. If a patient is healthy and has enough abdominal fat, they may be a good candidate for flap reconstruction. Using [a patient’s] own tissue looks and feels more natural, but it’s a longer surgery with a longer recovery. It also involves a second scar on the abdomen.

Implant reconstruction may not look or feel as natural, and there’s a higher risk for capsular contracture and implant rippling. But a lot of women favor implant reconstruction because it’s a shorter surgery with a faster recovery. For revisions, the plastic surgeon may try to lower the nipple or use fat injections with liposuction from the abdomen to remove rippling around the implant.

What does preoperative planning involve?

It’s very important to collaborate preoperatively with the radiologist to review all the films to make sure the cancer is not near the nipple or the skin and to coordinate with the plastic surgeon about the type of reconstruction they’re doing, the surgical approach, and the type of incision in order to ensure the best surgical outcome and to prevent the nipple from high-riding.

Tousimis is an advisor for Axogen and Aveta Biomics.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Alex is also an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com