Staged Mastopexy or Mammaplasty Prior to Nipple-Sparing Mastectomy: A Systematic Review of Safety and Nipple-Areola Complex Outcomes

Abstract Patients with large or ptotic breasts undergoing nipple-sparing mastectomy (NSM) face reconstructive challenges, including higher risks of complications and suboptimal aesthetic outcomes. Pre-shaping procedures, such as mastopexy or reduction mammoplasty, have been proposed to optimize surgical outcomes by improving breast dimensions prior to NSM. This systematic review evaluates the safety and efficacy of these approaches. A comprehensive search of PubMed, Embase, Web of Science, and Cochrane identified studies involving pre-shaping mastopexy or reduction prior to NSM. Data on surgical technique and complications—including nipple-areola complex (NAC) necrosis, mastectomy flap necrosis, infection, hematoma, and seroma—were extracted and pooled. Fourteen studies with 322 patients and 605 breasts met inclusion criteria. The weighted mean interval between pre-shaping and NSM was 167 days. NAC complications occurred in 5.27% of cases, most commonly partial necrosis or superficial epidermolysis. Mastectomy flap complications were reported in 4.90%, and infection occurred in 9.29% of cases, primarily minor infections. Notably, the majority of included mastectomies were prophylactic, which may contribute to lower complication rates, as prophylactic cases generally carry lower risk of nipple and skin flap necrosis than therapeutic ones. Overall, pooled complication rates were comparable to those in stand-alone mastopexy, reduction, or NSM procedures. Findings suggest that pre-shaping is a safe strategy that improves aesthetic and reconstructive outcomes in NSM for large or ptotic breasts. These techniques enhance NAC positioning, reduce flap tension, and improve postoperative symmetry without significantly increasing complications. This evidence supports the use of pre-shaping procedures in surgical planning for NSM.