Reduction Mammaplasty Prior to Nipple-Sparing Mastectomy Is Associated With Decreased Ischemic Complications in Large-Breasted Patients

BACKGROUND: Nipple-sparing mastectomy (NSM) improves aesthetic outcomes but carries a higher risk of ischemic complications, particularly in patients with large, ptotic breasts. This study evaluates whether reduction mammaplasty prior to NSM with deep inferior epigastric perforator (DIEP) flap reconstruction can help mitigate these risks. METHODS: All patients who underwent NSM with immediate DIEP flap reconstruction between 2016 and 2024 were identified. Only those with native breast cup size D or larger were included. Patients were divided into 2 cohorts: those who underwent reduction mammaplasty prior to NSM (reduction cohort) and those without prior breast surgery (control cohort). RESULTS: The reduction group included 21 patients (39 breasts), and the control group included 29 patients (51 breasts). Both groups had an average preoperative breast cup size of DD. Within the reduction group, 41.0% underwent planned staged reductions (average interval, 4.63 months), whereas 59.0% had prior elective reductions (average interval, 13.35 years). Postoperatively, the reduction group experienced significantly lower rates of skin necrosis (5.1% vs 37.3%, P < 0.001) and nipple-areolar complex (NAC) necrosis (2.6% vs 21.6%, P = 0.011). Infection rates were also lower, approaching statistical significance (5.1% vs 19.6%, P = 0.061). On multivariate regression, reduction mammaplasty was a significant protective factor against both skin ( β = -2.774, P = 0.002) and NAC necrosis ( β = -2.385, P = 0.030), reducing the odds by 93.8% and 90.8%, respectively. CONCLUSION: Our findings suggest that prior reduction mammaplasty is associated with decreased ischemic complications in large-breasted patients undergoing NSM and DIEP flap reconstruction.