You can live without a nipple, but what if you don’t have to?

Historically, this specialized region of the breast—known as the nipple-areolar complex—was one of the most vital aspects of human anatomy, providing not only nutrition but also immunologic safety for the infant via breastfeeding. The nipple deserves our respect; without it, human society would not exist.

While there are ample supplemental options today that allow people to forego breastfeeding, we should not overlook its importance in low-resource, economically disadvantaged communities. Nevertheless, there are large subsets of the population for whom the nipple does not serve life-giving or life-supporting functions—such as males, post-menopausal females, and those who choose not to or are unable to breastfeed.

For patients with breast cancer, the debate on the importance of the nipple often becomes secondary to the priority of treating the disease. As a result, conventional mastectomy techniques commonly involve its removal, whereas more contemporary nipple-sparing mastectomy techniques aim to preserve it. Yet even with preservation, the nipple is rendered non-functional and often lacks sensation.

So the question is: why spare the nipple during breast cancer treatment if the result is a non-functional body part that patients can live without?

The answer is very simple: because people want it.

To appreciate the value of nipple-sparing in breast cancer care, we must understand the context of its historically aggressive surgical background. In 1894, the Halsted radical mastectomy was first described for the management of breast cancer. The procedure certainly lived up to its name. The whole breast, all lymph nodes in the underarm, and the underlying chest muscles were resected. In some cases, an “extended” version involved an even more extensive removal of tissue.

Now, in 2025, breast oncology has evolved significantly. We are in the modern era of de-escalating unnecessary treatments, including surgeries, for patients who meet specific criteria. Many patients undergo treatment with small, inconspicuous incisions and preserved breasts. The goal today is to appropriately treat breast cancer while also optimizing both psychosocial and aesthetic outcomes. The nipple-sparing mastectomy reflects this shift, allowing for preservation of the nipple and giving patients a more natural appearance.

Recent studies have shown that sparing the nipple improves patient-reported outcomes, even if it does not affect cancer survival. Many patients report improved psychosocial and sexual well-being following nipple-sparing mastectomy, even indicating they would undergo the procedure again if needed. Most importantly, nipple-sparing mastectomy is not associated with worse outcomes in terms of cancer recurrence or overall survival.

Fortunately, more breast cancer patients are now eligible to undergo nipple-sparing procedures. In recent years, patients with higher BMI and larger breast volumes are being offered nipple-sparing mastectomies. Additionally, tumors located closer to the nipple may safely undergo nipple sparing as long as surgical margins are cancer-free. Even in my own research, I have found that nipple discharge, a current contraindication per guidelines for nipple-sparing mastectomy, may not necessarily need to disqualify a patient from undergoing the procedure.

Still, much remains unknown about the future of nipple-sparing mastectomy. This prompts three important questions regarding its utility, equity, and safety:

Utility: What are the differences in selection criteria for nipple-sparing mastectomy compared to lumpectomy, with the latter allowing for more conservation of the breast?

Equity: How do we prevent nipple-sparing mastectomy from becoming a “luxury” treatment that is selectively utilized in more advantaged social and demographic groups?

Safety: What are the long-term outcomes of this procedure beyond 10, 15, or even 20 years?

Answers to these questions have yet to be fully uncovered and should be considered in the ever-changing field of breast oncology.

Sparing the nipple is a humanistic approach to breast cancer care because, at the center of this complex landscape, is the patient. Even though nipple-sparing does not improve survival and may carry a small yet real risk of leaving cancer at the nipple, patients report improved outcomes in their care. Prioritizing a patient’s mental and emotional well-being—while also treating their cancer effectively—is one of the most special aspects of breast oncology. It is a field that not only acknowledges but also embraces the sensitive, personal nature of the patient’s disease. De-escalated care and preservation of the patient’s body remind us that we are treating people with a disease, not a disease with a person.

Thomas Amburn is a general surgery resident.