Aesthetic Outcomes After Bilateral Nipple-Sparing Mastectomy: Radiation and Reconstructive Method Are the Primary Determinants Using BCCT.core Analysis.

BACKGROUND: Aesthetic outcomes after nipple-sparing mastectomy (NSM) with implant-based reconstruction are influenced by varying clinical and technical factors. BCCT.core, a validated objective assessment, provides a reproducible evaluation of postoperative symmetry. This study examined predictors of aesthetic outcome after bilateral NSM using BCCT.core. METHODS: A retrospective review of 123 patients undergoing bilateral NSM with immediate implant-based reconstruction was performed. BCCT.core software assigned postoperative cosmetic classifications (classes 1 to 4). Patients were stratified by reconstructive method [direct-to-implant (DTI) vs. tissue expander (TE)], implant pocket, post-mastectomy radiation therapy (PMRT), mastectomy weight, and prior augmentation. Logistic regression identified independent predictors of poor aesthetic outcome (class 3/4). RESULTS: Overall, 24.4% of patients achieved class 1, 60.2% class 2, and 15.4% class 3/4 results, with a mean classification of 1.93±0.64. PMRT had the strongest adverse effect on aesthetic outcome, with irradiated patients demonstrating markedly higher rates of class 3/4 results and worse mean postoperative classification. TE reconstruction produced more favorable outcomes than DTI, especially among nonirradiated patients, and remained an independent predictor on multivariable analysis. Higher mastectomy weight correlated with worse postoperative classification. Prior augmentation increased preoperative asymmetry but did not compromise postoperative aesthetic quality when TE reconstruction was used. Major complications were associated with poorer classification. CONCLUSION: PMRT and reconstructive methods are the strongest determinants of postoperative symmetry after NSM with implant-based reconstruction. TE reconstruction is associated with more favorable aesthetic outcomes than DTI, particularly in nonirradiated patients, while PMRT remains the principal driver of asymmetry. These retrospective findings support more individualized reconstructive planning and highlight the value of objective BCCT.core analysis in aesthetic evaluation.