The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction.

Since its initial description in the 1960s by Freeman (1,2), the use of the nipple-sparing mastectomy (NSM) has significantly increased (3,4). In general, NSM is considered for patients with T0 to T2 tumours smaller than 4.5 cm in size, further than 2.5 cm from the areolar edge and 4 cm from the nipple centre, and no clinical involvement of the nipple-areolar complex (NAC) or skin (5). Recent studies, however, report that NSM can be used in all cases in which total mastectomy is indicated when histological analyses of intraoperative frozen sections from sub-NAC tissues are negative (6). From a reconstructive perspective, preservation of the NAC improves aesthetic outcomes without increasing the rate of cancer recurrence (7–11). The principal reconstructive benefit of the technique is preservation of the NAC; however, the NAC is also the most vulnerable anatomical element during the mastectomy and reconstructive procedures. If significant epidermolysis or full-thickness loss of the nipple occurs, then the advantage of performing a NSM is nullified. While a variety of NSM incisions are available to the breast surgeon, there is a paucity of data investigating the effects of incision type on reconstructive outcomes. The most common incisions used in NSM are periareolar, lateral or inframammary (12–15). Several advantages and disadvantages have been described for each incision location. Periareolar incisions enable central access to all quadrants of the breast during the mastectomy while maintaining a well-hidden incision scar within the periphery of the NAC (6). However, following mastectomy, a significant source of blood flow to the NAC occurs through the skin flaps and dermal vascular plexus. Therefore, making an incision across one-half of the NAC can disrupt this critical blood supply. Lateral incisions also allow for easy central access to all quadrants of the breast, but do not cut across the skin-based blood supply to the nipple (because the incision is axial to the NAC periphery). Inframammary incisions allow the scar to be well-concealed in the inframammary fold with very minimal disruption of the skin-based blood supply to the NAC (6,7,11,12). The problem with this approach lies in the difficulty of accessing the upper quadrants of the breast for mastectomy (7,11). There is significant variability in the literature regarding the incidence of nipple necrosis with varying incision location. For example, the reported incidence of nipple necrosis with an inframammary approach ranges between 2% and 67% (9,13,16–22). A potential rationale for the wide divergence in the nipple necrosis outcomes stems from the variability in surgical methodology; in some cases, outcomes with both autologous and expander implant-based reconstructions were combined. The present study assessed the relationship between incision choice and NAC survival by selecting cases involving a standardized oncological and reconstructive technique with the only variable relating to incision location – periareolar, lateral or inframammary. While the primary outcome measure was nipple necrosis, the effects of radiation, chemotherapy, breast size and intraoperative expansion on NAC survival were also analyzed.