Nipple-Areolar Sparing Mastectomy via an Inframammary Fold Incision for Patients with Scarring from Prior Breast Surgery
Tara L. Huston, MD, Alexander J. Swistel, MD, Jonathan Martin, BA, Mia Talmor, MD.
New York Presbyterian Hospital - Weill Cornell, New York, NY, USA.
Background: Nipple-areolar sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis, by hiding the scar in a natural crease, and offers a high level of patient satisfaction. Due to concerns for nipple viability using this incision, selection criteria may be limited. Here we evaluate the impact of skin scarring from prior surgery on nipple viability.
Methods: A retrospective chart review was conducted on a prospectively collected database at a single institution between July, 2006 and July, 2009. Candidates for a skin sparing mastectomy were given the option of a NSM if there was no skin involvement, the tumor was more than two centimeters from the nipple and they could maintain frequent follow-up for examination of the remaining nipple and/or areolar complex. Sixty women underwent 105 NSMs through IMF incisions. We compared the outcomes of 41 NSMs in breasts with prior surgery to 64 NSMs in breasts without prior surgery. Clinicopathologic factors analyzed included indications, technical details, postoperative morbidity, adjuvant therapy, incidence of recurrence, and aesthetic outcome.
Results: There were 105 mastectomies all followed by immediate implant-based reconstruction. Indications for surgery included invasive breast cancer (n = 43), ductal carcinoma in situ (DCIS) (n = 17), and prophylaxis (n = 45). Partial thickness nipple necrosis, defined as epidermolysis, occurred in four of forty-one (9.7%) breasts with prior surgery and 6 of 64 (9.4%) breasts without prior surgery (p=NS). Of the four breasts with prior lumpectomies, two incisions were located in the upper outer quadrant and two in the lower outer quadrant. Of these four with prior surgery and epidermolysis, one with a lower outer quadrant incision and one with an upper outer quadrant incision had been radiated pre-operatively. Overall, six of ten nipple-areolar complexes with epidermolysis resulted in some degree of depigmentation. The remaining four healed without any residual scar or pigmentation changes. Full thickness nipple necrosis, defined by the presence of an eschar, occurred in 3 of 41 (7.3%) breasts with prior surgery and 3 of 64 (4.7%) breasts without prior surgery (p=NS). Two of the three breasts with prior incisions and one of the three without eventually lost the tissue expanders. In the three cases of lost tissue expanders, all prior incisions were located in the upper outer quadrant. One of these patients with implant loss had undergone prior radiation. At a median follow-up of 10 months (range, 0-36 months), patient satisfaction is excellent, and there are no local or distant recurrences.
Conclusion: Patients with scarring from prior breast surgery do not have a higher rate of complications and may be considered for NSM via an IMF incision. Radiation appears to confer a higher risk of nipple necrosis, regardless of prior surgery or incision placement.
Back to Program