Complete Nipple Research Articles

Surgical Management of Postoperative Nipple Necrosis After Inverted Nipple Correction: Experiences From a Series of 25 Cases.

The inverted nipple is a condition that affects approximately 10% of women and can have negative cosmetic and psychological implications. Surgical correction is a common approach to address this concern; however, this method can lead to complications, such as nipple necrosis. As comprehensive guidelines are currently lacking for postoperative nipple necrosis management, this study reports our experience in the management of postoperative nipple necrosis following initial attempt at surgical management. A retrospective chart review was conducted and included female patients who experienced postoperative nipple necrosis after inverted nipple correction between 2018 and 2021. Cases of recurrent nipple retraction following partial necrosis and cases of complete nipple necrosis were evaluated. Recurrent nipple retraction was managed using various inverted nipple correction techniques, while complete necrosis required a modified C-V flap for nipple reconstruction. A total of 25 patients with a total of 42 affected nipples were included. Thirteen cases (26 nipples) experienced recurrent nipple retraction following partial necrosis, while 12 cases (16 nipples) exhibited complete necrosis. No significant predictive variables for these complications were found. Notably, all patients achieved successful healing following single-stage surgical repair. At 6 months postoperation, the treated nipples exhibited satisfactory healing and appearance and an absence of infection or papillary necrosis. Seven reconstructed nipples showed a mean loss of projection (2.7 ± 0.98) compared with only 2 nipples in the inverted nipple correction group. Distinguishing between recurrent nipple retraction after partial necrosis and complete nipple necrosis is crucial and should be taken into consideration when managing patients following inverted nipple correction.

Early Experience of Direct-to-Implant Breast Reconstruction Using Acellular Dermal Matrix after Robot-Assisted Nipple-Sparing Mastectomy.

The authors performed a retrospective review to analyze operative outcomes of breast mound reconstruction after robot-assisted mastectomy. Patients who underwent nipple-sparing mastectomy (NSM) with a robotic device (Da Vinci Xi) and immediate prepectoral prosthetic reconstruction by lateral incision from June of 2018 to July of 2019 were enrolled. Patient characteristics, complications, and satisfaction rates as assessed by BREAST-Q were analyzed. The surgical technique was described in detail. Thirty-nine cases, including 7 bilateral cases (total 46 breasts), underwent robot-assisted NSM followed by immediate prepectoral prosthetic implant reconstruction. The median patient age was 46.63 years (range, 21 to 63 years). The mean operation time for each prepectoral breast mound reconstruction using the direct-to-implant technique was 126.55 minutes. Robot-assisted reconstruction resulted in superior BREAST-Q scores compared with the conventional reconstruction method. Major infection occurred in 7 cases (15.2%), and complete nipple loss occurred in 3 cases (6.6%). Severe complications requiring breast implant removal occurred in 4 breasts (8.7%). Two cases were due to the coexistence of infection and skin necrosis; in 1 case, the skin flap became congested on postoperative day 3 and required additional surgery to change the expander. Other complications were resolved with conservative care or minor revision. This report is the first concerning robot-assisted NSM followed by prepectoral acellular dermal matrix-wrapped prosthetic reconstruction. This procedure was not inferior to other methods. Further prospective research to evaluate oncologic outcomes is warranted. Therapeutic, IV.

How to Avoid Nipple Necrosis in Lifting and Reduction Mammaplasties

Partial or complete nipple areolar complex (NAC) necrosis following breast reduction mammaplasties is an overwhelming complication for both the plastic surgeon and the patient. Its reported incidence vary from 2% for full-thickness necrosis to 11% for superficial epidermolysis. Early identification and management of NAC vascular insufficiency is important in order to avoid total NAC loss. The Total Posterior Pedicle breast reduction technique described by Richard Moufarrege in 1982 consists of dissecting the skin away from the breast tissue offering free access to all breast quadrants. This technique is known for its preservation of the breastfeeding function, for its conservation of the nipple erogenous sensation, and for its low rate of long-term complications such as pseudoptosis. In this article, we demonstrate that the Moufarrege Total Posterior Pedicle has an absolute secure blood supply to the NAC and no risk of NAC necrosis.

Effects of Infant Driven Feeding Program on Provision of Breast Milk in Very Low Birth Weight Infants.

Background: The ability to complete nipple feedings is one of the discharge criteria for most premature neonates. The Infant Driven Feeding (IDF) program suggests a system of objective promotion of oral feeds in premature infants. There is a lack of studies systematically studying the effects of IDF on the provision of breast milk. Methods: This was a retrospective study of all premature infants born before 33 weeks and birth weight of <1,500 g admitted to a level IV neonatal intensive care unit. Infants on IDF were compared with those not on IDF. Results: A total of 46 infants in the IDF group and 52 in the non-IDF group met the inclusion criteria. A higher number of infants in the IDF group breastfed at first oral attempt (54% versus 12%). Forty-five percent of IDF mothers completed a full 72 hours of protected breastfeeding at the start of oral feeds, and IDF infants had earlier removal of nasogastric (NG) tube. There was no difference in the provision of breast milk and/or breastfeeding on discharge between the two groups. There was no difference in the length of stay between the two groups. Conclusion: The IDF program attempts to streamline the promotion of oral feeds in very low birth weight infants. Higher incidence of breastfeeding at the start of oral feeds and earlier removal of NG tube did not translate into higher provision of breast milk on discharge in very low birth weight infants in the IDF group. Prospective randomized trials are needed to validate cue-based infant driven feeding programs and their effects on the provision of breast milk.

“Scarless” excision of a nipple adenoma case report—a good aesthetic outcome after a circular nipple excision with purse-string closure technique

: Complete surgical excision of nipple adenoma with clear margins offers the lowest risk of recurrence of this locally infiltrative yet benign entity. A thorough triple assessment including histological assessment is crucial to exclude any malignant pathology, and confirm the diagnosis. There are many excisional and ablative techniques published that can give clear resection margins, but there remains a paucity of data on acceptable aesthetic outcomes. It is important to balance between adequate surgical margins to prevent recurrence and a good aesthetic outcome, particularly in a young patient. We wish to highlight a good aesthetic outcome following a simple circular excision with purse-string closure of the nipple defect. We present a 28-year-old lady with a progressively ulcerative lesion that involved the entire nipple. Ultrasound did not show any other underlying lesions or intraductal extension. Punch biopsy confirms the diagnosis of a benign nipple adenoma. She was counselled for complete nipple excision and the defect was primarily closed with purse-string technique. This may not be a novel technique as it has been described for closure of other defects. However, the benefit of a purse-string closure of a circular nipple excision defect to reduce scarring may be underreported in the literature. This technique helps to conceal the scar within the areola, retain its natural corrugated appearance, and prevent distortion to the overall shape of the areolar complex. The final outcome of a complete nipple excision resembles that of a ‘scarless’ excision and remains aesthetically pleasing. We hope to allay fears of clinician and patients faced with similar condition by offering a safe, easily reproducible, single staged technique that offers high patient satisfaction in selected patients. Using this technique may even preclude the need for further nipple reconstruction.

Single-stage Layered versus Nonlayered Mastopexy with Augmentation in Muscle Splitting Biplane: A Comparative Analysis.

Background:Single-stage layered mastopexy with augmentation is a modification of muscle-splitting pocket that reduces risk of complications and revision rate.Methods:A retrospective chart review of all the consecutive cases, performed by a single surgeon, from March 2007 to August 2019, was conducted. All patients had surgery with superomedial pedicle in an approved facility. The patients were divided into group A whose implants were placed through the mastopexy incision, and group B whose implants were placed first and access closed prior to mastopexy.Results:Nonlayered group A included 116 patients and layered group B included 102 patients. Groups A and B had a mean age of 32.3 + 9.70 and 34.8 + 10.39 years (range, 20–66), respectively (P value 0.070). In groups A and B, 95 (81.9%) and 74 (72.5%) patients underwent primary and 21 (18.1%) and 28 (27.5%) patients underwent secondary procedures, respectively (P value 0.099). There were no hematomas in group A and two patients had hematoma in group B (P value 0.218). In group A, one patient experienced periprosthetic infection with none in group B (P value 0.41). Wound breakdown was observed in ten (8.6%) patients in group A and four (3.9%) patients in group B (P value 0.128). In group A, there was a partial or complete nipple loss in two (1.7%) and none in group B (P value 0.412). In group A, 15 (12.9%) underwent revision surgery and six (6.5%) in group B (P value 0.127).Conclusion:Layered mastopexy with augmentation provides improved safety, fewer complications and revisions with adequate results.

The "Smile Mastopexy": A Novel Technique to Aesthetically Address the Excess Skin Envelope in Large, Ptotic Breasts While Preserving Nipple Areolar Complex During Prosthetic Breast Reconstruction.

Classically large, ptotic breasts have been a contraindication for nipple preservation during breast reconstruction. We present a technique of "smile mastopexy" (SM) to reduce the excess skin in both vertical and transverse directions, avoid a T-junction, preserve the nipple areolar complex, and add thickness to the upper pole of the breast at the time of mastectomy. The authors sought to demonstrate the safety and reliability of a novel technique that addresses the excess skin envelope during breast reconstruction while preserving the nipple-areola complex in large, ptotic breasts. This is a retrospective review of a single surgeon performing the SM for immediate 2-stage prosthetic breast reconstruction. All were performed in the prepectoral pocket without utilization of acellular dermal matrices. Thirty patients (total 54 breasts) aged a mean 50 years with BMI of 30 kg/m2 and mastectomy specimen weight of 683 g were included. All had class 2 or 3 ptosis. There were no cases of complete nipple loss. The overall complication rate was 14.8%. There were 3 explantations: 1 (1.8%) due to infection and 2 (3.7%) due to implant exposure. Radiation was associated with a higher complication rate. The SM is a safe and reliable technique in large, ptotic breasts during prosthetic breast reconstruction. It preserves the nipple-areola complex, reduces the excess skin envelope, adds thickness to the upper pole, and allows for future skin revisions with the same scar if necessary.

Stage III Breast Cancer Patients Are Less Likely to Complete Nipple Reconstruction: An Institutional Analysis of Cancer Stage Affecting Breast Reconstruction

Stage III Breast Cancer Patients Are Less Likely to Complete Nipple Reconstruction: An Institutional Analysis of Cancer Stage Affecting Breast Reconstruction

Immediate Reconstruction of Large Ptotic Breasts following Vertical Reduction Pattern Nipple-Sparing Mastectomy.

PurposeWomen with large and/or ptotic breasts are generally not considered candidates for nipple-sparing mastectomy because of concerns regarding the high incidence of postoperative complications including ischemic complications. Therefore, we adopted a vertical skin resection technique for nipple-sparing mastectomy, and obtained satisfactory results following immediate autologous breast reconstruction. In this study, we aimed to describe our operative technique and review its outcomes.MethodsBetween January 2010 and March 2017, immediate autologous breast reconstructions were performed in 28 patients with moderate or large ptotic breasts after nipple-sparing mastectomy using the vertical reduction pattern. Grade II ptosis was observed in 12 patients, and 16 patients were classified as having grade III ptosis.ResultsOf the 28 patients, 21 received abdominal free flap reconstruction. In the remaining 7 patients, extended latissimus dorsi flaps were used in conjunction with anatomic implants. The mean weight of the excised breast tissue in the 2 groups was 575 g and 482 g, respectively. Satisfactory esthetic outcomes without major complications were achieved in all patients. Similar vertical reductions or mastopexies in the contralateral breast allowed better postoperative adjustment for symmetry. There was only 1 case of complete nipple necrosis; however, the problem was solved with “skin banking.” No local recurrences or distant metastases were detected at follow-up (mean 18 months, range 4 months to 6 years).ConclusionTo enhance cosmetic outcomes in patients with large and/or ptotic breasts, the vertical skin resection pattern for nipple-sparing mastectomy can be used to achieve better breast shape while preserving the nipple-areola complex. Moreover, it can improve the esthetic outcome without compromising oncologic safety.

A combination of mupirocin and acidic fibroblast growth factor for nipple fissure and nipple pain in breastfeeding women: protocol for a randomised, double-blind, controlled trial

IntroductionNipple fissure and nipple pain are common complaints among breastfeeding mothers. Studies found that mupirocin was effective in preventing and treating infections of damaged nipple and nipple pain. Acidic fibroblast...

Management of Recurrent Symptomatic Macromastia: A Single Surgeon’s Experience

Abstract Background Breast reduction for symptomatic macromastia can have excellent long-term results and relief of symptoms. However, patients may require a re-reduction for recurrent symptoms. Previous reports of re-reduction after a primary inferior pedicle reduction have called into question the safety of blood supply to the nipple-areola complex with re-reduction. Objectives To examine a single surgeon’s experience and management of recurrent symptomatic macromastia after inferior pedicle breast reduction. Methods A retrospective review was performed of a single surgeon’s breast reduction experience using billing data to identify cases of breast re-reduction from January 2003 and January 2018. Breast re-reduction was performed either with a Wise pattern, inferior pedicle or with a smile reduction with an inferior pedicle. Liposuction was used in re-reductions only. Results In 15 years, 3530 breast reductions were performed in 1758 patients. In 7 patients, 14 total re-reductions were performed, including 13 secondary breast re-reductions (12 bilateral, 1 unilateral) and 1 tertiary, unilateral breast re-reduction. Seven Wise pattern, inferior pedicle and 7 smile reductions with inferior pedicle procedures were done at the breast level. This translates to a re-reduction incidence of 1 in 250 or 0.4% rate of re-reduction at the patient level in our practice. The minor complication rate was 14% (1 seroma), and the major complication rate was 0%. There were no instances of partial or complete nipple areola necrosis. Conclusions Recurrent symptomatic macromastia can be managed with re-reduction with re-creation of the inferior pedicle or a smile breast reduction as we describe without increased risk to nipple-areolar complex viability. Level of Evidence: 4

Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast.

Nipple-areolar skin-sparing mastectomy followed by autologous reconstruction in patients with large, ptotic breasts often offers a limited field, resulting in strenuous traction. Skin-sparing mastectomy (SSM) with immediate nipple grafting from the specimen was attempted for such patients. Patients who underwent SSM with immediate autologous breast reconstruction and nipple grafting between September 2016 and February 2019 were evaluated, including 33 nipple grafts in 30 patients. The average weight of the mastectomy specimen was 552.5 g and the average operation time for unilateral mastectomy was 109 minutes. No complete nipple loss or major skin flap necrosis was reported. Adjuvant therapy started after an average of 24 days. SSM with immediate nipple grafting on the autologously reconstructed breast could be an alternative for large, ptotic breasts. It is also useful for patients requiring contralateral balancing procedures or those with bilateral breast cancer in which only one nipple can be spared oncologically.

The Necessity of the Nipple: Redefining Completeness in Breast Reconstruction.

Satisfaction with breast reconstruction is thought to be greatest among patients who complete nipple and areolar complex (NAC) reconstruction. Anecdotally, many patients are known to decline NAC reconstruction. The authors aimed to characterize the epidemiology of and factors associated with incomplete breast reconstruction. Breast reconstruction patients with follow-up in a single institution's electronic medical record system were reviewed. Chi-squared and independent t-tests were used to identify variables associated with lack of NAC reconstruction; associated variables (P < 0.05) were used to build a binary logistic regression. Four hundred thirty-three patients were reviewed. Reconstructions consisted of an average of 4.0 ± 2.0 procedures over 503 (range, 2-3,652) days. One hundred twelve patients had NAC reconstruction or tattooing (25.9%) and 73 (17.6%) had both-226 women (54.6%) had neither. On multivariate analysis, a history of any implant removal was associated with a 93.4% decreased chance of NAC reconstruction (P = 0.002), whereas prophylactic or early-stage mastectomy was associated with 52.9% increased chances of NAC reconstruction (P = 0.009). Over half of the present cohort did not complete any NAC reconstruction. Patients with later-stage cancer and a history of implant removal were less likely to have NAC reconstruction. The high prevalence of incomplete reconstructions suggests that the classical definition of breast reconstruction completion as requiring NAC reconstruction may be outdated or not applicable to all populations. Instead, "completion" should be considered a subjective determination varying between patients.

Abstract 11. The Effect of Neoadjuvant Chemotherapy Compared to Adjuvant Chemotherapy in Nipple-Sparing Mastectomy

Purpose: The impact of neoadjuvant and adjuvant chemotherapy on outcomes in nipple-sparing mastectomy (NSM) have not yet been established. Methods: Patients undergoing NSM from 2006 to June 2015 were identified. Results were analyzed for reconstructions receiving neoadjuvant or adjuvant chemotherapy. Results: Of 840 NSMs, 28 received neoadjuvant chemotherapy while 93 received adjuvant chemotherapy. NSMs with neoadjuvant chemotherapy were significantly more likely to have implant explantation (p=0.0015) and complete nipple necrosis (p=0.0004) compared to those with no chemotherapy. Compared to NSMs with no chemotherapy, those with adjuvant chemotherapy were significantly more likely to have hematoma formation (p=0.0021). Those with neoadjuvant chemotherapy were significantly more likely to have explantation (p=0.0239) and complete nipple necrosis (p=0.0021) compared to those with adjuvant chemotherapy. NSMs with both neoadjuvant and adjuvant chemotherapy were significantly more likely to have complete nipple necrosis compared to those with neoadjuvant chemotherapy only and adjuvant chemotherapy only (p<0.0001). No differences were observed in NSMs with neoadjuvant chemotherapy and adjuvant radiation compared to NSMs with neoadjuvant chemotherapy alone. Conclusions: NSM is safe to perform in the setting of neoadjuvant and adjuvant chemotherapy. However, neoadjuvant chemotherapy appears to increase complications; a synergistic effect between neoadjuvant and adjuvant chemotherapy likely yields overall greatest risk.

NIPPLE RECONSTRUCTION USING THE C-V FLAP TECHNIQUE: LONG-TERM OUTCOMES

Introduction: Nipple creation using the C-V flap technique is often the final step in breast reconstruction. The aim of this study was to subjectively and objectively assess the cosmetic outcomes and satisfaction of patients undergoing C-V flap nipple reconstruction. Methods: Subjective assessments of patient satisfaction with the neo-nipple were recorded by visual analogue scoring (VAS; 0-10). Objective measurements were performed using a calliper to measure nipple projection relative to the native breast. Descriptive data analysis was performed with differences in projection assessed with the Mann-Whitney test and mean and median VAS scores (with inter-quartile ranges; IQR) calculated to describe satisfaction. Results: Thirty-three C-V flap nipple reconstructions were performed. 87.9% received latissimus dorsi (LD) reconstructions with implants and 12.1% had transverse rectus abdominis muscle (TRAM) reconstructions. The median projection of reconstructed nipples was 4.7 mm (range 4-10.2 mm) at 4.6 years mean follow-up, which was not significantly different from the contralateral nipple (p = 0.34). Patient satisfaction was 9 (IQR: 8-10) with shape, 9 (IQR: 7.5-10) with projection, 5 (IQR: 2-9.6) with sensation, and 8.5 (IQR: 6-9.5) with symmetry. Median overall satisfaction was 9 (IQR: 8-10). Three patients had complete nipple loss, of whom two had undergone nipple piercing post procedure and none had received radiotherapy. Conclusion: C-V flap nipple reconstructions provide a simple and reliable method to reconstruct the nipple that enhances confidence and perception of body image. Satisfaction was high with long-term outcomes in terms of projection equivalent to the contralateral breast.

Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes.

Total skin-sparing mastectomy (TSSM) with preservation of the breast and nipple-areolar complex (NAC) skin was developed to improve aesthetic outcomes for mastectomy. Over time, indications for TSSM broadened and our technique has evolved with a series of systematic improvements. We reviewed all cases of TSSM with immediate breast reconstruction performed from 2005 to 2012. Patient comorbidities, treatment characteristics, postoperative complications, and outcomes were obtained prospectively and through medical chart review. Locoregional recurrences, distant recurrences, and patient survival were analyzed with Kaplan-Meier methods. During this 8-year period, 633 patients (981 cases) underwent TSSM with median follow-up time of 29 (interquartile range 14-54) months. Immediate breast reconstruction was performed with tissue expander placement (89%), pedicle TRAM (5%), free flap (5%), permanent implant (0.3%), or latissimus flap (0.2%). The incidences of postoperative complications decreased significantly over time. In 2012, these were down to 3.5% for superficial nipple necrosis, 1.0% for complete nipple necrosis, 3.0% for minor skin flap necrosis, 4.4% for major skin flap necrosis, 13.3% for infections requiring oral antibiotics, 9.9% for infections requiring intravenous antibiotics, 3.4% for infections requiring operative intervention, and 8.5% for expander/implant. Overall 5-year cumulative incidences of recurrence were 3.0% (locoregional) and 4.2% (distant), and there were no recurrences in the NAC skin. Systematic changes in our technique of TSSM and immediate breast reconstruction have decreased postoperative complications over time. Oncologic outcomes of locoregional and distal recurrences remain similar to skin-sparing mastectomy techniques.

Immediate Implant-Based Breast Reconstruction following Total Skin-Sparing Mastectomy in Women with a History of Augmentation Mammaplasty

Preservation of the nipple-areolar complex with total skin-sparing mastectomy is becoming a popular mastectomy technique. As experience increases, the patient inclusion criteria for total skin sparing mastectomy expand. The authors assessed outcomes of total skin-sparing mastectomy and immediate prosthetic reconstruction in women with a prior history of augmentation mammaplasty. Between 2005 and 2012, all women with a history of augmentation mammaplasty and implants in place, undergoing total skin-sparing mastectomy and immediate prosthetic reconstruction, were prospectively tracked. Patient demographics, expander coverage type, adjuvant treatment, and incidence of complications were analyzed. Outcomes in these patients were compared with those of patients undergoing the same operation, without prior augmentation history. Thirty-four women with prior augmentation underwent total skin-sparing mastectomy and immediate tissue expander placement on 51 breasts. Comparison to the nonaugmentation group showed similar rates of superficial nipple necrosis (0 percent, p=0.324), complete nipple necrosis (0 percent, p=0.324), and skin flap necrosis (4 percent, p=1.0). The prior augmentation group did have a higher rate of implant loss (10 percent, p=0.515), with all but one of these occurring in irradiated patients. Total skin-sparing mastectomy and immediate prosthetic reconstruction is a safe technique in women with a history of augmentation mammaplasty. The preferred reconstructive technique is immediate submuscular tissue expander placement. In the setting of no radiation history, this operation carries a safety profile similar to that of patients without a history of prior augmentation, and can be offered safely. Risk, II.

Treatment of a Supernumerary Large Breast with Medial Pedicle Reduction Mammaplasty

Accessory breast tissues including nipples, areolas, and glandular tissue may develop on the chest in addition to two normal breasts. An accessory breast with a complete ductal system, areola, and nipple is termed a "supernumerary breast." Supernumerary nipples are fairly common, but complete supernumerary breasts are rare. This report describes an 18-year-old woman who presented with a complete supernumerary breast including a nipple-areola complex located on the upper outer quadrant of her left breast and causing severe breast asymmetry. She was referred to the authors for aesthetic reasons. Unilateral reduction mammaplasty was performed to remove the supernumerary breast and correct the breast asymmetry. The medial pedicle Wise technique was used for en bloc resection of the ectopic breast, including the nipple-areola complex together with the upper outer breast quadrant. The woman's postoperative course was uneventful. At 8months after surgery, she was very satisfied with the results. Ectopic breast tissue can be treated by a variety of methods such as liposuction or excision. However, breast deformation because of a complete supernumerary breast is very rare, and research on the treatment of such patients is lacking. No reports describing surgical treatment for this condition were identified in the literature. The authors suggest that unilateral breast reduction is the most appropriate treatment, allowing excision of the accessory tissues, with the best possible cosmetic outcome. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reducing the Risk of Nipple Necrosis: Technical Observations in 340 Nipple-sparing Mastectomies

Optimizing cosmesis is a common goal of breast surgery. In support of immediate breast reconstruction, nipple-sparing techniques have evolved. There is still a lack of agreement on the optimal technique and skin flap necrosis can be problematic. In this study, we review our experience with 340 NSM. Between March 2006 and February 2011, 340 NSMs were performed. Mammography, ultrasonography and magnetic resonance imaging were reviewed. Patient demographics and surgical techniques were reviewed. Anatomic observations were made and supported by breast images. A total of 340 NSMs in 231 patients by a single surgeon (AJS) were reviewed. Risk reduction was the indication for surgery in 59% with 50 patients (21.6%) testing positive for a BRCA1/2 gene mutation. There were two flap losses and 14 hematomas. Complete nipple necrosis occurred in three cases (0.8%) and partial loss in six patients. Recommendations are made to reduce the risk of nipple necrosis included the following: (a) preserving major perforating vessels (b) elevating skin flaps in the plane between the subcutaneous fat and the breast glandular tissue (c) the use of incisions that do not devascularize the nipple-areola complex. Nipple-sparing mastectomy can be performed with an acceptably low risk of nipple necrosis. Attention to detail including preserving major perforating vessels, elevating skin flaps in the appropriate plane and careful attention to incision planning are all required for a consistently good cosmetic outcome.

The Lateral Inframammary Fold Incision for Nipple-Sparing Mastectomy: Outcomes from Over 50 Immediate Implant-Based Breast Reconstructions

Nipple-sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Mean patient age was 46 years, and mean follow-up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176-750 cc), and average fat grafting volume was 86 cc (range 10-177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple-areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant-based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low.