title: The lateral inframammary fold incision for nipple-sparing mastectomy: outcomes from over 50 immediate implant-based breast reconstructions.
abstract: 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.
authors.affiliation: New York University, School of Medicine, NY, USA.
authors.forename: Keith M
authors.initials: KM
authors.lastname: Blechman
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp
authors.forename: Chaya
authors.initials: C
authors.lastname: Levovitz
authors.forename: Amber A
authors.initials: AA
authors.lastname: Guth
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Axelrod
authors.forename: Richard L
authors.initials: RL
authors.lastname: Shapiro
authors.forename: Mihye
authors.initials: M
authors.lastname: Choi
mesh_terms: D062088:Acellular Dermis; D000273:Adipose Tissue / Q000637:transplantation; D000328:Adult; D001943:Breast Neoplasms / Q000473:pathology / Q000517:prevention & control / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000473:pathology / Q000517:prevention & control / Q000601:surgery*; D002481:Cellulitis / Q000209:etiology; D003646:Debridement; D004210:Dissection; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D015414:Mastectomy, Subcutaneous / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology / Q000601:surgery; D009558:Nipples / Q000473:pathology / Q000601:surgery*; D059351:Organ Sparing Treatments; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy; D013524:Surgical Flaps / Q000009:adverse effects / Q000473:pathology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome