title: Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.
abstract: BACKGROUND
  Nipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability.
  
  
  METHODS
  A retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy.
  
  
  RESULTS
  The overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7-1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%).
  
  
  CONCLUSIONS
  Patients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.
authors.affiliation: From the *Divisions of Plastic Surgery and †Breast Surgery,Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY.
authors.forename: Tara L
authors.initials: TL
authors.lastname: Huston
authors.forename: Kevin
authors.initials: K
authors.lastname: Small
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Swistel
authors.forename: Briar L
authors.initials: BL
authors.lastname: Dent
authors.forename: Mia
authors.initials: M
authors.lastname: Talmor
mesh_terms: D000328:Adult; D000368:Aged; D002921:Cicatrix / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia / Q000453:epidemiology / Q000209:etiology; D015412:Mastectomy, Segmental / Q000379:methods*; D008875:Middle Aged; D009558:Nipples / Q000098:blood supply* / Q000601:surgery; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies