Nipple sparing mastectomy (NSM) has become an increasingly popular option for patients undergoing breast cancer surgery or risk-reducing mastectomy. The technique allows for the removal of breast tissue while preserving the nipple-areolar complex (NAC), offering improved cosmetic outcomes and psychological benefits. One of the most critical aspects of NSM is the choice of incision, which impacts both oncologic safety and aesthetic results. Surgeons must carefully select incision types that provide adequate access for tissue removal while minimizing complications and maintaining blood supply to the nipple. Understanding the different approaches and their implications is essential for both patients and healthcare providers.
What Is Nipple Sparing Mastectomy?
Nipple sparing mastectomy is a surgical procedure designed to remove breast tissue while preserving the skin envelope and the nipple-areolar complex. This procedure is commonly used for patients with early-stage breast cancer, ductal carcinoma in situ (DCIS), or those at high risk for breast cancer due to genetic factors such as BRCA mutations. By maintaining the NAC, NSM aims to achieve better aesthetic outcomes compared to traditional mastectomy, which often removes the nipple and much of the skin.
Importance of Incision Choice
The incision in a nipple sparing mastectomy plays a critical role in surgical outcomes. Proper incision placement is necessary to
- Provide sufficient access to remove all breast tissue effectively.
- Preserve blood supply to the nipple-areolar complex to prevent necrosis.
- Minimize visible scarring and maintain breast contour for reconstruction.
- Allow for future interventions if necessary, such as sentinel lymph node biopsy.
Factors Influencing Incision Selection
Several patient-specific and tumor-specific factors influence the choice of incision
- Breast size and shapeLarger breasts may require longer incisions or additional access points.
- Tumor locationTumors close to the NAC may require careful planning to ensure complete tissue removal while sparing the nipple.
- Skin quality and elasticityGood skin tone and elasticity allow for better healing and cosmetic results.
- Planned reconstruction methodImmediate reconstruction, whether implant-based or autologous, can influence incision design.
Common Incision Types for Nipple Sparing Mastectomy
Inframammary Fold Incision
The inframammary fold (IMF) incision is placed along the natural crease beneath the breast. This approach offers several advantages
- Conceals the scar beneath the breast, improving cosmetic appearance.
- Provides good access to the breast tissue for complete removal.
- Reduces the risk of visible scarring on the anterior breast surface.
However, this incision may be technically challenging in patients with very large or ptotic breasts, as exposure of upper breast tissue can be limited.
Lateral Breast Incision
A lateral incision is made along the side of the breast, typically extending from the lateral edge toward the axilla. Advantages include
- Good access to both breast tissue and axillary lymph nodes.
- Reduced risk of nipple necrosis compared to periareolar incisions.
- Minimal visible scarring from the frontal view.
This approach is particularly useful for tumors located in the outer quadrants of the breast.
Periareolar or Circumareolar Incision
A periareolar incision encircles the nipple-areolar complex, providing direct access to the central breast tissue. Key points include
- Excellent exposure for tissue removal beneath the NAC.
- Scar blends with the natural edge of the areola, making it less noticeable.
- Requires careful technique to preserve blood supply and reduce the risk of nipple necrosis.
Transverse or Horizontal Incisions
Transverse incisions may be used in combination with other approaches, especially in cases of larger or ptotic breasts. They
- Allow wide exposure for thorough tissue removal.
- Enable simultaneous access for immediate reconstruction.
- May create more visible scarring if not placed along natural skin folds.
Oncologic and Aesthetic Considerations
While NSM focuses on preserving the nipple for cosmetic reasons, oncologic safety remains the priority. Surgeons must ensure
- Complete removal of all glandular tissue to reduce recurrence risk.
- Assessment of tumor-to-nipple distance using imaging or intraoperative evaluation.
- Proper handling of tissue to maintain viability and reduce complications.
From an aesthetic perspective, careful planning of incision location, length, and orientation contributes to better symmetry, minimized scarring, and improved patient satisfaction after reconstruction.
Potential Complications Related to Incisions
Even with optimal incision planning, certain complications may arise
- Nipple necrosisInsufficient blood supply can lead to partial or complete loss of the nipple-areolar complex.
- Delayed wound healingLarger or more complex incisions may increase the risk of slow recovery.
- Visible scarringPoorly positioned incisions can lead to noticeable scars, affecting cosmetic outcomes.
- Infection or hematomaAll surgical incisions carry some risk of infection or bleeding complications.
Techniques to Optimize Outcomes
Several strategies can help enhance both oncologic and cosmetic results in NSM
- Preoperative imaging to assess tumor location and plan incision accordingly.
- Use of intraoperative fluorescence or Doppler to evaluate blood supply to the nipple.
- Minimizing tension on incision edges to promote better healing.
- Close collaboration with a reconstructive surgeon to plan incision placement in conjunction with reconstruction method.
Nipple sparing mastectomy represents a significant advancement in breast surgery, allowing patients to maintain the nipple-areolar complex while ensuring oncologic safety. The choice of incision is a critical component of the procedure, balancing adequate surgical access with optimal cosmetic outcomes. Common incision types, such as inframammary fold, lateral, periareolar, and transverse approaches, each have advantages and limitations depending on patient anatomy, tumor characteristics, and reconstruction plans. Careful preoperative planning, attention to blood supply, and meticulous surgical technique are essential to minimize complications such as nipple necrosis, delayed healing, and visible scarring. Understanding the principles behind NSM incisions helps patients make informed decisions and allows surgeons to optimize both functional and aesthetic results. By considering these factors, nipple sparing mastectomy can achieve safe, effective, and cosmetically satisfying outcomes for individuals undergoing breast surgery.