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The Lateral Inframammary Incision for Nipple/Areola-Sparing Mastectomy: Outcomes from Over 50 Implant-Based Breast Reconstructions
Keith M. Blechman, MD, Chaya Levovitz, BA, Mihye Choi, MD, Nolan S. Karp, MD.
New York University School of Medicine, New York, NY, USA.

PURPOSE:
Performing nipple-sparing mastectomy for select patients with breast cancer, or as a prophylactic procedure for individuals with a genetic predisposition, is rapidly gaining popularity as the literature continues to support its safety and efficacy. Nipple-sparing mastectomy affords a decreased scar burden and leaves the nipple-areola complex (NAC) intact, allowing superior aesthetic results to be achieved compared to traditional skin-sparing mastectomy reconstructions. The lateral inframmammary fold (IMF) incision provides adequate access and eliminates an anterior scar on the breast, making this incision cosmetically preferable to radial or periareolar approaches. Here we present our experience with nipple-sparing mastectomy through a lateral IMF approach with immediate implant-based reconstruction, which to our knowledge is the largest reported series to date using this type of incision.
METHODS:
We retrospectively reviewed 51 consecutive nipple- or areola-sparing mastectomies, whether prophylactic or therapeutic, between June 2008 and October 2010. All procedures were performed through a lateral IMF incision with immediate implant-based reconstruction, with or without placement of a tissue expander. When appropriate, Alloderm was placed as an inferolateral sling. All breasts were lightly tumesced prior to incision, and sharp dissection rather than electrocautery was used as much as possible to minimize thermal injury to the mastectomy flap. Intraoperative subareolar biopsies were performed. Prior to mastectomy and upon completion of all reconstructive procedures, three-dimensional (3D) photographs were obtained. 3D parameters assessed included volume, antero-posterior projection, and degree of ptosis (defined by the distance in the sagittal plane from a set point superiorly to the inferior pole of the breast).
RESULTS:
Average age was 44 years. All patients were non-smokers. Mean follow-up time post-mastectomy was 1 year. All procedures were bilateral except one, which included a contralateral augmentation. Mastectomy for known pathology was performed in 44% of the patients, and for prophylaxis in the setting of genetic predisposition or strong family history in 56%. Tissue expansion was used in 76% of patients, and Alloderm was placed in 80%. Fat grafting was performed as a third procedure if contour deformities remained. NAC survival reached 94%. One patient required a salvage procedure with a latissimus dorsi flap. Pre- versus post-reconstruction 3D analysis demonstrated larger (196 vs. 248cc), more projected (80 vs. 90 mm), and less ptotic breasts (146 vs. 134 mm), with all parameters reaching statistical significance (p<0.01).
CONCLUSION:
Exceptional reconstructive outcomes can be achieved following nipple-sparing mastectomy by encouraging close communication with the oncologic surgeon, using a lateral IMF incision, and following a two-stage expander/implant approach. NAC survival is reliable. Furthermore, we feel that nipple-sparing mastectomy reconstruction should be regarded by the plastic surgeon as an opportunity, in certain cases, to achieve an aesthetic result that will be equivalent or superior to the preoperative appearance, typified by larger, more projected, and less ptotic breasts.


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