Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis

Abstract

Background: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method. Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed. Results: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. Conclusions: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.

Mastectomy Incision Design to Optimize Aesthetic Outcomes in Breast Reconstruction

“…When considering how to implement the conclusions described by the authors, the practicing plastic surgeon must contextualize the surgical plan with the individual patient’s oncologic needs, treatment plan, general state of health, breast size and shape, body mass index, and the patient’s preference and priorities. 13 , 14 Obstacles to executing the ideal breast reconstruction will inevitably arise and the surgical plan must be modified to preserve the patient’s health and promote uneventful healing as the primary directives.…”

Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

“…NAC necrosis is considered the most problematic complication of NSM, leading to adverse outcomes such as nipple deformity, hypopigmentation in the NAC area, or loss of the NAC. The rate of NAC ischemia or necrosis after NSM ranges from 0% to 48%, with large variations across different studies [ 2 , 5 , 8 , [19] , [20] , [21] , [22] ]. However, a meta-analysis of recent studies revealed an overall partial NAC necrosis rate of 4.62% and a complete NAC necrosis rate of 2.49%, which are acceptably low [ 22 ].…”

“…The rate of NAC ischemia or necrosis after NSM ranges from 0% to 48%, with large variations across different studies [ 2 , 5 , 8 , [19] , [20] , [21] , [22] ]. However, a meta-analysis of recent studies revealed an overall partial NAC necrosis rate of 4.62% and a complete NAC necrosis rate of 2.49%, which are acceptably low [ 22 ]. Several studies have identified the type of surgical incision as one of the risk factors of NAC necrosis, with the highest necrosis rate in periareolar incision [ 8 , 19 , [22] , [23] , [24] , [25] , [26] ].…”

Safe and Efficient Implant-based Breast Reconstruction

“… 6 , 7 While many different types of incisions have been used in NSM, the inframammary incision is associated with lower rates of complications, including nipple necrosis. 8 , 9…”