Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement

Abstract

Background: The authors refine their anatomical patient selection criteria with a novel midclavicular-to–inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach. Methods: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained. Results: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch–to-nipple distance, was strongly correlated with midclavicular-to–inframammary fold measurement on linear regression (R 2 = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to–inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to–inframammary fold measurement was less than 30 cm. Conclusions: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to–inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to–inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Modified goldilocks nipple-sparing mastectomy with immediate prepectoral implant-based reconstruction: a case report

“…NSM with prosthetic-based reconstruction presents a technical challenge in patients with large or ptotic breasts due to poor control of the skin envelope/NAC position and high risk of ischemia (3). Traditionally, these issues have been addressed by either staging the reconstruction or performing a free nipple graft (3,7). However, neither of these options are ideal as staging the reconstruction delays oncologic therapy and increases overall treatment cost, while free nipple grafts may have loss of projection and pigment changes over time.…”

“…Modified goldilocks nipple-sparing mastectomy with immediate prepectoral implant-based reconstruction: a case report to compromised blood supply (3). Thus, in this subset of women who desire NAC preservation, traditional options include free nipple grafts or staged reconstruction with reduction mammaplasty/mastopexy followed by NSM with prosthetic insertion (4).…”

Predicting Complications in Breast Reconstruction

“…measurements have also been identified as predictors of NAC complications. [12][13][14] Intraoperative risk factors for NAC complications include mastectomy specimen weight and periareolar mastectomy incision. 15 However, the effect of reconstructive variables on the risk of NAC necrosis has not been clearly delineated.…”

“…Clinicopathologic risk factors associated with NAC necrosis have included increased age and body mass index (BMI), history of smoking, radiation therapy, and adjuvant chemotherapy 7,9–11 . Preoperative breast measurements have also been identified as predictors of NAC complications 12–14 . Intraoperative risk factors for NAC complications include mastectomy specimen weight and periareolar mastectomy incision 15 .…”

Minimally invasive approach to diseases of the breast and contemporary factors affecting breast cancer surgery

“…(50)(51)(52)(53)(54)(55) For cytology, pooled sensitivity was only 38%, although the pooled specificity was high (90%) (Supplemental Figure 4), indicating that cytology is not very useful for the detection of breast cancer in patients with PND. 13 However, biomarker analysis of nipple discharge, as by RNA assessment, 69 may be more promising 6,[70][71][72][73][74][75][76][77] .…”