Safety of Incision Placement with Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction

Abstract

Background: In nipple-sparing mastectomy, adequate perfusion to the nipple-areolar complex (NAC) during reconstruction is paramount to avoiding unwanted outcomes. Previous studies have suggested that periareolar incisions may result in higher rates of NAC complications. However, studies to date have not specifically investigated this in prepectoral reconstruction. The purpose of this study is to evaluate the impact of incision location on NAC complications in patients undergoing prepectoral breast reconstruction. Methods: We performed a retrospective review of all patients who underwent immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy between 2015 and 2018 at a single institution. We identified two types of incisions utilized: superior periareolar or inframammary fold (IMF). Patient demographics, comorbidities, and surgical details were compared between incision types, as were NAC complications. Results: A total of 181 consecutive prepectoral breast reconstructions were included for analysis. A superior periareolar incision was used in 113 reconstructions (62%), and an IMF incision was used in 68 reconstructions (38%). There were 33 (18%) total NAC complications in our series. The periareolar incision group had a higher rate of any NAC complication (25% versus 7.4%; P < 0.01), as well as a higher rate of nipple necrosis requiring debridement (9.7% versus 1.5%; P = 0.03). Conclusions: In patients undergoing immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy, periareolar incisions are associated with an increased risk of NAC complications compared with IMF incisions. For patients who are candidates for either an IMF or periareolar incision, a periareolar incision should be avoided.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

“…20,35 In this study of prepectoral TE-based breast reconstruction after NSM, we found an 8% rate of partial nipple necrosis and a 0% rate of complete nipple necrosis, which is within the less than 1% to 18% range reported in the literature following NSM. [19][20][21][22][23][24][25] A few studies report the incidence of NAC necrosis following prepectoral breasted reconstruction after NSM: Avila et al 20 reported a less than 1% rate of nipple necrosis, which was significantly lower than 3% reported in their control group undergoing subpectoral reconstruction. However, 74% of the 203 prepectoral breasts studied in this cohort underwent direct-to-implant breast reconstruction versus 33% of 202 subpectoral breasts, which makes their cohort results less comparable to our cohort.…”

“…The prevalence of ischemic complications affecting the NAC ranges from less than 1% to 18% after NSM. [19][20][21][22][23][24][25] Intraoperative efforts to mitigate this risk vary in their nature, from incision placement to splitting the NSM into 2 stages in an effort to "delay" the nipple by promoting compensatory blood flow to the nipple before completion of mastectomy. 19,[32][33][34] Although there is no evidence of increased rates of NAC necrosis with prepectoral versus submuscular implants, NAC necrosis is potentially more devastating in the prepectoral breast reconstruction, as it could lead to an exposed implant more readily than in a submuscular reconstruction.…”

“…[19][20][21][22][23][24][25] Intraoperative efforts to mitigate this risk vary in their nature, from incision placement to splitting the NSM into 2 stages in an effort to "delay" the nipple by promoting compensatory blood flow to the nipple before completion of mastectomy. 19,[32][33][34] Although there is no evidence of increased rates of NAC necrosis with prepectoral versus submuscular implants, NAC necrosis is potentially more devastating in the prepectoral breast reconstruction, as it could lead to an exposed implant more readily than in a submuscular reconstruction. 20,35 In this study of prepectoral TE-based breast reconstruction after NSM, we found an 8% rate of partial nipple necrosis and a 0% rate of complete nipple necrosis, which is within the less than 1% to 18% range reported in the literature following NSM.…”

“…[16][17][18] Rates of NAC necrosis after prepectoral breast reconstruction vary widely, with reports of its incidence ranging between less than 1% and 18% in the literature. [19][20][21][22][23][24][25] Although a few studies have commented on the possible link between intraoperative tissue expander (TE) fill and NAC necrosis, none have been able to definitively establish a relationship. 19,21 We hypothesized that there is an optimal intraoperative TE fill that could prevent NAC complications following prepectoral TE-based reconstructions after NSM.…”

“…The viability of the NAC after prepectoral breast reconstruction following NSM is contingent on several factors including the integrity of the nipple's blood supply, incision placement, quality of mastectomy flaps, mastectomy weight, undue tension on flaps from implants, and patient comorbidities such as smoking, hypertension, diabetes, or peripheral vascular disease 16–18 . Rates of NAC necrosis after prepectoral breast reconstruction vary widely, with reports of its incidence ranging between less than 1% and 18% in the literature 19–25 . Although a few studies have commented on the possible link between intraoperative tissue expander (TE) fill and NAC necrosis, none have been able to definitively establish a relationship 19,21 …”