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

Daar, David A. M.D., M.B.A.; Abdou, Salma A. B.A.; Rosario, Lauren B.A.; Rifkin, William J. B.A.; Santos, Pauline J. M.D.; Wirth, Garrett A. M.D., M.S.; Lane, Karen T. M.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 906e-919e
doi: 10.1097/PRS.0000000000005502
Breast: Original Articles

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.

New York, N.Y.; and Orange and Newport Beach, Calif.

From the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine; the Departments of Plastic Surgery and Surgery, University of California, Irvine Health; and Wirth Plastic Surgery.

Received for publication April 9, 2018; accepted September 25, 2018.

Drs. Wirth and Lane should be considered co–senior authors.

Disclosure: The authors have no financial interest to declare in relation to the content of this work.

Karen T. Lane, M.D., Department of Surgery, University of California, Irvine Health, 333 City Blvd. West, Suite 1600, Orange, Calif. 92868,

Copyright © 2019 by the American Society of Plastic Surgeons