Comparative Outcomes of Incision Techniques in Breast-Conserving Mastectomy

Overview

This retrospective study compared complications among different incision types in conserving mastectomy with immediate breast reconstruction. It identified incision type as a significant risk factor for nipple areola complex (NAC) and skin necrosis, with periareolar and Wise-pattern incisions showing higher complication rates.

Background

Breast-conserving surgery and neoadjuvant treatments have reduced mastectomy rates, yet about 30% of breast cancer patients still undergo mastectomy. Modern techniques aim to preserve the nipple areola complex (NAC) and skin to improve oncologic safety and aesthetic outcomes. Nipple-sparing mastectomy (NSM) allows immediate breast reconstruction but carries risks of skin or NAC necrosis, which can lead to wound healing delays and implant loss. Surgical incision type, along with patient factors like smoking and diabetes, influences these complication risks.

Data Highlights

The study included patients undergoing conserving mastectomy with immediate breast reconstruction from 2014 to 2024. Incisions were categorized as radial, transverse with skin/NAC excision, inframammary fold, omega areola, periareolar, and Wise-pattern. Complications within 1 year were classified by Clavien–Dindo criteria, focusing on MSF ischemia, skin necrosis, NAC necrosis, delayed wound healing, bleeding, seroma, hematoma, and implant loss. Surgical time, tumor characteristics, and adjuvant treatments were also analyzed.

Key Findings

• Periareolar and Wise-pattern incisions were associated with the highest rates of NAC and skin necrosis compared to other incision types.
• Patient-related risk factors such as smoking and type II diabetes mellitus increased the risk of necrosis complications.
• Surgical factors including injury to blood supply during tissue resection and reduced mastectomy skin flap thickness contributed to necrosis risk.
• Inframammary fold and radial incisions showed lower complication rates, suggesting better preservation of blood supply.
• Immediate breast reconstruction was more frequently feasible with nipple-sparing techniques but required careful incision selection to minimize complications.
• Use of tissue expanders was preferred over direct-to-implant reconstruction when mastectomy skin flap ischemia or tension was suspected intraoperatively.

Clinical Implications

Surgeons should carefully select the incision type in conserving mastectomy to minimize NAC and skin necrosis risk, favoring incisions that preserve blood supply such as inframammary fold or radial incisions when oncologically feasible. Patient risk factors like smoking and diabetes must be optimized preoperatively. Intraoperative assessment of skin flap viability can guide reconstruction choice to reduce implant loss.

Conclusion

Incision type significantly impacts complication rates in conserving mastectomy with immediate reconstruction. Tailoring incision choice to patient and tumor characteristics can improve surgical outcomes and reduce necrosis-related complications.

References

1. Policlinico Tor Vergata Breast Unit Study 2014-2024 -- Comparative Outcomes of Different Incision Techniques in Breast-Conserving Mastectomy