Since its initial description in the 1960s by Freeman [12], nipple-sparing mastectomy (NSM) without indication for breast-conserving surgery has become a standard procedure with curative intent for breast cancer [3]. Recent studies report that NSM can be used in all cases in which total mastectomy is indicated when histological analyses of intraoperative frozen sections from sub-nipple-areola complex (NAC) tissues are negative [4]. NSM has demonstrated improved cosmetic outcome without compromising oncologic safety [56].

Various NSM approaches have been applied, and there are various incisions associated with these approaches, including inframammary, radial, and periareolar incisions, which have been extensively described in the literature [3789]. Inframammary incisions leave a discreet scar, but access to the breast and axilla is difficult. Radial incisions provide enough exposure and easy access to the axilla but are considered “radical” because of the amount of exposure [379].

Periareolar incisions have not been routinely used because they are technically difficult and thought to be associated with increased risk of ischemia and necrosis of the NAC. However, periareolar incisions can produce the best esthetic results because the incision scar remains well hidden within the periphery of the NAC. Recently, the NSM approaches with a periareolar incision have been reported to produce successful outcomes, including no serious NAC complications [810].

In an attempt to maximize esthetic effects, we also used this periareolar incision approach. We performed NSM through periareolar incision and 1-stage immediate reconstruction. Herein we present our first results with this approach.

The mean age and body mass index were 46.74 ± 6.69 years (range, 38–62 years) and 22.68 ± 2.71 kg/m² (range, 18.5–27.6 kg/m²), respectively. The operations indications were distributed as follows: luminal (n = 16), HER2 (n = 3), triple-negative (n = 3), and carcinoma in situ (n = 12). Bilateral mastectomy was performed in 3 cases due to the bilateral breast cancer. Mean operation time for mastectomy was 96.68 ± 28.00 minutes. Six cases of SLN evaluation were done through the same periareolar incision, and 28 cases were performed through additional axilla incision. The mean weight of the mastectomy specimens was 277.84 ± 85.81 g, and the mean volume and weight of the implants and DIEP flaps were 273.97 ± 86.50 mL and 357.67 ± 146.41 g, respectively (Table 1).

One case of hematoma occurred, and this was treated with a hematoma evacuation operation. One wound infection and 1 minor NAC problem was observed. No other complications including fistula, implant exposure, or reconstruction failure was observed. Ten patients (29.4%) received adjuvant chemotherapy, and 2 patients (5.9%) received adjuvant radiotherapy. Nineteen patients (55.9%) received hormonal therapy. During a median follow-up period (18.2 months), no grade III or IV Baker scale contractures were observed. At the time of writing, no case of local recurrence had been observed (Table 2).

In this study, all NSMs were performed by the same surgeon, potentially minimizing case-by-case variation in our initial report. NSM through periareolar incision with immediate reconstruction was revealed to be technically feasible and to allow easy access to the mammary parenchyma. The approach was performed successfully with low rates of complications.

Various incision types have been used to remove glandular tissue and prepare flaps, depending on tumor location and breast type. Periareolar incisions have not been usually performed because of the risk to NAC viability [11121314]. Our operative method emphasizes the careful preservation of the periareolar dermis to maximize NAC viability after NSM. Recently, the approach of NSM with a periareolar incision and 2-stage reconstruction has also been shown to produce successful outcomes [8]. However, 2-stage reconstruction could be inconvenient for the patients. Furthermore, the team who reported outcomes of the periareolar incision and 2-stage reconstruction used a semicircular incision below the NAC with a 3- to 4-cm lateral radial elongation, which is not a true periareolar incision and would have sacrificed cosmetic considerations.

We performed 1-stage immediate breast reconstruction in which the plastic surgeon placed a breast implant or DIEP flap immediately after the breast surgeon removed any malignant breast tissue. One-stage immediate reconstruction has several advantages [1516]. One-stage surgery lowers risk, decreases costs, minimizes patient discomfort and maximizes patient satisfaction. Tissue expansion after mastectomy in 2-stage surgery can be avoided. Reduced scarring and better cosmetic results can be expected also. Furthermore, faster recovery and return to active lifestyle can be expected.

We performed NSM through only periareolar incision without any elongation, which maximized cosmesis. Patients with large NACs are ideal candidates for NSM through a single periareolar incision. For those with very small areolae and large breast volume, medial and/or lateral extensions may be needed to perform the mastectomy meticulously and for easier extraction of the surgical specimen [810]. We used a lateral periareolar semicircular incision for easy access to the axilla (Fig. 1). However, for easy access to the locations of tumor, a superior or inferior semicircular incision also can be considered. In Table 3, we compared several periareolar approaches including our method.

Of relevance to operation procedure, preservation of fatty tissue around the axillary tail and fibrous tissue of the inframammary fold is also important to maintain the original breast contour after reconstruction. The fasciae of the serratus anterior and rectus abdominis should also be preserved during NSM to avoid implant dislocation. In 6 cases of ductal carcinoma in situ, SLN biopsies were successfully performed through a single periareolar incision. All of these surgical techniques maximize the cosmesis.

There was 1 major complication (postoperative hematoma) requiring reoperation (bleeding control was performed in pectoralis muscle with general anesthesia). One minor NAC problem (delayed wound healing) case was occurred and cured with steri-strip apply. One case of wound infection was treated incision and drainage with local anesthesia and antibiotics treatment. No other complications including fistula, implant exposure, or reconstruction failure was observed.

Overall, the esthetic outcomes were satisfactory (Fig. 2) and comparable to previous study results [1718]. Periareolar incisions without any elongation produce well-hidden incision scars within the periphery of the NAC (Fig. 2). Radiotherapy was administered after NSM according to international mastectomy guidelines, and only low level of capsular contracture (Baker grade I) was observed.

The oncological safety of NSM has been subject to debate [561718]. So far, no prospective randomized study has been conducted to demonstrate the efficacy of the technique. In the present study, no recurrence was observed after 18.2 months of median follow-up, although the sample was small and the follow-up period was short.

In summary, our initial report shows that NSM with immediate reconstruction may safely be performed through periareolar incision. This method can maximizes cosmesis and may be a good surgical option for NSM.