The vertical infra-areolar approach to nipple skin-sparing or total skin-sparing mastectomy

The total skin-sparing mastectomy has become routinely offered to patients in our practice as the mastectomy has evolved from the radical, to modified radical, to simple mastectomy, then skin-sparing, and now total skin-sparing or nipple skin-sparing mastectomy. The current literature suggests that the total skin-sparing mastectomy is an oncologically safe procedure for patients, excluding those with involvement of the nipple-areola complex and those with skin involvement or inflammatory breast cancer. Throughout our experience with the total skin-sparing mastectomy, our techniques and inclusion criteria for the procedure have evolved as more data has become available. We begin with our pre-incision injections for routine performance of the axillary reverse mapping procedure. This technique is used for sentinel lymph node biopsies as well as axillary lymph node dissections to minimize lymphedema of the ipsilateral upper extremity. Although our initial experience with the total skin-sparing mastectomy was mostly via an inframammary incision, we have transitioned to the vertical infra-areolar approach to the nipple-sparing mastectomy in most cases. This incision provides maximal preservation of the blood supply to the nipple and creates a superior cosmetic outcome to most other incisions as it sets the nipples in correct and matching position. However, we do recognize that there are exceptions, and we do utilize various other incisions when necessary.