Is it advisable to make an incision in the center of the nipple?

Incision in the Center of the Nipple is Not Advisable

Making an incision in the center of the nipple is not advisable as it can lead to devascularization, nipple necrosis, and poor cosmetic outcomes. 1

Optimal Incision Placement for Breast Procedures

Recommended Incision Approaches

• Curvilinear incisions following Langer's lines (natural lines of skin tension) generally achieve the best cosmetic results for most breast procedures 1
• Radial incisions are preferred at the 3 o'clock and 9 o'clock positions and in the lower breast, particularly when skin removal is necessary 1
• Incisions should be placed over or close to the tumor and of adequate size to allow removal in one piece 1

Specific Considerations for Nipple-Areolar Complex

• For subareolar tumors, partial areolar excision with careful approximation can provide adequate tissue removal while maintaining good cosmesis 1
• Very superficial tumors in the subareolar area may require excision of the nipple-areolar complex to ensure adequate tumor margins 1
• Periareolar incisions for lesions in the periphery of the breast are inappropriate and should be avoided 1

Risks of Nipple Incisions

Vascular Complications

• Central nipple incisions can compromise blood supply, leading to devascularization 1
• Research shows periareolar incisions have significantly higher rates of nipple-areolar complex ischemia or necrosis (31.1%) compared to inframammary fold (9.7%) or radial incisions (17.0%) 2
• The nipple receives primary innervation from branches of the fourth intercostal nerve, which can be damaged during central nipple procedures 3

Functional and Aesthetic Outcomes

• Nipple sensation is crucial for women's psychological and sexual health 3
• Preservation of the subcutaneous tissue with separate closure improves cosmetic results 1
• Incisions through the nipple can distort its natural appearance and lead to poor cosmetic outcomes 4

Best Practices for Breast Tissue Management

• Excise lesions with a rim of grossly normal tissue while avoiding excessive sacrifice of breast tissue 1, 5
• Use subcuticular technique for skin closure to achieve optimal cosmesis 1, 5
• Avoid breast tissue reapproximation as it often results in breast distortion when the patient is upright 1
• Maintain meticulous hemostasis to prevent hematoma formation, which can complicate future physical examinations and mammography 1
• Avoid placing drains in the breast 1

Alternative Approaches for Nipple-Adjacent Lesions

• For lesions near the nipple-areolar complex, consider lateralized parabolic multiplanar incisions that maintain circulation to the areola 4
• For tumors in the immediate subareolar area, partial areolar excision with careful approximation can provide adequate tissue removal with good cosmesis 1
• In cases requiring nipple preservation, inframammary fold incisions have shown the lowest complication rates (18.8%) compared to periareolar approaches (42.6%) 2