When choosing the incision, the size of the breast and degree of ptosis are the two most important factors. Regardless of the etiology of ptosis, a useful tool for the surgeon is to classify patients by the degree of ptosis present. It is important to clarify with the patient at this time what her goals are in terms of the final appearance of the breast. Regnault’s classification system should be used to grade the extend of ptosis [72, 73]. The amount of preoperative ptosis can be used as a guide to selecting the operation necessary to achieve correction and symmetrization.

The patient in Fig. 21.2 is a good example of an excellent candidate for NSM (Fig. 21.2). On the other hand the patient in Fig. 21.3 is an unclear example for NSM until the nipple to IMF is measured which in her case was 11 cm and therefore she was a reconstructive candidate for NSM (Fig. 21.3). Lastly, the patient in Fig. 21.4 with given asymmetry is an example of how a carefully selected patient who has asymmetry can achieve symmetry following mastectomy and reconstruction (Fig. 21.4). Her candidacy was determined by the measurement of the larger breast as this will play a major role in achieving symmetry postoperatively. Figure 21.5 demonstrates a patient with prior right BCT for medullary carcinoma and a newly diagnosed left triple negative infiltrating ductal carcinoma (Fig. 21.5) Given the nature of her triple negative disease and close proximity of the mass to the nipple, the left nipple will have to be removed and this is demonstrated in Fig. 21.5 with delayed removal of left nipple and simultaneous grafting from the right nipple. In addition, this patient is an example of whether an implant-based reconstruction should be attempted in a patient with prior radiation following lumpectomy. This discussion is beyond the scope of this chapter but the criteria for successful reconstruction depends on where the lumpectomy scar is located. If her lumpectomy scar is in the upper pole of the breast, as seen in Fig. 21.5, and her skin is not scarred down, then an attempt for implant-based reconstruction can be made. However, if the scar is in the lower pole, where the maximum expansion is going to take place, then an autologous vs. latissimus flap and expander should be considered.

For patients with small and medium sized non-ptotic breasts, an inframammary (IMF) incision can be chosen safely. Lateral mastectomy incisions can also be chosen for NSM, but the risk is that the NAC can be pulled laterally when the scar heals. Surgeons have also used the central vertical incision.