All patients underwent periareolar MICS +/- HD 3D endoscopic visualization with minimal rib-spreading. A soft tissue retractor with a maximum diameter of 4 cm is utilized, along with a rib spreader when necessary for further exposure. During the procedure, patients are positioned in a 30-degree left lateral decubitus position. In all cases, transesophageal echocardiography (TEE) was performed to confirm preoperative diagnosis and evaluate postoperative end results. Following appropriate sterile preparation and draping, 5000 units of heparin are given to target an ACT more the 200 msec. Our Cardio-Pulmonary bypass (CPB) perfusion technique consists of femoro-femoral cannulation combined with internal jugular cannulation. The right common femoral vessels are exposed through a 2 cm oblique groin incision. Under ultrasound and TEE guidance, Seldinger technique is used to cannulate the right internal jugular vein with a 17 F cannula, while the exposed right common femoral vein is cannulated with a 25 F multistage cannula. Arterial cannulation is obtained through sewing an 8 mm Hemashield graft to the right common femoral artery. At this point, the plastic surgery team conducts a preoperative marking for a classic periareolar breast augmentation technique, with an incision ranging from 3 o’clock to 9 o’clock. Size of the incision differs from one patient to another depending on the areolar size. Dissection is performed in an inferior fashion, leaving a 2 cm thick S flap extending down to the prepectoral pocket. Dissection above the pectoralis muscle is carried out at the level of the 4th intercostal space, similar to prepectoral breast augmentation techniques. If a breast implant is present, the implant will be removed to expose the thoracic wall.

A right mini thoracotomy is performed in the fourth intercostal space, and a 2 − 0 ethibond pledgeted suture is used to retract the diaphragm caudally. The pericardium is opened 3 cm above the phrenic nerve then suspended laterally. Two pledgeted 3 − 0 prolene sutures are placed on the aorta below the planned cross clamp level for the cardioplegia cannula. Once the cardioplegia cannula is inserted, a transthoracic “Chitwood” aortic cross clamp is applied. Custodiol cardioplegia (1.5 L) is infused in an antegrade fashion to induce cardiac arrest during diastole. Patients body temperature is cooled down to 32 degrees celsius as a protective strategy for the brain and other organs during CPB. The left atrium is accessed through sondergaard’s groove while the right atrium is accessed through an oblique right atrial incision. In this study, the scar outcome at different stages in all patients was carefully assessed. All patients included in the study provided their consent to have their cases reported, and corresponding figures showcasing the scar progression were attached to support the findings. Patients were considered for inclusion in this study if they were female, had an indication for cardiac surgery, and expressed a preference for a minimally invasive approach with an emphasis on aesthetic outcomes. Exclusion criteria included male gender, inability to provide informed consent, and the presence of contraindications to minimally invasive surgery, such as severe pulmonary hypertension or previous right thoracic surgery. Patients with a history of breast surgery or implants were not excluded from this study.

A 29-year-old female patient with a history of mitral valve prolapse with severe mitral valve regurgitation, as well as bilateral prepectoral breast augmentation, presented for minimally invasive mitral valve repair utilizing a periareolar incision approach with right-sided implant revision. The patient had an American Society of Anesthesiologists (ASA) classification of 3. Prior to the cardiac procedure, the plastic surgery team performed a periareolar incision on the right breast, extending from 3 to 9 o’clock, exposing the chest wall. Subsequently, the cardiac surgery team proceeded with the mitral valve repair using a bileaflet neochordae implantation technique and a slightly oversized annuloplasty ring. During the procedure, the plastic surgery team conducted an implant revision and closed the incision in a standard multilayer fashion. The estimated cross clamp time was 103 min, and no intraoperative complications occurred.

Following the surgery, the patient was admitted under the care of the cardiac surgery team for a five-day duration, including one day in the intensive care unit (ICU). The patient’s postoperative course was uneventful, apart from experiencing multiple episodes of delirium. Regarding the breast augmentation aspect, upon admission to the hospital, the patient reported no pain, redness, tenderness, hematoma, discharge, or signs of infection at the incision site. Subsequent follow-up visits at the clinic revealed a well-healed, flat scar with preserved breast shape. The scar size measured approximately 3 cm, without any noticeable hypo/hyperpigmentation changes. The patient expressed satisfaction with the augmentation results and scar outcome.

The patient reported temporary numbness around the areola and nipple for the initial two weeks following the surgery, which is a known and expected complaint associated with the periareolar incision technique, as documented in the literature. It is important to note that an areola diameter smaller than 3 cm can pose challenges in exposing cardiac structures during the surgery, sometimes requiring additional efforts, and potentially resulting in extensions beyond the areolar region, thereby increasing the risk of numbness in that area. However, in this particular case, the patient did not experience any complications related to the surgical approach. Additionally, the patient mentioned a small breast lump on the lower aspect of the breast, but subsequent radiological studies confirmed benign findings.

A 17-year-old female patient was diagnosed with a superior sinus venosus atrial septal defect (SV-ASD) with partial anomalous pulmonary venous drainage (PAPVD) since birth. She had no other underlying medical conditions and was classified as ASA 3 by the anesthesia team. The anatomy of her ASD and associated anomalies necessitated surgical intervention. The plastic surgery team performed a periareolar incision encircling the areola, extending from 3 to 9 o’clock, to gain access to the chest wall and heart. The cardiac surgery team proceeded with the repair of the SV-ASD and the PAPVD using a two patch (bovine pericardium) technique, where a baffle was created to direct the drainage of the right superior and middle anomalous pulmonary veins to the left atrium and a second patch to enlarge the cavoatrial junction to prevent SVC narrowing. The total estimated cross clamp time was 164 min, and the operation proceeded smoothly without encountering any complications.

Following the procedure, the patient was initially admitted to the Intensive Care Unit (ICU) and subsequently transferred to the ward under the care of the cardiac surgery team and discharged home on the 4th day postop. Throughout this period, there were no indications of pain, redness, swelling, discharge, or signs of infection at the incision site. The wound was diligently maintained, with regular assessments of its integrity, cleaning, and dressing performed by the plastic surgery team. During follow-up visits at the clinic, the patient did not report any concerns regarding the periareolar incision scar. No instances of numbness, pain, or discoloration were reported by the patient. In fact, the scar exhibited clarity and a flat appearance, characterized by well-defined borders. The patient expressed satisfaction with the overall outcome of the scar. The size of the scar measured approximately 2.8 cm, with minor hypopigmentation changes noted.

A 35-year-old female patient was diagnosed with Left Atrial Myxoma after presenting with a headache and blurry vision. Aside from this condition, she had no other underlying medical issues and was classified as ASA 3 by the Anesthesia team. A transesophageal echocardiogram showed that tumor was located at the cranial aspect of the left atrium at the entrance of the right superior pulmonary vein. Surgical resection of the tumor was planned for the patient. The surgical approach involved a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. This incision provided adequate exposure for the cardiac surgery team to perform an en Bloc resection of the myxoma. Following the successful resection, the plastic surgery team meticulously closed the incision. The total estimated cross clamp time was 92 min. The patient was admitted to the Intensive Care Unit (ICU) initially and subsequently transferred to the ward, she was discharged home on the 6th day postop. Throughout her hospitalization, the plastic surgery team consistently monitored the wound, which exhibited no signs of pain, redness, swelling, discharge, or infection. The wound was diligently cleaned and appropriately dressed.

During follow-up visits at the clinic, the scar was found to be clean with well-defined margins, flat, and mildly hyperpigmented. The patient expressed satisfaction with the outcome of the scar, reporting no history of color changes or raised areas at the incision site. However, she did experience numbness at the site of the incision for a duration of 1 month following the surgery.

A 42-year-old female patient was diagnosed with a large size secundum atrial septal defect (ASD) with a deficient inferior rim. She had no other concurrent medical conditions and was assessed by the anesthesia team, who classified her as ASA 3. The surgical approach utilized in her operation was consistent with the previously mentioned cases, involving a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. The ASD was successfully patched using bovine pericardium, with no complications encountered during the procedure. The total estimated cross clamp time was 100 min.

Following the surgery, the patient was admitted to the ICU and subsequently transferred to the ward and was discharged home on the 5th day postop. Throughout her hospital stay, the plastic surgery team consistently monitored and assessed the wound, which remained clean and exhibited no indications of pain, redness, swelling, discharge, or infection. During the patient’s follow-up visit at the clinic, she expressed satisfaction with the outcome of the scar. The scar appeared clean, flat, with well-defined margins. Overall, there was minimal pigmentation, except for a slight hypopigmentation noted at the 5 o’clock position. However, the patient conveyed contentment and satisfaction with the overall result (Fig. 1).

Scar Outcome at Different Stages in Different Patients. (A) Immediate postoperative scar after skin closure. (B) Scar appearance at 10 days after closure. (C) Scar appearance at 2 months after surgery. (D) Scar appearance at 4 months after surgery, where the scar is nearly invisible

A 57-year old female patient was diagnosed with secundum ASD and cor triatriatum sinister. She had no other concurrent medical conditions and was assessed by the anesthesia team and classified as ASA 3. The surgical approach utilized in her operation was consistent with the previously mentioned cases, involving a periareolar incision performed by the plastic surgery team, extending from 3 to 9 o’clock. However, in this case a cor triatriatum sinister was present. Upon identification, resection of the fibromuscular membrane with complete visualization of the left atrium including the mitral valve and pulmonary veins was achieved. The ASD was patched utilizing bovine pericardium with no complications encountered during the procedure. The total estimated cross clamp time was 173 min. The patient was admitted to the ICU after the surgery and she was subsequently transferred to the ward. The wound was assessed and monitored daily by the plastic surgery team. On the 6th day postop, the patient was discharged home with no cardiac or wound complications. A comprehensive summary of patient demographics, clinical diagnoses, surgical approaches, and postoperative outcomes is presented in Table 1.