Curve or crease: comparative pain and healing profiles in submammary and transaxillary thoracotomy for MICS-MVR

Abstract Objective Submammary lateral thoracotomy and transaxillary thoracotomy are two common approaches for minimally invasive mitral valve replacement (MICS-MVR). However, their impact on postoperative pain, wound healing, and cosmetic outcomes remains underexplored. Methods In this prospective cohort study, 80 patients undergoing elective MICS-MVR were assigned to submammary (n = 40) or transaxillary (n = 40) thoracotomy. Pain was assessed using the visual analogue scale (VAS) at defined postoperative intervals. Opioid use, wound healing (Southampton grade, ASEPSIS score), scar quality (patient and observer scar assessment scale, POSAS), and cosmetic satisfaction were recorded. Results aseline characteristics were comparable. At 24 hours, VAS scores were lower in the transaxillary group (5.1 ± 1.0) versus submammary (6.3 ± 1.2; p < 0.001). Opioid use over 72 hours was also less with transaxillary (38 ± 10 mg vs. 46 ± 12 mg; p = 0.002). Wound healing at day seven was similar (grade I-II in 92.5% vs. 85%; p = 0.32). Minor wound complications occurred in three and five patients, respectively; none developed deep infections. At three months, POSAS scores favored the submammary approach (14.2 ± 3.5 vs. 17.8 ± 4.2; p < 0.001), with higher cosmetic satisfaction (4.6 ± 0.5 vs. 4.2 ± 0.6; p = 0.004). Conclusions Transaxillary thoracotomy in MICS-MVR reduced early postoperative pain and opioid use, whereas submammary thoracotomy yielded better long-term scar appearance and cosmetic satisfaction. Both approaches had similar wound healing profiles; thus, surgical choice may be guided by patient priorities.