Nipple-Areola Complex Evaluation in Long Pedicled Breast Reductions with Real-Time Fluorescent Videoangiography

Abstract

Sir: We read with great interest the viewpoint and abstract entitled “Fluorescent Intraoperative Tissue Angiography with Indocyanine Green: Evaluation of Nipple-Areola Vascularity during Breast Reduction Surgery” by Dr. Murray et al.1 In their article, they state that “although intraoperative surgical decisions were not altered based on these images, they nonetheless supported the surgeon's operative evaluation.” In response to their article, we report a case in which laser-assisted indocyanine green angiography identified a decrease in perfusion to the nipple-areola complex that was not apparent to the surgeon intraoperatively. Laser-assisted indocyanine green angiography ultimately proved to be predictive of partial nipple areola loss, and could have been used to positively alter intraoperative decision-making. We present the clinical course of a 45-year-old woman with darkly pigmented skin tone and large breasts who underwent bilateral reduction mammaplasty. Preoperative measurements revealed sternal notch–to-nipple distances of 41 cm on the right and 43 cm on the left, with inframammary fold–to-nipple distances of 19 cm on the right and 20 cm on the left. A Wise-type skin pattern with a superomedial dermal pedicle was selected. A total of 1638 g of breast tissue was removed from the right breast, and 1620 g was removed from the left breast. Because of the patient's long dermal pedicles (20 cm on the right and 21 cm on the left) and dark nipple-areola complex skin tone, we elected to perform laser-assisted indocyanine green angiography to better assess nipple-areola complex vascularity. Intraoperative angiography showed a completely viable right nipple-areola complex and a partial filling of the left nipple-areola complex, with the superior portion showing poor perfusion (Fig. 1). Clinically (color, capillary refill, and bleeding edges), the patient's nipple-areola complex appeared viable. Based on our clinical experience, we elected to loosely inset the nipples and not perform a free nipple graft. On postoperative day 1, clinical assessment was unremarkable. One week postoperatively, however, the patient developed a superficial skin blister in the exact area of concern mapped by laser-assisted indocyanine green angiography. Throughout the following postoperative period, this area progressed to a full-thickness skin loss along the superior one-fourth of the nipple (Fig. 2). This was treated with local dressings and the patient continued to heal and is now satisfied with her results. Retrospectively, the laser-assisted indocyanine green angiographic information could have altered our intraoperative decision-making, to either débride a portion of the nipple or perform a free nipple graft, for example.Fig. 1.: Intraoperative laser-assisted indocyanine green angiographic image of the left breast.Fig. 2.: Appearance of the left breast 2 weeks postoperatively.We have previously demonstrated the ability of fluorescent intraoperative angiography to predict subclinical ischemia in free tissue transfer, in pedicle flap design, and in mastectomy flap analysis.2–4 Intraoperative evaluation of nipple-areola complexes during breast reduction surgery can be challenging as well, and may offer another opportunity to use this technology. In particular, patients with dark skin tone, smokers, and women with long dermal pedicles would be good candidates to undergo laser-assisted indocyanine green angiography. Traditionally, dermal pedicle length, the volume of the reduction needed, history of smoking, and clinical judgment are factors contributing to nipple-areola complex viability and are sometimes used to determine whether free nipple grafting should be performed. We do not routinely perform intraoperative fluorescent angiography on all of our breast reduction cases. However, in patients with these risk factors, we now consider intraoperative angiography to assist with intraoperative planning. We propose that intraoperative fluorescent videoangiography can be used and may alter the surgeon's operative evaluation during breast reduction surgery in challenging cases where patients are at risk for poor nipple-areola complex perfusion. DISCLOSURE Dr. Samson and Dr. Newman are paid consultants and speakers for Novadaq Technologies, Inc. Dr. Newman is a paid consultant and speaker for LifeCell Corp. Louis S. Brunworth, M.D. Michel C. Samson, M.D. Martin I. Newman, M.D. Department of Plastic Surgery Cleveland Clinic Florida Weston, Fla. Jose R. Ramirez, M.D. Department of General Surgery Cleveland Clinic Cleveland, Ohio