Protecting Nipple Perfusion by Devascularization and Surgical Delay in Patients at Risk for Ischemic Complications During Nipple-Sparing Mastectomies.

Abstract

Indications for nipple-sparing mastectomy (NSM) are expanding; however, high-risk patients have more ischemic complications. Surgical devascularization of the nipple-areolar complex (NAC) prior to NSM can reduce complications. This study reports perfusion patterns and complications in high-risk patients undergoing 2-stage NSM. Surgical devascularization of the NAC was performed 3-6weeks prior to NSM in 28 women. Risk factors included ptosis, obesity, smoking, prior breast surgery, and radiation. Using indocyanine green (ICG)-based fluorescence and an infrared camera, blood inflow was visualized intraoperatively. NAC perfusion patterns were classified as: V1, underlying breast; V2, surrounding skin; V3=V1+V2, or V4, capillary fill following devascularization. Ischemic complications were analyzed. Baseline perfusion for 54 breasts was 35% V1, 32% V2, and 33% V3. Increasing ptosis was associated with V1 pattern: 86% for grade 3, 31% for grade 2, and 18% for grade 1. Postdevascularization epidermolysis was observed in 63% of V1 baseline, 41% of V2, and 22% of V3 (P=.042) and after NSM in 26% for V1, 7% for V2, and 6% for V3 (P=.131). Ptosis was significantly associated with epidermolysis postdevascularization (P=.002) and NSM (P=.002). Smoking and BMI ≥30 were related to increased ischemic complications. Two or more risk factors were associated with postdevascularization ischemic changes (P=.026), but were not significant after NSM. Nipple loss was not observed, but 2 patients underwent partial areolar resection. Adaptive circulatory changes after devascularization allow tissues to tolerate the additional ischemic challenge of mastectomy. Our findings support extending 2-staged operations to high-risk women previously considered unsuitable for NSM.