Nipple-areolar Complex Ischemia Research Articles

Predicting Complications in Breast Reconstruction: Development and Prospective Validation of a Machine Learning Model.

Necrosis of the nipple-areolar complex (NAC) is the Achilles heel of nipple-sparing mastectomy (NSM), and it can be difficult to assess which patients are at risk of this complication (Ann Surg Oncol 2014;21(1):100-106). To develop and validate a model that accurately predicts NAC necrosis in a prospective cohort. Data were collected from a retrospectively reviewed cohort of patients who underwent NSM and immediate breast reconstruction between January 2015 and July 2019 at our institution, a high -volume, tertiary academic center. Preoperative clinical characteristics, operative variables, and postoperative complications were collected and linked to NAC outcomes. These results were utilized to train a random-forest classification model to predict necrosis. Our model was then validated in a prospective cohort of patients undergoing NSM with immediate breast reconstruction between June 2020 and June 2021. Model predictions of NAC necrosis in the prospective cohort achieved an accuracy of 97% (95% confidence interval [CI], 0.89-0.99; P = 0.009). This was consistent with the accuracy of predictions in the retrospective cohort (0.97; 95% CI, 0.95-0.99). A high degree of specificity (0.98; 95% CI, 0.90-1.0) and negative predictive value (0.98; 95% CI, 0.90-1.0) were also achieved prospectively. Implant weight was the most predictive of increased risk, with weights greater than 400 g most strongly associated with NAC ischemia. Our machine learning model prospectively predicted cases of NAC necrosis with a high degree of accuracy. An important predictor was implant weight, a modifiable risk factor that could be adjusted to mitigate the risk of NAC necrosis and associated postoperative complications.

Salvage of Nipple-Areolar Complex Ischemia With Dimethyl Sulfoxide: A Case Series.

Nipple-areolar complex (NAC) necrosis is a known risk of breast surgery, particularly mastectomy. Disruption of the underlying blood supply to the NAC can lead to ischemia and subsequent necrosis. Nitroglycerin paste is currently used to combat NAC ischemia but has limited efficacy and an unfavorable side effect profile. Topical dimethyl sulfoxide (DMSO) has been shown to increase tissue perfusion in microsurgery and various skin flaps, but its role in the treatment and prevention of NAC ischemia has not been reported. Through a prospective case series, this study aims to introduce DMSO as a safe treatment for NAC ischemia after breast surgery. Patients treated by 2 breast surgeons and a single plastic surgeon who underwent nipple-sparing mastectomy or breast reduction and developed NAC ischemia were identified via a prospectively maintained database. Ischemic changes were diagnosed, and treatment to the affected NAC with DMSO was initiated at the conclusion of the procedure, or postoperative day 1 in most cases, and continued 4 times daily until ischemic changes had resolved clinically. Collected demographic, surgical, and outcome variables were analyzed using descriptive statistics. Eleven patients with a mean age of 47.8 ± 9.5 years (range, 35-61 years) and mean body mass index of 26.0 ± 4.4 kg/m2 (range, 20.7-33.4 kg/m2) were identified. The mean duration of time between surgery and the clinical diagnosis of NAC ischemia was 1.3 ± 2.8 days (range, 0-7 days). The average length of time from DMSO initiation to clinical improvement or resolution of NAC ischemia was 7.5 ± 2.5 days (range, 5-12 days). All patients demonstrated significant improvement or complete resolution of NAC ischemia following serial topical DMSO application. This study demonstrates DMSO is a safe treatment for threatened NACs. All patients in this series showed either dramatic improvement or resolution of NAC ischemia after DMSO application, and threatened NACs of all 11 patients were successfully salvaged. These promising results set the basis for ongoing randomized controlled studies to determine the efficacy of DMSO treatment for NAC ischemia.

Impact of Body Composition on Postoperative Outcomes in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction.

Nipple-areolar complex (NAC)-related complications are common during nipple-sparing mastectomy (NSM), with obesity as a risk factor. Although the incidence of NAC-related complications after robotic NSM (RNSM) with immediate breast reconstruction (IBR) is lower than that after conventional NSM, it remains one of the most unwanted complications. We aimed to evaluate body composition-based risk factors for NAC-related complications after RNSM with IBR. Data of 92 patients with breast cancer who underwent RNSM with IBR using direct-to-implant or tissue expander from November 2017 to September 2020 were analyzed retrospectively. Risk factors for NAC-related complications were identified with a focus on body composition using preoperative transverse computed tomography at the third lumbar vertebra level. Postoperative complications were assessed for 6 months. The most common complication was NAC ischemia, occurring in 15 patients (16%). Multivariate analysis revealed a low skeletal muscle index/total adipose tissue index (SMI/TATI) ratio as an independent NAC ischemia risk factor. An increase in the SMI/TATI ratio by one decreased the incidence of NAC ischemia by 0.940-fold (p = 0.030). A low SMI/TATI ratio is a risk factor for postoperative NAC ischemia in patients undergoing RNSM with IBR for breast cancer. Preoperative body composition-focused evaluation is more valuable than simple body mass index assessment.

Negative Pressure Wound Therapy for Improved Nipple Survival in Large Volume Reduction Mammaplasty.

Large volume breast reductions are at increased risk of nipple ischemia and necrosis due to tenuous blood supply of long pedicles. We adapted incisional negative pressure wound therapy to augment nipple survival in such patients undergoing mammaplasty by inferior pedicle technique. Patients with nipple-to-inframammary fold distance >14 cm were informed of increased risk of requiring free nipple graft. All patients underwent inferior pedicle technique with Wise pattern skin incision. Once incisions were closed and the nipple-areolar complex was inset, the complex was assessed for vascularity. In 12 cases there was evidence of compromised arterial inflow or venous outflow. For these patients, incisional negative pressure wound therapy was applied to the bilateral nipple-areolar complexes for 5-7 days. None of the 12 patients (24 breasts) in this series experienced nipple-areolar complex ischemia or necrosis. Only 2 patients experienced delayed wound healing which was successfully managed by local wound care. This study demonstrates the utility of negative pressure wound therapy in nipple survival for at-risk patients. We believe it augments healing by allowing improved micro-circulation. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Do Nipple Necrosis Rates Differ in Prepectoral Versus Submuscular Implant-Based Reconstruction After Nipple-Sparing Mastectomy?

Nipple-sparing mastectomy (NSM) has become increasingly popular, given its oncologic safety and preserved nipple areolar complex (NAC) aesthetics. Reconstruction has recently shifted from traditional submuscular (SM) to prepectoral (PP) implant placement. It remains unclear how the plane of implant placement might affect NAC perfusion. Our goal was to assess postoperative outcomes following NSM with SM versus PP implant placement. A retrospective single-institution review was performed of all patients undergoing NSM and immediate breast reconstruction in either the PP or SM plane from January 2015 to June 2019. Clinicopathologic details and 90-day complication rates were collected. SM and PP group complications were compared using Chi square analysis. A total of 288 breasts (160 patients) were included, including SM in 79 cases (44 patients) and PP in 209 cases (116 patients). Clinicopathologic features between groups were similar. Overall, the rate of NAC necrosis was 15.1%, with no differences between the SM and PP cohorts (p = 0.79). In cases of NAC necrosis, there was no difference between the SM and PP groups in return to the operating room for debridement (p = 1.0) or explant (p = 0.33). In our cohort, immediate implant-based reconstruction in the SM and PP planes following NSM was equally safe with respect to postoperative complications and NAC ischemia.

Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

BackgroundNipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR. MethodsWe retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis. ResultsData from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis. ConclusionsCompared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple.

Nipple-Areolar Complex Ischemia After Nipple-Sparing Mastectomy With Immediate Implant-Based Reconstruction: Risk Factors and the Success of Conservative Treatment

Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Intraoperative Imaging of Nipple Perfusion Patterns and Ischemic Complications in Nipple-Sparing Mastectomies

Nipple-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. Ischemic complications involving the nipple-areolar complex (NAC) occur in 3-37 % of cases. Skin perfusion can be monitored intraoperatively using indocyanine green (IC-GREEN™, ICG) and a specialized infrared camera-computer system (SPY Elite™). The blood flow pattern to the breast skin and the NAC were evaluated and a classification scheme was developed. Preincision baseline and postmastectomy skin perfusion studies were performed intraoperatively using 3 mL of ICG. The pattern of arterial blood inflow was classified according to whether perfusion appeared to originate predominantly from the underlying breast tissue (V1), the surrounding skin (V2), or a combination of V1 and V2 (V3). Ischemia, resection, or delayed complications of NAC were recorded. Thirty-nine breasts were interrogated. Seven (18 %) demonstrated a V1 pattern, 18 (46 %) a V2 pattern, and 14 (36 %) a V3 pattern. Seven (18 %) NACs were removed; six intraoperatively and the seventh in a delayed fashion. Notably, five of the seven resected NACs had a V1 pattern. Overall, 71 % of all V1 cases demonstrated profound ischemic changes by intraoperative clinical judgment and SPY imaging. The rates of resection of the NAC differed significantly between perfusion patterns (Fisher's exact test, p = 0.0003). Three perfusion patterns for the NAC are defined. The V1 pattern had the highest rate of NAC ischemia in NSM. Imaging NAC and skin perfusion during NSMs is a useful adjunctive tool with potential to direct placement of mastectomy incisions and minimize ischemic complications.

Revisiting the Free Nipple Graft: An Opportunity for Nipple Sparing Mastectomy in Women with Breast Ptosis

Nipple areolar complex (NAC) sparing mastectomy improves the cosmetic outcome of patients with breast cancer. However, women with significant breast ptosis are not candidates for this technique due toexcessive skin flap length and ensuing risk of NAC ischemia.1 (-) 3 We report a novel technique using free nipple graft during skin sparing mastectomy for patients with significant ptosis while concurrently maintaining oncologic integrity. Case series. Community and tertiary care hospital practices. Women with breast cancer desiring NAC preservation who are otherwise candidates for nipple sparing mastectomy, but with significant breast ptosis that precludes NAC viability. All women underwent immediate, autologous breast reconstruction. Bilateral and unilateral free nipple grafts were harvested, placed on ice during skin sparing mastectomy and free flap reconstruction, grafted at the conclusion of the case and secured with a bolster. Full or partial NAC preservation, ischemia time, local wound complications at NAC grafting site, pathologic outcomes. A total of three patients underwent free nipple grafting at the time of skin sparing mastectomy and free or pedicled flap for breast cancer between March and September 2012. Of five total nipple grafts, one had partial NAC loss but did not require operative debridement. Pathologic review of areolar tissue removed during intraoperative defatting of free nipple graft demonstrated residual duct epithelium. Women with significant breast ptosis that would preclude them from NAC sparing mastectomy can successfully preserve their NAC using a free nipple graft. Duct epithelium present in defatted tissue during preparation of the free nipple graft suggests that oncologic integrity can also be maintained.

Feasibility of Performing Total Skin-Sparing Mastectomy in Patients With Prior Circumareolar Mastopexy or Reduction Mammoplasty Incisions.

Total skin-sparing mastectomy (TSSM) techniques with preservation of the nipple-areolar complex (NAC) skin are becoming increasingly popular due to improved cosmesis without compromise in oncologic safety. However, these techniques are not routinely offered to patients who have undergone previous breast surgery involving circumareolar incisions due to concern for NAC viability. We reviewed the outcomes of TSSM in 11 patients who underwent 21 TSSM procedures at our institution between 2008 and 2011. All patients had undergone previous breast surgery including reduction mammaplasty (7 breasts), mastopexy (4 breasts), augmentation (3 breasts), and combined mastopexy-augmentation (7 breasts). Incisions from previous breast surgery included circumareolar (11 cases) and Wise pattern (10 cases) incisions. All patients underwent TSSM through an inframammary incision followed by immediate tissue expander reconstruction and subsequent implant exchange. Patient demographics, previous breast surgery details, tumor and treatment characteristics, and postoperative complications were reviewed. Mean patient age was 43 years (range, 35-53 years) and mean body mass index was 24 kg/m (range, 19-32 kg/m). Mean follow-up was 10.2 months (range, 3-20 months).Indications for TSSM included prophylactic risk reduction in 10 cases, in situ cancer in 2 cases, and invasive cancer in 9 cases. Mean time from previous breast surgery to mastectomy was 6.9 years (range, 6 months-26 years). Major complications requiring operative reintervention included 1 (4.8%) case of cellulitis requiring expander removal and 2 (9.5%) cases of wound breakdown requiring operative closure. There were no complications involving the NAC. Total skin-sparing mastectomy with immediate reconstruction can safely be performed in patients who have undergone previous breast surgery involving circumareolar incisions. Our preferred technique in this group of patients is to perform TSSM through an inframammary incision with 2-stage expander-implant reconstruction to minimize NAC ischemia and subsequent complications.

Abstract P4-14-01: Incidence rate of nipple areolar complex ischemia after nipple sparing mastectomy. Analysis of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry.

Abstract Objectives: The American Society of Breast Surgeons (ASBS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non- randomized, IRB approved multi-center registry. The ASBS NSMR has been designed to facilitate compilation of information on metrics utilized, techniques utilized, aesthetic outcomes, as well as oncologic outcomes for the nipple sparing mastectomy. The NSMR will be ongoing for 10 years with an initial N of 1000. Patient selection entails all patients undergoing a NSM at the participating institutions who have agreed to participate. We evaluated the incidence rate of nipple or nipple areolar complex ischemia after a nipple sparing mastectomy. Method: The first 173 patients entered into the ASBS NSMR (2011–2012) were analyzed for incidence rate of ischemia of the nipple or nipple areolar complex (NAC). Ischemia is defined as epidermolysis (partial thickness necrosis) or full thickness necrosis. Metrics analyzed included: postoperative NAC status, indication for surgery, patient characteristics, incision utilized, sub areolar and flap dissection technique, as well as cosmetic outcomes. Results: (Thirty-five) surgeons entered 265 NSMs on 173 patients into the ASBS NSM Registry. Indications included invasive carcinoma, DCIS, and prophylaxis. Incisions utilized included radial +/− peri -areolar extension, infra mammary fold, peri- areolar ellipse/ hemi batwing, previous lumpectomy site, and previous mastopexy incisions. Sub areolar and flap dissection technique included sharp +/− tumescent injection, electrocautery, or plasma blade. Reconstruction type included tissue expander, immediate implant, or autologous flap. Median follow-up was 5 months (range 1–16 months). The nipple or NAC in 33 (12%) of 265 mastectomies experienced some degree of ischemia. Out of a total of 265 mastectomies 3 (1%) required surgical debridement, 1 (0.3%) required surgical excision, and 29 (11%) experienced epidermolysis with full recovery (17 topical treatment and 12 no treatment). No correlation in incision type, method of dissection, utilization of separate axillary incision for SLNBx/AXLND, size or location of tumor, type of reconstruction, initial fill volume if tissue expanders utilized, previous breast surgery, previous radiation therapy, previous chemotherapy, smoking history, cup size, degree of ptosis, or indication for surgery was found in NACs undergoing ischemia versus those that did not. Cosmetic outcome assessed by the surgeon as well as patient satisfaction did not vary from the population that did not experience nipple/NAC ischemia. Cosmetic results were rated consistently as good or excellent. Conclusion: We report a 12% incidence rate of nipple or nipple areolar complex ischemia ranging from epidermolysis to full thickness necrosis: 3 (1%) requiring surgical debridement, 1 (0.3%) requiring excision, and 29 (11%) exhibiting epidermolysis with full recovery. Surgical debridement or excision was rarely necessary. Epidermolysis was found to resolve with no bearing on perceived cosmetic outcome. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-01.

Place de la réduction mammaire à pédicule supérieur dans les gigantomasties

Subject. – The authors present technical details, complications, morphologic and aesthetic results of 26 breast reduction mammaplasty for macromastia (breast reduction more than 1000 g) showing advantages and reliability of technique. Materials and methods. – From January 2000 to December 2001, 223 patients underwent bilateral reduction mammaplasty with superior-based pedicled dermo-glandular flap. In 26 of them the weight of removed mammary tissue was over 1000 g in each breast. These 26 cases were evaluated, and the criteria adopted to analyse the results was morphologic and aesthetic evaluation of patient herself (very good, good, acceptable, unacceptable). Results. – Mean follow-up for all patients was 15 months. Twenty-six patients (mean age 33.2 years) underwent an average weight of 1131 g (930/2200 g) removed per breast. The following complications were observed: 1 Nipple Areolar Complex ischemia without necrosis; three infections (abscess); four delayed wound closure. The patient subjective evaluation of result was: “very good” in 19 cases (73%); “good” in 5 cases (19.2%) and “acceptable” in the others two cases (7.8%). No case was evaluated “unacceptable”. Conclusion. – Superior dermoglandular pedicle mammaplasty represent a very good and reliable solution for the treatment of macromastia, giving satisfactory cosmetics results with good nipple viability without necrosis. This technique is actually our first choice in the management of macromastia.