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

• Published in: Annals of surgical oncology Vol. 23; no. 8; pp. 2665 - 2672
• Main Authors: Bertoni, Danielle M., Nguyen, Dung, Rochlin, Danielle, Hernandez-Boussard, Tina, Meyer, Shannon, Choy, Nicole, Gurtner, Geoffrey C., Wapnir, Irene L.
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 01.08.2016; Springer Nature B.V
• Subjects: Adult; Aged; Breast Neoplasms - complications; Breast Neoplasms - pathology; Breast Neoplasms - surgery; Female; Follow-Up Studies; Humans; Indocyanine Green; Ischemia - etiology; Ischemia - prevention & control; Mastectomy - adverse effects; Medicine; Medicine & Public Health; Middle Aged; Nipples - blood supply; Nipples - surgery; Oncology; Organ Sparing Treatments - methods; Perfusion; Postoperative Complications; Prognosis; Reconstructive Oncology; Skin - blood supply; Surgery; Surgical Oncology; Ischemic Complication; Perfusion Pattern; Nipple; Baseline Perfusion; Mastectomy Flap Necrosis
• ISSN: 1068-9265; 1534-4681
• DOI: 10.1245/s10434-016-5201-8

Background 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. Methods Surgical devascularization of the NAC was performed 3–6 weeks 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. Results 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. Conclusion 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.