title: Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA, wapnir@stanford.edu.
authors.forename: Irene
authors.initials: I
authors.lastname: Wapnir
authors.forename: Monica
authors.initials: M
authors.lastname: Dua
authors.forename: Anne
authors.initials: A
authors.lastname: Kieryn
authors.forename: John
authors.initials: J
authors.lastname: Paro
authors.forename: Douglas
authors.initials: D
authors.lastname: Morrison
authors.forename: David
authors.initials: D
authors.lastname: Kahn
authors.forename: Shannon
authors.initials: S
authors.lastname: Meyer
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Gurtner
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007208:Indocyanine Green; D007511:Ischemia / Q000175:diagnosis*; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D009367:Neoplasm Staging; D009558:Nipples / Q000098:blood supply* / Q000601:surgery; D059351:Organ Sparing Treatments; D011183:Postoperative Complications; D011379:Prognosis; D012867:Skin / Q000098:blood supply*
chemical_list: D007208:Indocyanine Green