title: Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.
abstract: BACKGROUND
  Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery at New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York.
authors.forename: Briar L
authors.initials: BL
authors.lastname: Dent
authors.forename: Kevin
authors.initials: K
authors.lastname: Small
authors.forename: Alexander
authors.initials: A
authors.lastname: Swistel
authors.forename: Mia
authors.initials: M
authors.lastname: Talmor
mesh_terms: D000279:Administration, Cutaneous; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001414:Bacitracin / Q000008:administration & dosage; D019928:Breast Implantation / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D015414:Mastectomy, Subcutaneous / Q000009:adverse effects*; D008875:Middle Aged; D009558:Nipples / Q000098:blood supply* / Q000601:surgery*; D009824:Ointments; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D009824:Ointments; D001414:Bacitracin
keywords: breast reconstruction; complications; conservative treatment; implant-based reconstruction; implants; inframammary fold; ischemia; nipple-areolar complex; nipple-sparing mastectomy; tissue expanders