title: 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 3-6 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.
  
  
  
  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.
authors.affiliation: Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Danielle M
authors.initials: DM
authors.lastname: Bertoni
authors.affiliation: Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Dung
authors.initials: D
authors.lastname: Nguyen
authors.affiliation: Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Danielle
authors.initials: D
authors.lastname: Rochlin
authors.affiliation: Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Tina
authors.initials: T
authors.lastname: Hernandez-Boussard
authors.affiliation: Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Shannon
authors.initials: S
authors.lastname: Meyer
authors.affiliation: Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Choy
authors.affiliation: Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Geoffrey C
authors.initials: GC
authors.lastname: Gurtner
authors.affiliation: Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA. wapnir@stanford.edu.
authors.forename: Irene L
authors.initials: IL
authors.lastname: Wapnir
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007208:Indocyanine Green; D007511:Ischemia / Q000209:etiology / Q000517:prevention & control*; D008408:Mastectomy / Q000009:adverse effects*; D008875:Middle Aged; D009558:Nipples / Q000098:blood supply* / Q000601:surgery; D059351:Organ Sparing Treatments / Q000379:methods*; D010477:Perfusion; D011183:Postoperative Complications; D011379:Prognosis; D012867:Skin / Q000098:blood supply*
chemical_list: D007208:Indocyanine Green