Nipple-areolar complex ischemia and necrosis in nipple-sparing mastectomy

Introduction: Nipple-sparing mastectomy (NSM), combined with immediate breast reconstruction, has become the preferred surgical option to achieve better patient satisfaction and aesthetic outcome. However, nipple-areolar complex (NAC) ischemia and necrosis are common complications following nipple-sparing technique. Materials and methods: We performed a retrospective analysis of 220 breasts that underwent NSM and immediate reconstruction from May 2010 to December 2016 at our institute. For accurate evaluation of ischemia rate after nipple-sparing mastectomy, we suggested a nipple-areolar ischemia grading system. We also found association between various factors and complications of nipple-areolar complex through statistical analysis. Results: Among 220 breasts that underwent NSM in 207 patients, ischemia occurred in 141 (64.1%) breasts. However, necrosis required surgical reoperation in only 69 (31.3%) breasts. Patient factor affecting NAC complications was existence of ptosis. Also, surgical techniques for periareolar incision as well as oncologic surgeon's technique impacted NAC necrosis. Reconstruction methods including direct to -implant, latissimus dorsi island flap with implant, and transverse rectus abdominis free flap showed higher rate of necrosis compared to tissue-expander reconstruction. Conclusion: We clarified factors that affect NAC necrosis. Among them, modifiable factors were skin tension and periareolar incision. When periareolar incision is necessary, lower periareolar incision is safer than upper periareolar incision to preserve vascularity of NAC. (C) 2018 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.