Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction

Abstract

BackgroundAutologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution.MethodsWe reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis.ResultsEighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery.ConclusionsNAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

Can Vascular Patterns on Preoperative Magnetic Resonance Imaging Help Predict Skin Necrosis after Nipple-Sparing Mastectomy?

“…However, NAC and skin flap ischemia and necrosis can occur and result in morbidity to the patient. Previous studies have reported various patient, clinical, and surgical factors, such as age, smoking history, and type of surgical incision, that are associated with ischemic and necrotic complications after NSM (2,9,14,15,19,21,22). Our study is unique in that it addresses vascular features on pre-operative MRI that are predictive of ischemic and necrotic complications.…”

“…Several factors associated with NAC and skin flap ischemia and necrosis have been reported, including age, body mass index (BMI), smoking history, hypertension/diabetes mellitus, pre-operative radiation therapy, oncologic indication for NSM, breast volume, type of incision, reconstruction approach, and NAC involvement with areola flap thickness less than 5 mm (2,9,14,15,19,21,22,25). To our knowledge, however, there are no published studies on the vascular supply to the breast, as characterized by pre-operative MRI, and its association with NAC and skin flap ischemia and necrosis.…”

Immediate breast reconstruction following nipple-sparing mastectomy in an Asian population: Aesthetic outcomes and mitigating nipple-areolar complex necrosis

“…Various methods have been described to mitigate NAC necrosis. These include banking the NAC as a free graft [ 13 ], adding a delay procedure prior to NSM [ 14 ], and banking a skin paddle from the autologous flap beneath the mastectomy flaps [ 15 , 16 ]. We prefer the skin banking method, as it permits prompt healing by primary intention, thus avoiding a nonhealing wound during chemotherapy.…”

Microsurgical Flaps in Nipple Sparing Mastectomy: Surgical Techniques and Aesthetic Principles

“…Furthermore, the patients desired postoperative volume may help guide the aesthetic of the reconstructive surgeon. Mastectomies of greater volume are associated with higher rates of NAC necrosis [16]. Thus, one may argue that the ideal candidate for NSM is a patient with small/moderate-sized breasts with minimal ptosis.…”