Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)—analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features

Abstract

Background The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM). Methods We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap. Results A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel. Conclusion Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

“…In addition to a periareolar incision, old age and large mastectomy weights were also known risk factors for NAC ischemia/necrosis after NSM 16,36 . Age was not a significant predictor in our study; however, we found a relationship between increasing mastectomy weight and NAC compromise, with every 10-g increase in mastectomy weight being associated with at least a 1.10 higher odds of partial NAC necrosis.…”

“…This finding is ubiquitous in the literature, with numerous studies showing a dose-response relationship between increasing mastectomy weight and NAC necrosis complications. 16,36,37 Another finding of interest in this study is the potential protective effect of higher BMI on the NAC, as higher BMI was associated with lower odds of partial NAC necrosis. This directly contradicts the adage that obesity is associated with more postoperative complications after implant-based breast reconstruction that is well established in the literature.…”

“…Age was not a significant predictor in our study; however, we found a relationship between increasing mastectomy weight and NAC compromise, with every 10-g increase in mastectomy weight being associated with at least a 1.10 higher odds of partial NAC necrosis. This finding is ubiquitous in the literature, with numerous studies showing a dose-response relationship between increasing mastectomy weight and NAC necrosis complications 16,36,37 …”

Factors associated with alteration of nipple or skin sensation and impact of duration of time following nipple-sparing mastectomy (NSM): an analysis of 460 cases with comparison of conventional versus endoscopic- or robotic-assisted NSM

“…Novel surgical techniques of NSM, like endoscopic- or robotic-assisted NSM (R-NSM), had shown a decreased risk of nipple ischemia necrosis [ 12 , 13 ]. There has been a paucity of studies reporting on the effect of different surgical approaches on nipple or skin sensation post-surgery due to the relatively recent advent of these surgical methods in the past decade.…”

Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery

“…However, in this study, there were reports of no cases of flap necrosis in R-E-NSM, and necrosis of the NAC in the R-E-NSM group was lower than that in the C-E-NSM group (1.3% vs. 3.8%), as reported in other studies and even lower than other studies ( 27 – 30 ). Tissue necrosis is associated with damage to blood vessels and enlarged incisions during the operation, and periareolar incisions were identified as predictors of NAC necrosis ( 29 , 31 ). However, in the R-E-NSM group, gas can evenly expand tissue and expose it well, reducing the damage to surrounding tissues and blood vessels and combining minimal peri-areola accessory incision (HUAXI hole 1), thereby decreasing necrosis complications.…”