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Intraoperative Imaging of Nipple Perfusion Patterns and Ischemic Complications in Nipple-Sparing Mastectomies

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Abstract

Background

Nipple-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. Ischemic complications involving the nipple–areolar complex (NAC) occur in 3–37 % of cases. Skin perfusion can be monitored intraoperatively using indocyanine green (IC-GREEN™, ICG) and a specialized infrared camera–computer system (SPY Elite™). The blood flow pattern to the breast skin and the NAC were evaluated and a classification scheme was developed.

Methods

Preincision baseline and postmastectomy skin perfusion studies were performed intraoperatively using 3 mL of ICG. The pattern of arterial blood inflow was classified according to whether perfusion appeared to originate predominantly from the underlying breast tissue (V1), the surrounding skin (V2), or a combination of V1 and V2 (V3). Ischemia, resection, or delayed complications of NAC were recorded.

Results

Thirty-nine breasts were interrogated. Seven (18 %) demonstrated a V1 pattern, 18 (46 %) a V2 pattern, and 14 (36 %) a V3 pattern. Seven (18 %) NACs were removed; six intraoperatively and the seventh in a delayed fashion. Notably, five of the seven resected NACs had a V1 pattern. Overall, 71 % of all V1 cases demonstrated profound ischemic changes by intraoperative clinical judgment and SPY imaging. The rates of resection of the NAC differed significantly between perfusion patterns (Fisher’s exact test, p = 0.0003).

Conclusions

Three perfusion patterns for the NAC are defined. The V1 pattern had the highest rate of NAC ischemia in NSM. Imaging NAC and skin perfusion during NSMs is a useful adjunctive tool with potential to direct placement of mastectomy incisions and minimize ischemic complications.

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Acknowledgment

This study was funded in part by educational and research support provided by Novadaq Technologies and LifeCell to authors Geoffrey Gurtner, Irene Wapnir, Anne Kieryn, David Kahn and Shannon Meyer.

Author information

Correspondence to Irene Wapnir MD.

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Wapnir, I., Dua, M., Kieryn, A. et al. Intraoperative Imaging of Nipple Perfusion Patterns and Ischemic Complications in Nipple-Sparing Mastectomies. Ann Surg Oncol 21, 100–106 (2014). https://doi.org/10.1245/s10434-013-3214-0

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Keywords

  • Nipple
  • Myocutaneous Flap
  • Ischemic Complication
  • Perfusion Pattern
  • Skin Perfusion