Breast Oncology

Annals of Surgical Oncology

, Volume 21, Issue 1, pp 100-106

First online:

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

  • Irene WapnirAffiliated withDepartment of Surgery, Stanford University School of Medicine Email author 
  • , Monica DuaAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , Anne KierynAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , John ParoAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , Douglas MorrisonAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , David KahnAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , Shannon MeyerAffiliated withDepartment of Surgery, Stanford University School of Medicine
  • , Geoffrey GurtnerAffiliated withDepartment of Surgery, Stanford University School of Medicine

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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.