Annals of Surgical Oncology

, Volume 21, Issue 1, pp 100–106 | Cite as

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

  • Irene WapnirEmail author
  • Monica Dua
  • Anne Kieryn
  • John Paro
  • Douglas Morrison
  • David Kahn
  • Shannon Meyer
  • Geoffrey Gurtner
Breast Oncology



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.


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.


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).


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.


Nipple Myocutaneous Flap Ischemic Complication Perfusion Pattern Skin Perfusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



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.

Supplementary material

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Supplementary material 1 (DOCX 215 kb)

Supplementary material 2 (AVI 54491 kb)


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Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Irene Wapnir
    • 1
    Email author
  • Monica Dua
    • 1
  • Anne Kieryn
    • 1
  • John Paro
    • 1
  • Douglas Morrison
    • 1
  • David Kahn
    • 1
  • Shannon Meyer
    • 1
  • Geoffrey Gurtner
    • 1
  1. 1.Department of SurgeryStanford University School of MedicineStanfordUSA

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