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Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI

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Abstract

Background

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed. However, nipple areolar complex (NAC) and mastectomy skin necrosis represent significant complications requiring reoperation and revision. Breast MRI, often obtained for oncologic assessment, can visualize the dominant breast and NAC vascular supply. This study describes the surgical technique utilizing breast MRI blood flow information to preserve important NAC blood supply, thereby, reducing ischemic complications.

Methods

After IRB approval, a prospectively maintained database of all NSM by a single breast surgeon from 2018 to 2020 formed the study group. Preoperative contrast enhanced Breast MRI analysis determined the dominant NAC blood supply. Intraoperatively, the dominant Internal Mammary Artery Perforator (IMP) to the NAC was preserved (IMP-NSM). The IMP-NSM surgical technique preserving the IMP blood flow, evaluation of breast MRI blood flow patterns, surgical findings, and ischemic complications were analyzed.

Results

114 NSM were performed in 74 patients (mean age: 49 years [range, 22–73 years], BMI 25.8 kg/m2 [range, 19–41 kg/m2]). Breast MRI identified the dominant IMP to the NAC in 92%. IMP preservation was successful in 89% (101/114). Necrosis requiring NAC removal occurred in 0.9% (1/114), and skin necrosis reoperation in 1.8% (2/114). Including all post-operative necrosis occurred in 10.5% (12/114), statistically significantly lower compared to the literature for NSM assessing MRI blood flow data without surgical IMP preservation (necrosis 24.4%, p < 0.001) (Bahl et al. in J Am Coll Surg 223(2):279–285, 2016) utilizing Doppler for IMP preservation (necrosis 37%, p < 0.001) (Swistel et al. in Plast Reconstr Surg Glob Open 2(8):e198, 2014) and dividing the IMP in all (necrosis 31.4%, p < 0.001) (Ahn et al. in Eur J Surg Oncol 44(8):1170–1176, 2018).

Conclusions

The IMP-NSM surgical technique preserves the dominant blood supply to the NAC, thereby, decreasing ischemic complications.

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Acknowledgements

We would like to thank Jarrett Rosenberg, Biostatistician, Stanford University Department of Radiology for statistical analysis and Madeline Verbica, MS, Medical Animator, for figure preparation.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Division of General Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA

    Mardi R. Karin

  2. Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA

    Sunita Pal & Debra Ikeda

  3. Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA

    Max Silverstein & Arash Momeni

Authors
  1. Mardi R. Karin
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  2. Sunita Pal
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  3. Debra Ikeda
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  4. Max Silverstein
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  5. Arash Momeni
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Correspondence to Mardi R. Karin.

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The authors have no financial disclosures or conflicts of interest.

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The study was approved by the Stanford University Institutional Review Board.

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Accepted for Presentation at World’s Congress of Surgery 2022, Breast Surgery International Prize Abstract Session.

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Karin, M.R., Pal, S., Ikeda, D. et al. Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI. World J Surg 47, 192–200 (2023). https://doi.org/10.1007/s00268-022-06764-x

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