Intraoperative Assessment of the Relationship Between Nipple Circulation and Incision Site in Nipple-Sparing Mastectomy With Implant Breast Reconstruction Using the SPY Imaging System.

INTRODUCTION: Nipple-sparing mastectomy (NSM) and immediate breast reconstruction with gel implants have grown in popularity because of superior aesthetic outcomes. One risk of this procedure is overexcision of the flap leading to inadequate circulation in the breast envelope. METHODS: We investigated 17 cases of NSM and gel implant breast reconstruction. Patients were divided into an infra-areolar incision group and a supra-areolar incision group. Nipple-areolar complex perfusion was evaluated using the SPY imaging system after NSM and gel implant breast reconstruction. We aimed to discover any relationships between the incision method and nipple-areolar complex (NAC) circulation in NSM and gel implant breast reconstruction. RESULTS: For successful breast surgery, awareness of the blood supply to the breast, especially the NAC, is very important. In our study, with the indocyanine green SPY imaging system, most ingress (arterial inflow) and egress (venous outflow) rates in the infra-areolar incision group were better than those in the supra-areolar incision group (P < 0.005). CONCLUSIONS: We have shown that an infra-areolar incision provides better blood flow following NSM and gel implant breast reconstruction. In our experience, in order to prevent the possible ischemia of NAC, we used the smaller gel implants, which is approximately 10 to 20 mL smaller than the original implant size measured by the sizer, if the egress rate of NAC is lower than 0.2. These findings have implications in the clinical setting as surgeons have a choice to provide a better outcome for patients.

Quantitative assessment of nipple perfusion with near-infrared fluorescence imaging.

Preserving the nipple-areolar complex with a nipple-sparing mastectomy improves cosmesis compared with skin-sparing mastectomy. However, complications such as necrosis of the nipple-areolar complex significantly affect cosmetic outcome. Many factors influence nipple-areolar perfusion, and no consensus currently exists on optimal incisional choice. This study evaluates 2 nipple-sparing mastectomy incision models using near-infrared fluorescence to assess perfusion quantitatively. The periareolar and radial incisions were compared with 2 control models in Yorkshire pigs (N = 6). Methylene blue and indocyanine green were injected intravenously, and near-infrared fluorescence images were recorded at 3 time points: before surgery, immediately after (0 hour), and 3 days postoperatively. Contrast-to-background ratio was used to assess perfusion. At 72 hours, radial incisions showed a statistically significantly higher perfusion compared with periareolar incisions (P < 0.05). Based on our findings, radial incisions for nipple-sparing mastectomy may be preferable due to higher perfusion; however, clinical trials are necessary for further assessment.

Immediate prosthetic breast reconstruction: the ensured subpectoral pocket (ESP).

Implant exposure due to cutaneous necrosis is one of the most feared complications of mastectomy with immediate prosthetic reconstruction. A key issue is to ensure good blood supply to the skin and complete integrity of the submuscular pocket. The latter is created with the pectoralis major and supplemented with the serratus anterior, the rectus abdominis sheat, the obliquus mayor and the pectoralis minor. The main drawback is that those muscles, when sutured to create a complete pocket, only allow the setting of small-sized implants. The authors present the application of polyglycolic mesh in an original fashion, mimicking the anatomy of the muscles usually employed in pocket creation. The proposed technique has been denominated Ensured Subpectoral Pocket and has proved to be a valid strategy in immediate single stage prosthetic breast reconstruction. It allows the setting of bigger implants without previous tissue expansion while preventing implant displacement. In addition, it reduces emotional trauma on patients and lowers surgical costs.