Highlight
- Nipple-areolar complex (NAC) necrosis remains a significant complication despite advances in nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR).
- Venous drainage plays a critical role in NAC viability, with venous injury correlating strongly with clinically significant NAC necrosis.
- Near-infrared (NIR) imaging enables quantitative assessment of NAC venous branches intraoperatively, facilitating risk stratification when combined with indocyanine green angiography (ICGA).
- A predictive model incorporating venous injury and mastectomy weight offers strong discrimination to identify patients at risk and guide surgical decision-making.
Study Background
Nipple-sparing mastectomy (NSM) combined with immediate implant-based breast reconstruction (IBBR) has transformed breast cancer surgery by delivering superior aesthetic outcomes while maintaining oncologic safety. Preservation of the nipple-areolar complex (NAC) is vital to patient satisfaction, but it is often complicated by ischemic events leading to NAC necrosis, which can compromise cosmetic results and increase morbidity.
Historically, arterial blood supply insufficiency has been the primary focus of research and intraoperative assessment to predict NAC viability. However, venous drainage pathways may be equally important, as they facilitate outflow and prevent congestion, which can precipitate tissue necrosis despite adequate arterial inflow. The venous anatomy around the NAC and its role in post-NSM necrosis have been less thoroughly characterized.
Study Design
This investigation comprised two key components: an anatomical cadaveric study and a prospective clinical cohort study.
The cadaveric phase mapped the superficial venous network adjacent to the areolar margin, focusing on the polygonal venous architecture that drains the NAC region.
The clinical study prospectively enrolled 123 breasts undergoing NSM with immediate IBBR. Near-infrared (NIR) imaging technology was utilized intraoperatively to visualize cutaneous NAC veins, quantifying venous injury as vein branch loss (VBL). Clinical endpoints included the incidence of significant NAC necrosis, defined by necrosis extent and clinical impact.
Predictors of necrosis were assessed by univariate and multivariable statistical analyses. Additionally, a subset of 32 breasts underwent intraoperative indocyanine green angiography (ICGA) to evaluate arterial perfusion, facilitating comparison and complementary risk prediction by combining venous and arterial parameters.
Key Findings
The cadaveric dissection confirmed a polygonal network of superficial veins immediately adjacent to the areolar margin, underscoring the complexity of venous drainage in this critical region.
In the clinical cohort, significant NAC necrosis occurred in 15.4% (19 of 123 breasts), reaffirming the persistent clinical challenge.
Univariate analysis identified several correlates of necrosis: increased vein branch loss (VBL), higher mastectomy specimen weight, elevated body mass index (BMI), and presence of diabetes mellitus (all P < .05).
Multivariable modeling revealed a significant interaction between VBL and mastectomy weight, suggesting that larger resections exacerbate the impact of venous injury on NAC viability.
The final prediction model demonstrated excellent discriminative ability (area under the receiver operating characteristic curve 0.902; 95% CI, 0.82–0.98). Notably, it identified a low-risk subgroup within breasts showing poor arterial perfusion by ICGA who nonetheless experienced no significant NAC necrosis, highlighting venous integrity as a crucial complementary factor.
The integrated use of NIR-based venous imaging with ICGA offers a more comprehensive assessment of NAC viability than arterial perfusion alone, enabling enhanced intraoperative decision-making and tailored surgical planning.
Expert Commentary
These findings underscore an evolving paradigm in breast reconstructive surgery, shifting focus from primarily arterial to also include venous considerations in the prevention of ischemic complications. The innovative use of near-infrared imaging for venous assessment advances the surgeon’s armamentarium for real-time evaluation.
However, the study’s limitations include the observational design and a single-center cohort, which may influence generalizability. Further multicenter validation and standardization of imaging protocols are warranted. Moreover, the practical integration of venous imaging into routine clinical workflows requires feasibility assessments.
Mechanistically, the interplay of venous outflow with tissue perfusion and edema dynamics provides biological plausibility to the observed association between venous injury and NAC necrosis. Prior studies have documented similar ischemia-reperfusion injury patterns where compromised venous drainage exacerbates tissue damage despite adequate arterial inflow.
Conclusion
Venous drainage integrity represents a pivotal determinant of NAC viability following nipple-sparing mastectomy. Quantitative assessment of venous injury using near-infrared imaging complements arterial perfusion evaluation via ICGA, collectively enhancing prediction of NAC necrosis risk.
This dual-imaging approach facilitates nuanced perioperative risk stratification, guides intraoperative surgical strategy, and may reduce NAC necrosis incidence. Future research should focus on refining this combined imaging technique, validating predictive models, and integrating findings into clinical guidelines to optimize patient outcomes.
Funding and Clinicaltrials.gov
The study was supported by institutional research funds; specific grant information was not stated. There was no mention of registration on Clinicaltrials.gov.
References
Yoon S, Park SO, Imanishi N, Zhu Y, Chang H. Venous Drainage and Nipple-Areolar Complex Necrosis After Nipple-Sparing Mastectomy: A Cadaveric and Prospective Clinical Cohort Study. Aesthetic Surgery Journal. 2026 Sep 16;46(10):1127-1136. PMID: 42336360.
Additional relevant literature:
- Spear SL, Parikh RP. Nipple-Sparing Mastectomy and Reconstruction. Plast Reconstr Surg. 2017;140(5S):40S-48S.
- Losken A, Dugal CS, Styblo TM, Carlson GW, Jones GE. Indocyanine green angiography in nipple-sparing mastectomy: predicting necrosis. J Surg Oncol. 2014;110(2):146-149.
- Robertson SA, Ashton MW. The role of venous outflow in flap viability: A review. Microsurgery. 2015;35(4):302-311.
