Venous Drainage and Nipple-Areolar Complex Necrosis After Nipple-Sparing Mastectomy: A Cadaveric and Prospective Clinical Cohort Study.

BACKGROUND

Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) offers excellent aesthetic outcomes, but nipple-areolar complex (NAC) necrosis remains a major complication. Although arterial insufficiency has been emphasized, venous injury may also play a critical role.

OBJECTIVES

The aim of this study was to characterize NAC venous anatomy and determine whether venous injury contributes to clinically significant NAC necrosis after NSM.

METHODS

The authors performed a cadaveric study of superficial periareolar venous anatomy and a prospective clinical cohort study of 123 breasts undergoing NSM with immediate IBBR. Cutaneous NAC veins were visualized using near-infrared (NIR) imaging, and venous injury was quantified as vein branch loss (VBL). We evaluated predictors of clinically significant NAC necrosis and developed a prediction model compared with intraoperative indocyanine green angiography (ICGA) in 32 breasts.

RESULTS

Cadaveric dissection demonstrated a polygonal venous network adjacent to the areolar margin. In the clinical cohort, significant NAC necrosis occurred in 19 of 123 breasts (15.4%). On univariate analysis, higher VBL, greater mastectomy weight, higher BMI, and diabetes were associated with NAC necrosis (P < .05). Multivariable analysis demonstrated that the effect of VBL increased with mastectomy weight. The final model showed strong discrimination (area under the receiver operating characteristic 0.902; 95% CI, 0.82-0.98) and identified a low-risk subset among breasts with poor ICGA perfusion in which no significant NAC necrosis occurred.

CONCLUSIONS

Venous integrity is a key determinant of NAC viability after NSM. NIR-based vein analysis enables quantitative assessment of venous injury and may complement ICGA in perioperative risk stratification and surgical planning.

LEVEL OF EVIDENCE: 4 (RISK): For image description, please refer to the figure legend and surrounding text.