Protecting nipple-areolar complex perfusion by devascularization and surgical delay

: The greatest challenge to nipple areolar complex (NAC) preservation during mastectomy has been ischemic complications which can range from epidermolysis to complete necrosis. Women with macromastia, ptosis, or smokers are at greater risk for these complications. Additional risk factors associated with ischemia that have been described include mastectomy incision placement, reconstruction type, and other known medical comorbidities. In this manuscript techniques for evaluation of skin perfusion patterns with angiography to aid in optimal incision placements and surgical delay are described. Devascularization of the NAC prior to a nipple sparing mastectomy is a surgical delay technique aimed at preventing irreversible skin ischemia. Devascularization consists of separating the NAC and surrounding skin from the underlying breast tissue. Similar to other surgical delay procedures utilized in other plastic reconstructive procedures, blood inflow through the skin is enhanced as a compensatory mechanism after the first stage devascularization. The first stage NAC devascularization can be performed with a lumpectomy procedure in patients with a newly diagnosed cancer and the second stage completion mastectomy is performed after 3 to 6 weeks later after temporary ischemic changes have resolved. The timing for completion mastectomy can also be adjusted for a later time point if more urgent systemic or locoregional treatment is needed. The utilization of a staged devascularization and delayed nipple sparing mastectomy allows more patients to achieve the desired aesthetic goals of nipple areolar preservation while minimizing ischemic complications, and most importantly does not compromise oncologic safety of the breast cancer patient.