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

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ID: 318660
2026
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Abstract
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: To characterize NAC venous anatomy and determine whether venous injury contributes to clinically significant NAC necrosis after NSM. METHODS: We performed a cadaveric study of superficial peri-areolar 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 body mass index, 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 (AUROC 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. CONCLUSION: 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.
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openalex_W7165789125 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Sehoon Yoon, Seong Oh Park, Nobuaki Imanishi, Ying Zhu, Hak Chang
Journal Aesthetic surgery journal
Year 2026
DOI
10.1093/asj/sjag125
URL
https://doi.org/10.1093/asj/sjag125
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