Indocyanine Green Angiography-Assisted Pure Hemi-Periareolar Incision Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Although pure hemi-periareolar incisions for mastectomy can prevent visible scarring, nipple-areolar complex (NAC) necrosis is a potential risk. Superficial-arterial inflow of the NAC can be evaluated by indocyanine green angiography (ICG-A). This study evaluated the impact of ICG-A assisted periareolar incision on NAC necrosis during nipple-sparing mastectomy (NSM) and direct-to-implant (DTI) breast reconstruction. Between December 2018 and November 2021, lateral hemi-periareolar incisions for NSM were routine. After that time, ICG-A-assisted hemi-periareolar incisions were performed between December 2021 and Sept. 2023. The location of the main arterial inflow was evaluated during preoperative ICG-A and the periareolar incision was planned to avoid disruption. NAC necrosis in the ICG-A-assisted and blind-incision groups was compared using univariate and multivariate analyses. A total of 202 breasts were analyzed including 80 breasts from 75 patients in the ICG-A-assisted group and 122 breasts from 115 patients in the blind-incision group. On preoperative ICG-A, superficial-arterial inflow was observed in 67 of 80 (83.75%) breasts. Perfusion of the nipple without superficial-arterial inflow (base-perfusion pattern) was observed in 13 breasts (16.25%). The main arterial inflow was most common in the upper-medial direction at the areolar margins (65.67%). The full-thickness NAC necrosis rate in the ICG-A-assisted incision group was significantly lower than that in the blind-incision group (2.5% vs. 13.1%, p = 0.010). Multivariate analysis demonstrated that ICG-A-assisted incisions significantly reduced the risk of NAC necrosis (odds 0.155, p = 0.030). ICG-A-assisted pure hemi-periareolar incisions reduced NAC necrosis in DTI breast reconstructions.