Background

The evaluation of adequate arterial and venous flow within the nipple-areolar complex (NAC) during breast reduction surgery can be clinically difficult, especially in very pale or very dark skin tones.

Objectives

We review our experience with fluorescent intraoperative tissue angiography (FITA) with indocyanine green (ICG) to evaluate nipple vascularity during breast reduction surgery.

Methods

Twelve women underwent breast reduction surgery, resulting in 21 reduction mammaplasties.  A color tone, from six color types, was noted for each nipple.  Pedicle design included a superomedial pedicle (14 reductions), superior pedicle (6 reductions), and inferior pedicle (2 reductions).  While each NAC was examined in standard intraoperative fashion, each NAC was also imaged using FITA (Novadaq Spy SP2001, Mississauga, Ontario, Canada)with ICG (Akorn, Buffalo Grove, IL).  Imaging occurred at three stages: immediately after dissection of the nipple-areolar pedicle, immediately after inset of the NAC, and ten minutes after inset of the NAC.  As an internal control, images were compared in arterial and venous phases against that of the adjacent breast flaps for possible arterial or venous compromise.
Results

Three nipples exhibited an extremely pale color tone, six nipples a cream tone, seven nipples a tan tone, and two nipples a dark brown tone.  The average reduction weight was 635 gms.  While clinical appreciation of nipple vascularity within very pale or dark brown nipples was more challenging, each nipple-areolar complex exhibited excellent comparative fluorescent arterial inflow and venous outflow before and after inset.  No further surgical dissection, either of the pedicle or the breast flaps, was required.  Each breast completed subsequent uneventful healing with acceptable cosmetic appearance.

Conclusions

FITA with ICG rapidly assists the surgeon to evaluate both nipple perfusion and venous outflow during breast reduction surgery.  Imaging can be completed multiple times during one operative case. This technology may assist decision making regarding technique during breast reduction surgery, especially in patients with very light or dark skin tones or in cases of suspected nipple vascular compromise.