Novel Approach for Nipple-Areolar Complex Preservation after Subglandular Mastopexy-Augmentations, Mastopexies and Breast Reductions
Methods/Technique: For the last 20 years, the senior surgeon has used a novel, previously unreported technique for NAC preservation in breast surgeries that place the NAC at higher risk for developing partial or complete postoperative necrosis: Breast reductions, mastopexies, and mastopexy-augmentations. Mastopexies were performed using the superior pedicle and either wise-pattern or vertical skin resection technique. All mastopexy-augmentations were performed using the superior pedicle technique for the mastopexy and either subglandular or submuscular pocket for the augmentation via either the vertical or inframammary incision. For all patients in these surgical categories, 2% nitroglycerin ointment is applied to the NACs at case conclusion after tapes were applied to the incision lines and reapplied every 6 hours thereafter. If the NACs had a dusky or altered color after nitroglycerin application, the patient was sent home (or to hotel) on supplemental oxygen via nasal cannula to be worn continuously throughout the night. All patients were re-evaluated in the clinic the following morning on postoperative day 1 (POD1). If the NAC color had normalized, the supplemental oxygen was discontinued and nitroglycerin ointment continued until the patient ran out of their supply (usually within one week postoperatively). If the NAC color continued to appear a little dusky or have a delayed capillary refill on POD1, a prescription for an oxygen generator was provided to the patient with supplemental oxygen worn continuously with daily photo reassessment by the senior surgeon. Once NAC color normalized, O2 therapy and nitroglycerin was discontinued (usually by 5 days postoperatively). If the NACs appeared very dark during the morning exam on POD1, patients were sent for same-day hyperbaric oxygen therapy (HBO).
Results/Complications: Five years of data were pulled for all breast reductions, mastopexies, or mastopexy-augmentations performed by the senior surgeon at an outpatient surgery center between January 1, 2020 and January 1, 2025. A total of 63 breast reductions, 540 mastopexies, 29 saline mastopexy-augmentations, and 117 silicone mastopexy-augmentations (146 total mastopexy-augmentations) were performed during this timeframe. All patients had 2% nitroglycerin ointment applied to the NACs at case conclusion after incision dressings were placed; nitroglycerin ointment was reapplied every 6 hours overnight by the patients’ caregivers. Any patients whose NACs remained dusky after nitroglycerin ointment application in the recovery room were sent home on supplemental oxygen via nasal cannula. All patients were examined in clinic the next morning to assess NAC color and perfusion by physical exam. Any patients with worsening or darkly dusky NAC color were sent for HBO treatment on POD#1. All cases of dusky NACs resolved fully within 2 HBO dives or within 5 days of supplemental O2 therapy via nasal cannula. No partial or complete NAC necrosis occurred during this 5-year timeframe. Moreover, no NAC necrosis has occurred for the senior surgeon in the last 20 years of practice with meticulous examination of NAC perfusion.
Conclusion: Our novel postoperative algorithm preserves NAC viability during even the most compromising surgeries including subglandular mastopexy-augmentations without utilization of costly surveillance equipment.