Application of preoperative three-dimensional vascular reconstruction assessment in preventing ischemic complications...

Ischemic complications are common and severe postoperative complications in nipple-sparing mastectomy (NSM). This study aimed to evaluate the impact of preoperative three-dimensional (3D) vascular reconstruction assessment on the incidence of ischemic complications following laparoscopic-assisted NSM.

In this prospective randomized trial (October 2023-November 2024), 126 women scheduled for laparoscopic-assisted NSM were allocated 1:1. The experimental group underwent preoperative breast MRI (1mm slices) segmented in Mimics Software to create a 360° vascular heat-map that was projected onto the skin after induction. Under endoscopy, electrocautery dissected along the superficial fascia in perforator-rich zones, preserving a 2mm adipose cuff and clipping side branches; avascular zones were dissected with a scalpel after tumescence (500mL saline + 1mg adrenaline), avoiding thermal injury. Control group received electrocautery alone without mapping. Primary endpoint was nipple-areola complex ischemia at 1 and 2 weeks.

A total of 126 patients were enrolled, with 39 cases (31.0%) experiencing ischemic events 1 week postoperatively. Two additional cases of ischemic events occurred 2 weeks postoperatively, while three patients recovered from mild ischemia. The use of 3D vascular reconstruction was associated with a significant reduction in the incidence of ischemic complications ( P = 0.012). Among those with ischemic events 1 week postoperatively, 23 had perfusion injury or ischemic damage, 12 had partial-thickness necrosis, and 4 had full-thickness necrosis. The severity of ischemic complications in the second week was similar to the first week. Regarding secondary endpoints, patients who underwent preoperative assessment with 3D vascular reconstruction had shorter operation time; however, no statistically significant differences were observed in body mass index, resected breast weight, blood loss, or BREAST-Q scores.

Preoperative 3D vascular reconstruction assessment and the use of a combination of sharp dissection and electrocautery during dissection of skin flaps in laparoscopic-assisted NSM can significantly reduce the risk of ischemic complications.