Peri-areolar dermal reinforcement to prevent prosthetic-related complications in prepectoral reconstruction with a compromised nipple-areola complex: a surgical technique

In prepectoral direct-to-implant (DTI) breast reconstruction following nipple-sparing mastectomy (NSM) via a hemi-periareolar incision, intraoperative ischemia of the nipple-areola complex (NAC) presents a critical challenge. Existing salvage procedures often require secondary interventions or NAC sacrifice, while leaving a vulnerable suture line resting directly over the implant-acellular dermal matrix (ADM) construct. To address this, we modified a de-epithelialized dermal flap technique, executed directly through the pre-existing incision, to interpose a protective biological barrier beneath the NAC base. This technique was applied in three female patients (aged 43 to 50 years) with breast cancer undergoing unilateral NSM and immediate prepectoral DTI reconstruction with ADM-wrapped implants. Following mastectomy and prior to implant placement, compromised NAC perfusion was recognized by dusky skin discoloration, qualitative indocyanine green angiography demonstrating reduced fluorescence, a capillary refill time of approximately 2 seconds, and preserved dermal edge bleeding. The maneuver was initiated based on the operating surgeon's clinical judgment. A 5- to 10-mm crescent adjacent to the areolar margin was de-epithelialized-leaving a 2- to 3-mm dermal bed-onto which the NAC-bearing flap was advanced and inset. Over follow-up periods ranging from 12 to 48 months, all three patients achieved complete NAC viability without partial or full-thickness necrosis, wound dehiscence, infection, implant exposure, or reoperation. Transient superficial epidermolysis developed on postoperative day 2 but resolved completely by days 14 to 17 with routine local wound care, and nipple position symmetry showed improvement in all cases. This preliminary experience demonstrates that immediate crescent de-epithelialization is technically feasible and yields acceptable clinical outcomes in selected cases. By establishing a dermal safety buffer against implant exposure, this maneuver offers a practical intraoperative salvage strategy. However, three cases from a single center cannot establish overall efficacy or superiority over alternative salvage methods, and larger prospective studies with standardized outcome metrics are required.