Pedicle Selection and Design in Reduction Mammaplasty: The Role of Preoperative Fluorescence Imaging.

BACKGROUND: Breast reduction has a wide selection of pedicles but often relies on the surgeon's preference and experience. Necrosis of the nipple-areola complex (NAC) is a catastrophic complication of breast reduction surgery. OBJECTIVES: To solve the above problem objectively, we applied fluorescence imaging technology to the pedicle selection and design of breast reduction surgery for the first time, so that the dominant vessels of the NAC were included in the designed pedicle. METHODS: We retrospectively enrolled 120 patients with breast reduction (a total of 239 breasts). We compared 60 patients who underwent breast reduction without fluorescence imaging for pedicle selection (Group A) with 60 patients who underwent pedicle selection with fluorescence imaging (Group B). The NAC blood supply was monitored after the operation. RESULTS: In this study, 60 Group A cases (119 breasts) and 60 Group B cases (120 breasts) were analyzed. There were no statistically significant differences in patient demographic data or intraoperative resection weights. There were 7 cases of NAC necrosis in Group A (1 case of complete necrosis and 6 cases of partial necrosis), while no NAC necrosis occurred in Group B. There was a significant difference in the rate of NAC necrosis between the 2 groups. CONCLUSIONS: Preoperative fluorescence imaging can guide the selection and design of breast reduction, significantly reducing postoperative NAC blood supply obstacles and necrosis.

Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features.

BACKGROUND: The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM). METHODS: We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap. RESULTS: A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel. CONCLUSION: Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.

The Importance of Fifth Anterior Intercostal Vessels following Nipple-Sparing Mastectomy.

BACKGROUND: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy. METHODS: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator. RESULTS: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another. CONCLUSION: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

Blood supply of the male breast nipple-areola complex evaluated by CTA.

PURPOSE: In addition to women, men also undergo breast surgeries, and early studies on the blood supply of breasts are nearly all conducted in female subjects. The vasculature of the male breast is seldom studied. Understanding the male-specific blood supply of the breast is important for pre-operative planning and reducing complications. The purpose of this retrospective study is to fill the gap in the literature by describing the main blood supply and its orientation in the male breast. METHODS: We retrospectively evaluated thoracic computed tomographic angiography (CTA) data from January 1, 2017 to July 30, 2019. Single or multiple dominant arteries and their origins were traced, and the artery route and orientation related to the nipple-areola complex (NAC) were revealed through data analysis of the images. RESULTS: Totally, 284 breasts were included. Most breasts were supplied by a single dominant artery (196, 69%), among which the lateral thoracic artery (LTA; 119, 41.9%; type I) and internal thoracic artery (ITA; 63, 22.2%; type II) were the most common arteries. A minority of breasts were supplied by vascular anastomoses formed by dual arteries (17, 6.0%; type III), and in 25.0% of breasts, no specific dominant artery was found (type IV). The predominant artery distribution was evaluated. CONCLUSION: This study cohort of male thoracic CTA provided and analysed the elaborate vascular anatomy of the NAC region. Our results favour inferior periareolar incision in regard to diminished vascular-related complications in male surgeries without pre-operative vascular evaluation. This study also suggests that super-lateral or lower-lateral-based pedicles can reserve more vasculature.

Nipple Sparing Mastectomy as a Risk-Reducing Procedure for BRCA-Mutated Patients.

Growing numbers of asymptomatic women who become aware of carrying a breast cancer gene mutation (BRCA) mutation are choosing to undergo risk-reducing bilateral mastectomies with immediate breast reconstruction. We reviewed the literature with the aim of assessing the oncological safety of nipple-sparing mastectomy (NSM) as a risk-reduction procedure in BRCA-mutated patients. Nine studies reporting on the incidence of primary breast cancer post NSM in asymptomatic BRCA mutated patients undergoing risk-reducing bilateral procedures met the inclusion criteria. NSM appears to be a safe option for BRCA mutation carriers from an oncological point of view, with low reported rates of new breast cancers, low rates of postoperative complications, and high levels of satisfaction and postoperative quality of life. However, larger multi-institutional studies with longer follow-up are needed to establish this procedure as the best surgical option in this setting.

Evaluating the Image Quality of Monoenergetic Images From Dual-Energy Computed Tomography With Low-Concentration and Low-Flow-Rate Contrast Media for the Arterials Supply to the Nipple-Areola Complex in Breast Cancer Compared With Conventional Computed Tomography Angiography.

OBJECTIVE: The objective of this study was to evaluate the image quality of monoenergetic images (MEIs (+)) acquired from dual-energy computed tomography with low-concentration and low-flow-rate contrast media for the arterial supply to the nipple-areola complex (NAC) in breast cancer compared with conventional computed tomography angiography (CTA). METHODS: We enrolled 25 patients (MEI (+)300 group, 300 mg/mL and 2.5 mL/s of contrast media) and 23 patients (CTA370 group, 370 mg/mL and 3.5 mL/s of contrast media) for assessing NAC blood supply angiography. The image quality of the 2 groups was evaluated objectively and subjectively. RESULTS: The 40 keV MEI (+)300 demonstrated higher attenuation and contrast-to-noise ratio than CTA370 group (P < 0.001). The subjective image quality and visualization of the arteries were comparable between 2 groups. CONCLUSIONS: The 40 keV MEI (+)300 acquired from dual-energy computed tomography can achieve comparable image quality of arterial supply to NAC with low-concentration and low-flow-rate contrast media in breast cancer compared with CTA370.

Clinical and sonographic features of nipple lesions.

BACKGROUND: The aim of this study was to present several cases of benign and malignant nipple lesions and contribute to diagnosis and differential diagnosis. METHODS: A retrospective study was conducted on 13 patients. All of the patients were evaluated by ultrasonography, and 11 of them had pathological results. We analyzed the clinical and sonographic features. RESULTS: There were 3 malignant lesions, 7 benign lesions, and 3 congenital nipple dysplasia, listed as follows:Malignant lesions (n = 3, 23%): Paget's disease (PD, n = 3, 23%). All of the patients with PD showed unilateral nipple erosion, discharge, and pain. The ultrasound showed abundant blood flow (n = 3, 23%); 2 patients (n = 2, 15%) had microcalcifications.Benign lesions (n = 7, 54%): Adenoma of the nipple (n = 2, 15%). One patient (n = 1, 8%) had nipple erosion and discharge. Two patients (n = 2, 15%) had a palpable nodule in the nipple. The ultrasound of both patients (n = 2, 15%) showed regular-shaped, clear border nodule with abundant blood flow (n = 2, 15%).Leiomyoma of the nipple (n = 1, 8%): This male patient was characterized by unilateral nipple enlargement and pain. The ultrasound showed a regular nodule with absent blood flow.Plasma cell mastitis (n = 2, 15%): Two patients showed unilateral nipple inversion and pain. One patient (n = 1, 8%) showed swollen and redness. The 2 patients showed a lesion in the gland around the nipple present as an irregular shape and unclear boundary hypoechoic mass.Nipple wart (n = 2, 15%): Two patients showed a unilateral soft exogenous neoplasm. Both of the patients showed a hypoechoic wart; the echo was similar to the nipple, the border was clear, and had no blood flow in the wart.Nipple Dysplasia (n = 3, 23%): Accessory nipple (n = 3, 23%). Two patients (n = 2, 15%) had accessory nipples in the subcoastal area, 1 patient (n = 1, 8%) in the areolar. All of the patients' sonographic features were the same as the nipple.The positive predict value (PPV) of the clinical symptoms: Erosion and discharge are both 75% (P < 0.05). The PPV of the US manifestations: irregular shape, indictinct margin, abundant blood flow, microcalcification, thicken skin in diagnosing malignant lesions are 60%,60%,60%,100%,100%, respectively (P < 0.05). CONCLUSIONS: The characteristic sonographic features together with clinical symptoms contribute to the diagnosis of nipple lesions.

Nipple-Areola Complex Ischemia or Necrosis in Freestyle Perforator Flap Reduction Mammoplasty Operations.

BACKGROUND: Necrosis of the nipple-areolar complex (NAC) is one of the most devastating complications of reduction mammoplasty. A variable, asymmetrical pattern of blood supply from the main sources was found in the same individual. To solve this problem, we present a method to be sure that the blood supply to the NAC is contained within the designed pedicle during reduction mammoplasty. This is done using the colored duplex scan and handheld Doppler to perform freestyle perforator flap reduction mammoplasty. METHODS: This is a prospective randomized study that has been performed on 105 patients in the period between January 2014 and 2019 at the Plastic and Reconstructive Surgery Department, Tanta University Hospitals. Freestyle perforator flaps were performed for all cases after perforator detection using handheld Doppler and confirmed by colored duplex scan. RESULTS: The procedure was performed as freestyle on medial perforators in 35 (33.3%) cases, on lateral perforators in 20 (19%) cases, on combined medial and lateral perforators, as a bipedicle in 30 (28.7%) cases, on upper pole perforators in 12 (11.4%) cases, and on lower pole perforators in 8 (7.6%) cases. CONCLUSIONS: The use of handheld Doppler and the confirmation by duplex scan are mandatory to decrease the incidence of NAC necrosis or ischemia. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Technical note: Development and evaluation of a standardized technique to assess blood perfusion in teats of dairy cows using power Doppler ultrasonography.

Ample research has described the assessment of dimensional changes for different teat traits, whereas diagnostic techniques to reliably assess blood circulation in teats of dairy cows are limited. Here, we describe the development and evaluation of a scanning technique to quantify blood flow in teats of dairy cows using power Doppler ultrasonography. In 2 consecutive trials, 384 teat scans [trial 1, n = 256 (sagittal plane, n = 128; transverse plane, n = 128); trial 2, n = 128 (transverse plane)] from 16 cows were obtained by the same 2 operators. Perfusion intensity from single images (trial 1) and video images (trial 2) were assessed using a commercially available software program. Intraclass correlation coefficients (ICC) and concordance correlation coefficients (CCC) were used to assess interoperator reproducibility (agreement between measurements performed by different operators) and intraoperator repeatability (agreement between measurements performed by the same operator). In trial 1, interoperator ICC and CCC indicated poor agreement (ICC ≤0.26, CCC ≤0.26). Intraoperator ICC and CCC demonstrated poor agreement between duplicate measurements within operators (ICC ≤0.19, CCC ≤0.19). Modifications after trial 1 included (1) a different ultrasound device, (2) analysis of video clips rather than single images, (3) restriction to 1 sectional plane (i.e., transverse), and (4) a scanning sequence such that repeated scans within operators were measured one after another. Through these modifications, intraoperator repeatability in trial 2 yielded fair to good agreement, with intraoperator ICC and CCC over both operators ranging from 0.44 to 0.70 and from 0.57 to 0.69, respectively, whereas interoperator ICC and CCC showed poor agreement (ICC = 0.35, CCC = 0.34). We conclude that repeatable measurements of blood perfusion intensity of teats in dairy cows can be attained with power Doppler ultrasonography. Power Doppler ultrasonography is a suitable tool to quantify slow flow in small vessels and may be an acceptable diagnostic technique to assess changes in blood circulation that result from machine milking in teats of dairy cows, although further research is necessary to validate this hypothesis.

[Research progress in breast blood supply and breast reduction].

OBJECTIVE: To review the research on distribution of the nerve and blood supply of breast, and the development of breast reduction in recent years. METHODS: The related literatures about the distribution of the nerve and blood supply of breast, the development of breast reduction, and postoperative lactation function in recent years were reviewed extensively. The above aspects were analyzed and summarized in combination with the author's experiences. RESULTS: With the anatomical study of mammary gland, nipple areola complex nerve distribution and blood supply, breast reduction has been developed rapidly, and a variety of surgical methods have been formed. But each has its own advantages and disadvantages, and its indications are different. Through the application and improvement of the auxiliary examination technique, severe complications such as nipple areola complex necrosis reduce obviously after operation. Through the selection of position of the incision and pedicle, the degree of retaining the pedicle glands, the application of auxiliary liposuction technique, and the improvement of suture technique, the scar of incision reduces, the sensation of nipple areola is preserved more, and a more satisfactory breast shape is obtained. Some of the patients who gave birth after breast reduction have lactation function. CONCLUSION: There are some shortcomings in various surgical methods at present, individualized surgical methods should be adopted according to the characteristics of the patients. Further research is needed on how to preserve more sensation of nipple areola, obtain a good and lasting breast shape, and preserve lactation function of women after operation.

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis.

BACKGROUND: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed. RESULTS: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. CONCLUSIONS: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.

Secondary reduction mammaplasty: does initial pedicle design matter?

Reduction mammaplasty is one of the most common plastic surgical procedures performed in the United States. Occasionally patients will require a second reduction to address persistent or recurrent symptomatic macromastia. When the vascular pedicle of a primary breast reduction is unknown, there is uncertainty regarding how best to proceed with a secondary reduction. When the pedicle is known, we include at least the primary pedicle in our operative plan. When unknown, we performed a modified central mound (MCM) reduction technique. The MCM reduction respects the blood supply to the nipple-areolar complex (NAC) by preserving any remaining vascularity that is present within the central mound tissue while also maintaining superior and inferior vascular pedicles. We avoid using a free nipple graft.Thirty patients (60 breasts) underwent repeat breast reductions between 2009 and 2016. Patients were placed into two groups whether their primary vascular pedicle was known or unknown, and then further grouped based on the type of reduction they received. There was no significant difference in the complication rate between patients that underwent an MCM reduction versus those that underwent reduction with other techniques. Most patients maintained breast sensation and none required a free nipple graft.Patients can be offered repeat reduction mammaplasty with the possibility of nipple sensation preservation and a normal-appearing NAC regardless if the primary vascular pedicle is known. If the primary pedicle is unknown, the MCM technique is an excellent option.

Safe delayed procedure of nipple reconstruction in poorly circulated nipple.

Nipple-areolar complex reconstruction represents the final step in breast reconstruction. However, there is no gold standard nipple reconstruction technique that addresses the issue of blood circulation in the flap, which is the most basic complication. Nipple reconstruction was performed in 21 patients. A delayed procedure was performed when a poor outcome was expected due to marginal pinpoint bleeding in the distal tip after flap elevation during nipple reconstruction. The delayed nipple reconstruction can be viewed as a safe and reliable method for improving nipple blood circulation, reducing complications, and enabling long-term nipple projection maintenance in high-risk patients.

Nipple-areolar complex ischemia and necrosis in nipple-sparing mastectomy.

INTRODUCTION: Nipple-sparing mastectomy (NSM), combined with immediate breast reconstruction, has become the preferred surgical option to achieve better patient satisfaction and aesthetic outcome. However, nipple-areolar complex (NAC) ischemia and necrosis are common complications following nipple-sparing technique. MATERIALS AND METHODS: We performed a retrospective analysis of 220 breasts that underwent NSM and immediate reconstruction from May 2010 to December 2016 at our institute. For accurate evaluation of ischemia rate after nipple-sparing mastectomy, we suggested a nipple-areolar ischemia grading system. We also found association between various factors and complications of nipple-areolar complex through statistical analysis. RESULTS: Among 220 breasts that underwent NSM in 207 patients, ischemia occurred in 141 (64.1%) breasts. However, necrosis required surgical reoperation in only 69 (31.3%) breasts. Patient factor affecting NAC complications was existence of ptosis. Also, surgical techniques for periareolar incision as well as oncologic surgeon's technique impacted NAC necrosis. Reconstruction methods including direct-to-implant, latissimus dorsi island flap with implant, and transverse rectus abdominis free flap showed higher rate of necrosis compared to tissue-expander reconstruction. CONCLUSION: We clarified factors that affect NAC necrosis. Among them, modifiable factors were skin tension and periareolar incision. When periareolar incision is necessary, lower periareolar incision is safer than upper periareolar incision to preserve vascularity of NAC.

Nipple-Sparing Mastectomy Incisions for Cancer Extirpation Prospective Cohort Trial: Perfusion, Complications, and Patient Outcomes.

BACKGROUND: Nipple-sparing mastectomy offers several advantages for women seeking postmastectomy breast reconstruction, but compromised skin and nipple perfusion may lead to skin and nipple necrosis. It is unclear whether the incisional approach contributes to these complications; therefore, the purpose of this study was to compare the impact of incision type on outcomes in patients undergoing nipple-sparing mastectomy. METHODS: This is a prospective cohort study of patients undergoing nipple-sparing mastectomy with prosthetic breast reconstruction through an inframammary fold versus a lateral radial incision. Skin and nipple perfusion as represented by fluorescence intensity, mammometric parameters, patient-reported outcomes, and clinical outcomes were analyzed and compared for the two cohorts, and multivariable logistic regression models were performed to evaluate the effects of covariates on outcomes. RESULTS: Seventy-nine patients were studied: 55 in the inframammary fold cohort and 24 in the lateral radial cohort. The inframammary fold group had significantly less fluorescence intensity to the inferior (21.9 percent versus 36.9 percent; p = 0.001) and lateral portions of breast skin (23.1 percent versus 40.7 percent; p = 0.003) after reconstruction. Decreased fluorescence intensity was associated with smoking, decreased mean arterial pressure, and greater specimen weight. Postreconstruction breast volumes were increased over preoperative volumes in the inframammary fold group (38.3 percent) versus the lateral radial (31.2 percent) group; however, patients with a lateral radial incision had a greater increase in satisfaction with their breasts and psychosocial well-being. CONCLUSIONS: There are significant differences in patient-reported outcomes and final breast volumes based on the incisional approach to nipple-sparing mastectomy. These data can be used to guide providers and counsel patients considering nipple-sparing mastectomy with prosthetic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Sonographic visualization of nipple blood flow can help differentiate Paget disease from benign eczematous nipple lesions.

PURPOSE: Paget disease of the breast is a rare cancer that originates from the nipple-areolar complex. It is often overlooked and misdiagnosed as benign chronic eczema of the nipple. We aimed to retrospectively verify whether blood flow analysis using Doppler sonography was useful for detecting the presence of Paget disease. METHODS: In this retrospective study, 12 patients with pathologically proven unilateral nipple eczematous lesions (seven with Paget disease and five with simple dermatitis) were included. Nipple blood flow signal was observed using Doppler sonography, and the detected blood flow signals were quantified using digitally recorded images. Quantified blood flow ratio and pathologically examined capillary density were evaluated between affected and unaffected nipples. Findings of mammography, grayscale sonography, and contrast-enhanced magnetic resonance imaging (CE-MRI) were reviewed. RESULTS: In patients with Paget disease, Doppler effects in the affected nipple were more clearly visible than those in the unaffected nipple. These effects were sufficiently visible to identify Paget disease. No obvious effects were observed in the affected and unaffected nipples of simple dermatitis. The quantified blood flow ratio and pathologically examined capillary density were significantly higher for the Paget lesion than those for the non-Paget lesion. The sensitivity of CE-MRI and Doppler sonography was markedly correlated, revealing blood flow changes in the nipple lesions of Paget disease. CONCLUSION: Doppler sonography visualized the proliferation of blood vessels in Paget lesions. The visualization of increased nipple blood flow using Doppler sonography is a simple and low-cost method that provides useful data for identifying Paget disease during routine medical care.

Intraoperative Assessment of the Relationship Between Nipple Circulation and Incision Site in Nipple-Sparing Mastectomy With Implant Breast Reconstruction Using the SPY Imaging System.

INTRODUCTION: Nipple-sparing mastectomy (NSM) and immediate breast reconstruction with gel implants have grown in popularity because of superior aesthetic outcomes. One risk of this procedure is overexcision of the flap leading to inadequate circulation in the breast envelope. METHODS: We investigated 17 cases of NSM and gel implant breast reconstruction. Patients were divided into an infra-areolar incision group and a supra-areolar incision group. Nipple-areolar complex perfusion was evaluated using the SPY imaging system after NSM and gel implant breast reconstruction. We aimed to discover any relationships between the incision method and nipple-areolar complex (NAC) circulation in NSM and gel implant breast reconstruction. RESULTS: For successful breast surgery, awareness of the blood supply to the breast, especially the NAC, is very important. In our study, with the indocyanine green SPY imaging system, most ingress (arterial inflow) and egress (venous outflow) rates in the infra-areolar incision group were better than those in the supra-areolar incision group (P < 0.005). CONCLUSIONS: We have shown that an infra-areolar incision provides better blood flow following NSM and gel implant breast reconstruction. In our experience, in order to prevent the possible ischemia of NAC, we used the smaller gel implants, which is approximately 10 to 20 mL smaller than the original implant size measured by the sizer, if the egress rate of NAC is lower than 0.2. These findings have implications in the clinical setting as surgeons have a choice to provide a better outcome for patients.