Abstract: Nipple-areola complex (NAC)-sparing mastectomies (NSM) have gained acceptance in the field of breast oncology. The superior aesthetic outcomes of NSM explain their increased use and rising popularity. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complication rates. An understanding of the NAC vascular anatomy is, therefore, clinically relevant beyond NSM. In this paper, the relevant clinical anatomy is described, mainly focusing on the anatomy of the NAC. This article also covers how to identify and classify the in vivo blood supply to the NAC using breast MRI exams which provide valuable information for assessing vascular anatomy of the NAC. This includes the arterial filling phase, venous drainage phase and 3-dimensional reconstructed maximum intensity projection (MIP) images. Finally, the indocyanine green (ICG) and a specialized infrared camera-computer system provide surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to reduce the risk of nipple ischemia and necrosis.

Key words: Nipple-areolar complex, Nipple-areola complex-sparing mastectomy, Perfusion, Nipple ischemia and necrosis