Application of preoperative 3-dimensional vascular reconstruction assessment in preventing ischemic complications after nipple-sparing mastectomy: a randomized controlled trial

Background: Ischemic complications are common and severe postoperative complications in nipple-sparing mastectomy (NSM). This study aimed to evaluate the impact of preoperative 3D vascular reconstruction assessment on the incidence of ischemic complications following laparoscopic-assisted NSM. Materials and Methods: In this prospective randomized trial (October 2023–November 2024) 126 women scheduled for laparoscopic-assisted NSM were allocated 1:1. The experimental group underwent pre-operative breast MRI (1 mm 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 2 mm adipose cuff and clipping side branches; avascular zones were dissected with a scalpel after tumescence (500 mL saline + 1 mg adrenaline), avoiding thermal injury. Control group received electrocautery alone without mapping. Primary endpoint was NAC ischemia at 1 and 2 weeks. Results: 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 two 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 BMI, resected breast weight, blood loss or BREAST-Q scores. Conclusion: 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.