Evaluating the Blood Supply to the Nipple Areola Complex in Oncoplastic Surgery Planning: A Case Report and Step by Step Method

Background: The oncoplastic management of lumpectomy defects presents technical challenges. Oncologic principles and aesthetic outcomes are now more aligned. The senior authors (BPD) previously published their methods of using contrast-enhanced breast MRI to evaluate blood supply to the nipple areola complex [NAC] in secondary mastopexy augmentation. As breast conservation advances, repeat lumpectomy (second chance operations) with oncoplastic reconstruction is becoming more common. Direct knowledge of the blood supply to the NAC in the reoperated breast will be paramount to prevent complications and optimize aesthetic outcomes in these second chance operations. Purpose: We describe a step by step, MRI guided approach to planning for oncoplastic surgery, and demonstrate how to perform preoperative localization markings for complex oncoplastic reconstructions. The intended audience for this educational reference are the early career Oncologic Breast Surgeon and Plastic & Reconstructive surgeon. Methods: A case report detailss the management of a patient who underwent successful split Wise-pattern oncoplastic reconstruction of a lumpectomy defect and contralateral mastopexy for symmetry. Preoperative imaging and physical exam findings are used to map NAC vascularity and guide preoperative markings. Results: A straightforward, reproducible 5-step lumpectomy marking system is described. The technique optimizes oncologic resection, anterior margin clearance, and ease of dissection for the oncologic surgeon while preserving axial pattern skin-flap viability and thickness for the plastic surgeon to maximize the aesthetic result. Maintaining well vascularized skin flaps minimizes long term sequelae of post lumpectomy radiation and facilitates potential secondary adjunctive mammary prosthesis or autologous reconstruction. Conclusions: Successful oncoplastic reconstruction requires a precise understanding of the blood supply to the NAC. Managing NAC blood supply becomes increasingly complicated if patients undergo sequential oncoplastic lumpectomy surgeries. Oncologic Breast Surgeons and Plastic & Reconstructive breast cancer surgeons need to be knowledgeable in advanced oncoplastic reconstruction techniques and be familiar with NAC anatomy. Preoperative Breast MRI provides an objective vascular roadmap enabling the multidisciplinary team to design a safe, individualized reconstruction plan that minimizes ischemic risk and maximizes aesthetic success.