To investigate the risk factors for nipple-areolar complex （NAC） ischemia and necrosis following nipple-sparing mastectomy （NSM）.

The clinical data of 150 patients who underwent NSM in the Affiliated Hospital of Putian University from May 2019 to September 2023 were retrospectively analyzed. Patients were divided into the non-necrosis group （with no significant necrosis） and the necrosis group （with significant necrosis） based on the degree of NAC ischemia and necrosis. Chi-square test or t test was used to compare clinical and surgical parameters between two groups. The variables with significant difference in univariate analysis were processed into a multivariate logistic regression model to identify independent risk factors for significant NAC ischemia and necrosis after NSM，and then a predictive model was constructed. At 6 months after surgery，the BREAST-Q questionnaire was used to evaluate breast satisfaction，psychosocial well-being，sexual well-being and physical well-being in both groups.

Seventy-one patients were in the non-necrosis group，and 79 were in the necrosis group. Compared with the non-necrosis group，patients in the necrosis group had a higher BMI，a higher proportion of diabetes history and neoadjuvant chemotherapy，and more excised breast tissue，more the surgeries with an upper quadrant periareolar incision，more breast implant reconstructions，and more frequent thermal dissection of sub-NAC tissue （P<0.050）. Multivariate logistic regression analysis showed that BMI>24 kg/m² （OR=3.371，95%CI： 1.243-9.144，P=0.017），history of diabetes （OR=6.003，95%CI： 1.234-29.203，P=0.026），preoperative neoadjuvant chemotherapy （OR=7.153，95%CI： 1.590-32.184，P=0.010），excised breast tissue volume>240 g （OR=9.923，95%CI： 3.511-28.041，P=0.001），upper quadrant periareolar incision （OR=7.173，95%CI： 2.247–22.894，P=0.001），and thermal dissection of sub-NAC tissue （OR=6.084，95%CI： 2.148-17.232，P=0.001） were independent risk factors for NAC ischemia and necrosis after NSM. The constructed prediction model showed good performance with a C-index of 0.754 and an area under the receiver operating characteristic curve of 0.885 （95%CI： 0.832-0.938）. Postoperative BREAST-Q scores indicated that the non-necrosis group was significantly superior to the necrosis group in breast satisfaction ［74 （68，89） vs 71 （57，89），P<0.001］，psychosocial well-being ［75 （69，93） vs 69 （56，84），P<0.001］，sexual well-being ［71 （53，100） vs 71 （56，90），P<0.001］，and physical well-being ［77 （62，90） vs 72 （59，90），P=0.013］.

The established prediction model provides a quantitative basis for preoperative risk assessment in NSM. Strict preoperative patient selection and optimized intraoperative procedures helps to reduce NAC ischemia and necrosis，thereby improving patient satisfaction and quality of life.