Off-Label Sildenafil Citrate as a Rescue Therapy for Areolar Venous Congestion Post-Breast Reduction: Case Series and Outcomes.

Background: The nipple-areolar complex (NAC) necrosis is a rare yet significant complication following breast reduction surgery, primarily linked to compromised vascularization of the NAC, particularly in nipple-sparing techniques. While multiple therapeutic strategies have been described in the postoperative setting, their application remains limited in clinical practice. Case series: We report on three patients that developed early NAC venous distress following bilateral breast reduction. Following discussion of therapeutic options-ranging from conventional methods such as scarification and local heparin therapy to off-label pharmacologic treatment-all three patients received oral sildenafil citrate (20 mg every 6 h), after excluding contraindications and obtaining informed consent. In two patients, sildenafil alone was sufficient to restore venous outflow and salvage the NAC. In one case, adjunct scarification and heparin therapy were necessary due to partial response. No arterial damage or major adverse effects related to sildenafil were observed during the postoperative period. Conclusions: This small series supports the potential use of off-label sildenafil citrate as a valuable, non-invasive pharmacologic option for treating postoperative areolar venous congestion. Its favorable safety profile, widespread hospital availability, and mechanism of enhancing microvascular circulation make it a promising adjunct in managing this complication. Further studies are warranted to standardize its use and determine its place within a broader postoperative management spectrum of compromised vascularization in breast surgery.