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Ischemic complications after nipple-sparing mastectomy (NSM) have been associated with numerous variables. However, the impact of NSM flap thickness has been incompletely evaluated.NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- or postoperative breast magnetic resonance imaging (MRIs). Demographics and outcomes were stratified by those with and without ischemic complications.Of 1,037 NSM reconstructions, 420 NSMs had MRI data available, which included 379 preoperative MRIs and 60 postoperative MRIs. Average total preoperative skin/subcutaneous tissue NSM flap thickness was 11.4 mm. Average total postoperative NSM flap thickness was 8.7 mm. NSMs with ischemic complications were found to have significantly thinner overall postoperative NSM flap thickness compared with those without ischemic complications (P = 0.0280). Average overall postoperative NSM flap thickness less than 8.0 mm was found to be an independent predictor of ischemic complications (odds ratio, 6.5263; P = 0.026). In NSMs with both pre- and postoperative MRIs, the overall average postoperative NSM flap thickness was 68.2% of preoperative measurements. Average overall postoperative NSM flap thickness was significantly less than average overall preoperative NSM flap thickness (P < 0.0001). NSMs with ischemic complications were found to have a significantly lower ratio of overall postoperative to preoperative flap thickness (52.0% versus 74.0%; P < 0.0001).Ischemic complications after NSM are significantly associated with thinner postoperative NSM flap thickness. Particularly, NSM flap thickness less than 8.0 mm is a positive independent predictor of ischemic complications. The ratio of postoperative to preoperative NSM flap thickness was significantly lower in reconstructions with ischemic complications.