Managing Necrosis of the Nipple Areolar Complex Following Reduction Mammaplasty and Mastopexy

Variability in Postoperative Nipple Sensation by Dermoglandular Pedicle in Bilateral Breast Reduction

BACKGROUND

Decreased nipple sensation following reduction mammoplasty can negatively affect a variety of patient-centered outcomes. This observational study examined the impact of dermoglandular pedicle type on subjective postoperative nipple sensation.

METHODS

A total of 178 women who underwent a bilateral reduction mammoplasty at a single institution from 2017 to 2023 and completed an 11-item survey assessing subjective postoperative nipple sensitivity across various tactile modalities were included. Patient-reported nipple sensations were compared across pedicle type and subgrouped by resection volume.

RESULTS

Of the included survey respondents, 72% (128) underwent reduction with an inferior pedicle and 28% (50) with a superior or superomedial pedicle. Over 92% of patients reported the preservation of postoperative nipple sensation. Compared to the inferior pedicle, the superior pedicle cohort reported decreased nipple sensitivity to light touch (56% vs 30%, respectively) and temperature (30% vs 15%). In resection weights greater than 500 grams, the superior pedicle cohort was less satisfied with postoperative nipple sensation (84% vs. 58%), reported decreased sensation in light touch (58% vs 24%), pressure (50% vs 21%), and experienced more numbness and tingling (17% vs 1.4%) (all p-values ≤0.05).

CONCLUSION

The majority of patients maintain some sensation after reduction mammoplasty; however, approximately 10% reported a relative decrease in subjective nipple sensation. Pedicle choice did not significantly affect sensory recovery in resection weights of less than 500 grams. When a greater resection weight is anticipated, the inferior pedicle may be associated with more favorable nipple sensation outcomes.

LEVEL OF EVIDENCE III

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Effect of pedicle type on breast reduction: Clinical and patient-reported outcomes

PURPOSE

The choice of pedicle in reduction mammaplasty is highly variable with prior studies demonstrating high patient satisfaction in most cases. This study aimed to examine the impact of pedicle type on clinical and patient-reported outcomes in patients undergoing reduction mammaplasty.

METHODS

A total of 588 patients underwent bilateral reduction mammaplasty with Wise pattern or modified Robertson incision by 13 surgeons at a single institution. Clinical outcomes were compared according to the pedicle type in all patients and BREAST-Q responders (32% response rate). Survey respondents were sub-grouped by resection volume, and the BREAST-Q satisfaction scores were compared.

RESULTS

Among all included reduction mammoplasties, 439 (75%) were performed using inferior pedicles, and 149 (25%) using superior or superomedial pedicles. Responders and non-responders were similar in preoperative characteristics including age, body measurements, and comorbidities. Although a higher incidence of infection occurred among the responders, clinical outcomes were comparable across all pedicle types. A total of 187 patients completed the BREAST-Q. Compared to the superior pedicle group, respondents in the inferior pedicle group reported higher nipple satisfaction, even when adjusted for resection weight over 500 g. In contrast, the superior pedicle group had better sexual well-being scores, which persisted in resection weight less than 500 g (all p values <0.05).

CONCLUSION

Inferior pedicles were associated with greater nipple satisfaction and superior pedicles were associated with greater sexual satisfaction. Our findings suggest that those with resections less than 500 g were more satisfied with superior pedicles whereas those with greater resections were more satisfied with inferior pedicles.

Superior Pedicle Inverted T-reduction Mammaplasty with Short Horizontal Scar

Background

Superior pedicle breast reduction is a very popular technique among plastic surgeons. This technique has had many variations looking for fewer complications and better long-lasting results. The aim of this article is to present a novel technique of breast reduction, making variations in the design of the periareolar incision, using a superior pedicle with a constant vertical incision of 5 cm and a shortened horizontal incision.

Methods

The superior pedicle inverted T-mammoplasty with a shortened horizontal scar technique was performed in 1200 patients who underwent surgery between 2010 and 2023; follow-up examination was carried out for an average of 1 year (3 months to 3 years). A patient satisfaction survey was conducted.

Results

Patient satisfaction rate was 99%. There were no cases of total necrosis of the areola-nipple complex, 2.7% of the patients presented partial necrosis of the areola-nipple complex, 1.4% of the patients presented local infection, 1.7% presented dehiscence at some point of the vertical or horizontal suture, 4% of the patients presented a widened scar, 8% of the patients presented alteration in the sensibility of the areola-nipple complex, and 0.6% of the patients presented hematoma. With this technique, a rise of the areola-nipple complex of up to 22cm was achieved.

Conclusions

The superior pedicle inverted T-mammaplasty with shortened horizontal scar technique showed a lower number of surgical complications compared with other techniques previously used for breast reduction, even when applied in gigantomasty. It provides lasting results and a high rate of patient satisfaction.

Using Laser-Assisted Indocyanine Green Angiography to Assess Nipple-Areolar Complex Survival During Reduction Mammoplasty

BACKGROUND

In reduction mammoplasty, preserving an appropriate skin flap is crucial to achieve a favorable postoperative appearance and prevent blood supply disorders in the nipple-areolar complex (NAC). Previous studies have indicated that a thinner or narrower flap is more favorable for breast shaping, but also increases the risk of blood supply disorders. Accessing the blood perfusion of the NAC and determining the critical threshold for NAC viability are essential aspects of reduction mammoplasty.

OBJECTIVES

The aim of this study was to utilize indocyanine green (ICG) angiography to assess NAC perfusion during reduction mammoplasty. It also sought to identify critical thresholds of various indicators affecting NAC survival and provide guidance for skin flap trimming.

METHODS

Thirty-eight patients who underwent reduction mammoplasty were included. Each patient received ICG angiography before and after skin flap trimming. Data on NAC perfusion, skin flap length, width, thickness, and other relevant indicators were collected.

RESULTS

Among the patients, 5 experienced NAC blood supply disorders. Multiple linear regression analysis demonstrated that the NAC blood supply had a significant correlation with the tissue thickness at the pedicle base (P < .001) and with the length-to-width ratio across the nipple (P < .05). To optimize NAC survival and achieve favorable breast shaping, cutoff points for the thickness at the pedicle base and the length-to-width ratio across the nipple of 1.15 cm and 1.71, respectively, were established.

CONCLUSIONS

ICG angiography provides an effective means to assess NAC blood supply and postoperative survival. The cutoff points established in this study help to predict the survival of the NAC and guide flap trimming.

LEVEL OF EVIDENCE: 3

Mitigating nipple areolar complex (NAC) ischemia following mastopexy augmentation using nitroglycerin application and methylprednisolone: a case report

A patient who underwent bilateral wise-pattern mastopexy augmentation with threatened nipple-areolar complex necrosis was successfully managed medically with IV methylprednisolone and topical nitroglycerin ointment as immediate consultation with the operating surgeon was not possible.

Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features

BACKGROUND

The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM).

METHODS

We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap.

RESULTS

A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel.

CONCLUSION

Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.

Hypertrophic breasts versus normal-sized breasts: Comparison of blood supply to the nipple-areola complex based on DCE-MRI

BACKGROUND

Understanding the blood supply to the nipple-areola complex (NAC) in hypertrophic breasts is essential to reduce the risk of NAC necrosis during reduction mammaplasty. The aim of this study was to use dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to determine the NAC blood supply of hypertrophic breasts compared with normal-sized breasts.

METHODS

DCE-MRI images of 100 Asian women (100 hypertrophic breasts and 100 normal-sized breasts) were included retrospectively. All vessels supplying the NAC were identified using axial, coronal, and sagittal maximum-intensity projection images. The diameter, length, and distance to the skin surface of source vessels were measured.

RESULTS

The number of source vessels in the hypertrophic breasts was larger than that in the normal-sized breasts. 97.0% of hypertrophic breasts had multizone blood supply to the NAC. In hypertrophic and normal-sized breasts, the proportion of vessels was highest in the supermedial zone, followed by the superolateral zone and central zone. The diameter of medial and lateral vessels was significantly increased in hypertrophic breasts. Besides, the length of source vessels in hypertrophic breasts was larger than that in normal-sized breasts.

CONCLUSIONS

Hypertrophic breasts tend to have a richer blood supply to the NAC than normal-sized breasts. The predominant vessels supplying the NAC of hypertrophic breasts are the superomedial, followed by the superolateral and central.

LEVEL OF EVIDENCE

IV.

Radio Electric Asymmetric Conveyer Tissue Reparative Treatment on Post-surgical Breast Skin Necrosis. A Report of Four Cases

Breast surgical treatments for both tumors and aesthetic reasons are very frequent. The nipple-areola complex (NAC) ischemia is a possible complication after breast surgery. This lesion can be devastating for the patient in the post-surgical course and can lead to final epidermolysis. The necrosis is generally attributed to vascular compromise or excessive tension of the flaps. Actually, the phenomena that prevent spontaneous repair are due to variations in the endogenous electrical potential at the cellular level. In damaged tissues, the electric potential difference across the epithelium is often profoundly altered.

In this manuscript, we are presenting four cases of NAC necrosis that were successfully treated with reparative tissue optimization (TO-RPR) treatment of the Radio Electric Asymmetric Conveyer (REAC) technology.

REAC technology was conceived to overcome the limits of exogenous electrical stimulations. Instead of administering an electrical stimulus that imposes itself on the endogenous bioelectric activity (EBA), the REAC technology restores the correct potential difference inside the tissues, which is essential for all reparative and regenerative processes. The REAC treatment applied was able to promote a fast-healing process of the necrosis of the NAC following surgery of the breast.

Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach

Background

Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases.

Objectives

The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation.

Methods

A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared.

Results

Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases.

Conclusions

Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.

Level of Evidence 3

The Use of DCE-MRI to Evaluate the Blood Supply to the Nipple-Areola Complex: A Study in 245 Asian Women

BACKGROUND

Understanding the main blood supply to the nipple-areola complex (NAC) is important for breast plastic surgery. However, previous reports have involved studies of cadavers and small sample sizes.

OBJECTIVES

This study aimed to identify and classify the in vivo blood supply to the NAC based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

METHODS

DCE-MRI images of 393 breasts in 245 Asian women obtained from March 2012 to October 2019 were included retrospectively. Axial, coronal, and sagittal maximum-intensity projection images were evaluated to identify all vessels supplying the NAC. Blood supply to the NAC was classified into 9 anatomic zones: superomedial (Ia), medial (Ib), inferomedial (Ic), superolateral (IIa), lateral (IIb), inferolateral (IIc), central (III), inferior (IV), and superior (V).

RESULTS

A total of 637 source vessels were identified in 393 breasts. Of the 393 breasts, 211 (53.7%) were supplied by a single zone, 132 (33.6%) by 2 zones, 38 (9.7%) by 3 zones, and 12 (3.1%) by 4 zones. Of the 637 vessels, 269 (42.2%) vessels were in zone Ia, 180 (28.3%) vessels were in zone IIa, and <10% of vessels were in the other zones. The number of NAC perfusion zones (P = 0.093) and the distribution of source vessels (P = 0.602) did not differ significantly between the left and right breasts.

CONCLUSIONS

DCE-MRI provides a clear indication of the blood supply to the NAC. Blood vessels from the superomedial and superolateral zones were the predominant sources of blood supplying the NAC.

Healing of Bilateral Nipple Areolar Complex Necrosis by Secondary Intention

Complete necrosis of the nipple, areola, or both is a uncommon complication of reduction mammaplasty, especially if it happens bilaterally. This case involving a young, black female illustrates that, in a large open wound of the breast, it would be ideal to leave it to heal by secondary intention as adding a skin graft would only speed up the healing process and not improve the result with the additional risk of keloid at the donor site. This open wound of the breast was treated with progressive surgical debridement while assessing the affected area in order to preserve as much tissue as possible due to the sensitive nature of the wound along with wet to dry dressing changes and antibiotic solution treatment. Our report suggests an additional approach to the standard of care involving a free flap to improve aesthetic outcomes.