Chapter 72

Free Nipple Areolar Graft Reduction MammaplastyAnthony Erian, Amal Dass

72.1Introduction

Free nipple graft reduction mammaplasty describes a breast reduction technique in which the nippleareolar complex (NAC) is transposed as a free graft to ensure its viability and to minimize complications. With advances in surgical techniques coupled with a better under-standing of the vascular anatomy of the breast and the NAC, the limits at which free nipple graft ing is preferred over transposition on a pedicle have been pushed fur-ther and further. However, it is still an operation that many surgeons turn to when faced with uncertainty over the viability of the NAC.

72.2History

Breast reduction techniques had been described as early as the late nineteenth century, and Morestins [1] report on transposing the nipple at the turn of the century. Th e concept of maintaining the nipple on a dermoglandular pedicle, as suggested by Strombeck in 1960 [2], revolu-tionized breast reduction surgery and still forms the basis of all subsequent improvements and modi ca-tions of the technique to this day. It was Th orek [3], however, who popularized free nipple graft ing in 1922. Th orek combined the free nipple graft with lower pole amputation and his technique continues to this day albeit with a Wise pattern modi cation.

72.3 Indications

Size and Haste would aptly describe the most com-mon indications for the free nipple graft reduction mammaplasty. Gigantomastia, described as a breast that requires resections in excess of 1,800 g per side, and the high risk in surgical patients [4], e.g., the elderly and those with medical comorbidities which limit the time that can be spent safely under general anesthesia, are the

most common reasons for considering a free nipple graft reduction mammaplasty.

Th ere are other indications for nipple areolar trans-plant in breast reduction (Table 72.1). Free nipple graft s are indicated if the NAC looks underperfused on a pedi-cle. Th is can be con rmed intraoperatively by intrave-nous (IV) administration of 2 g of uorescein followed by examination under a Woods lamp 15 min later. A yellowgreen uorescence of the NAC con rms an ade-quate blood supply, whereas a dark blue appearance indicates inadequate perfusion [4].

However, most surgeons would simply assess the nipple viability clinically. If there is no tension due to closure or constriction at the base of the pedicle and no hematoma or hypotension, the NAC should be removed from the pedicle and sited as a free nipple graft .

Avascular scar tissue from prior breast surgery may compromise the formation of a vascular pedicle. If this is the case, it may be prudent to consider free nipple graft ing at the outset.

Male patients with severe gynecomastia may require a subtotal mastectomy which precludes keeping the NAC on an adequate dermoglandular pedicle, while the significant skin excision required in male patients following massive weight loss may mandate free nipple graft ing for the best results [5]. Gender reassignment surgery to the breast involves breast amputation with free nipple graft ing. Th e areola also has to be harvested and reduced to approximate the smaller male areola.

72.4 Vascular Anatomy of the Breast

Th e blood supply to the breast comes from six main sources: the internal thoracic artery, the highest thoracic artery, the anterior and posterior branches of the inter-costal arteries, the thoracoacromial artery, the super cial thoracic artery, and the lateral thoracic artery. Of these, the internal thoracic vessels provide approximately 60% of the blood supply, with the lateral thoracic vessels pro-viding approximately 30%. Th e tributaries of these two vessels form a rich anastomotic network around the NAC [4]. Th e arterial anatomy of the NAC is complex as

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M.A. Shi man (ed.), Mastopexy and Breast Reduction: Principles and Practice, Springer-Verlag Berlin Heidelberg 2009

556 72 Free Nipple Areolar Graf t Reduc tion Mammaplast y

a result of the contributions from six di erent sources. Various sources have identi ed the internal thoracic and the lateral thoracic arteries as the main blood supply routes to the NAC [6]. Th e reliability of the internal tho-racic artery [7] as the sole blood supply route to the NAC has also been reported, as has the reliability of a lateral thoracic arterybearing pedicle [8, 9].

Th e arterial supply around the NAC has recently been described as split into a super cial and deep anas-tomotic network [10]. Th e super cial system comprises tributaries of the internal thoracic, the highest thoracic and the super cial thoracic arteries, whereas the deep system is formed by the anastomoses of the lateral tho-racic artery, the anterior and posterior branches of the intercostals arteries, and the thoracoacromial artery.

Th is may seem to suggest that the medial and lateral pedicles are the most reliable. However, the blood sup-ply of the NAC described above fails to describe the importance of the perforators of the anterior branches of the intercostals arteries and the highest thoracic artery from the rst to the ft h intercostals spaces [10]. Indeed, the perforators of the fourth and ft h intercos-tals vessels inferior to the NAC are remarkably consis-tent and of similar caliber to the internal thoracic and lateral thoracic vessels [11, 12].

Pedicle thickness and adherence to the pectoralis major muscle are also clearly important to the viability of the NAC. Th is may re ect on contributions from the perforators of the pectoralis major, which has been implicated in blood supply to the NAC. A thicker pedi-cle ensures that the vessels are enclosed safely within, thereby ensuring their viability while enhancing the reliability of the pedicle. An inferior pedicle with a base width of 810 cm is thought to ensure adequate perfu-sion for a pedicle of up to 21 cm in length [4].

While it has not been con rmed, as has been sug-gested, that the integrity of the NAC rests solely with the perforators rather than the subdermal plexi, there is lit-tle doubt that the perforators play an important role in NAC viability as evidenced by the success of the inferior

pedicle reduction techniques as well as the fact that the most reliable pedicles are thicker and fashioned with a wider base without releasing their attachment to the pectoralis fascia.

Cadaveric anatomic studies do not take into account, however, the ow rate within these vessels in vivo and cannot be relied on solely for formulating an operative approach. However, an intimate knowledge of the vas-cular anatomy of the breast and its NAC can aid in ensuring nipple viability and a better aesthetic result whether it be a nipple transposition on a pedicle or a free nipple graft .

72.5Preoperative Markings

Th e inferior pedicle reduction technique is most oft en used with free nipple graft s followed by the superior pedicle technique [13]. Other pedicles such as the supe-rolateral and medial pedicles have also been employed. All these reductions employ standard Wise pattern markings to fashion the skin envelope over the underly-ing reduced breast parenchyma.

Th e placement of the nipple is the most vital step in preoperative planning. A superiorly displaced nipple is aesthetically unpleasant and may even peek out over the bra, causing distress to the patient. Moreover, correction of a high nipple is virtually impossible.

Th e breast meridian lines are drawn and the infra-mammary fold is transposed to the front of the breast either using calipers or the surgeons nger within the fold. Th e sternal notch-to-nipple distance varies between 21 and 25 cm and should be tailored to the patients size and reduction. Th is should roughly correspond to the inframammary fold. Th e nipple position is placed 12 cm below the measured nipple position along the meridian. Th is is to accommodate the spring back or McKissock e ect when the weight of the breast tissue is removed and to prevent the nipple from pointing upwards secondary to lower pole fullness.

Th e position of the nipple can also be checked against the mid-point of the humerus 23 cm as well as the internipple distance which should approximate the sternal notch-to-nipple distance.

Gradinger [14] has suggested another method of identifying the transposed nipple position (Fig. 72.1). A line is drawn from the superior point of the anterior axillary fold to the xyphoid sternum. Th is is to approxi-mate the superior rim of a normal tting brassiere. Th e superior rim of the areola should be 3 cm below this line along the meridian.

Gradinger also drapes a weighted tailors tape mea-sure around the neck and over the patients chest, disre-garding whether it falls medial or lateral to the nipple. A second tape is placed horizontally across the breast at

Table 72.1 Indications for nipple areolar transplant in breast reduction

1. Gigantomastia

2. High-risk surgical candidates

3. Th reatened NAC viability intraoperatively

4. Patients with previous operative scars

5. Patients with severe gynecomastia

6. Male patients aft er massive weight loss, resulting in severely redundant and inelastic skin

7. Female to male gender reassignment

72.7 Complications 557

the level of the inframammary fold. Th e intersection of the two tapes is transposed onto the breast and describes the superior margin of the areola (Fig. 72.2). Th is should correspond to a point within 12 cm of that described by the prior technique. Th e point of the weighted tape

measure is to describe the true meridian to locate the nipple and to plan the operation around it rather than use the nipples of a massively hypertrophied breast to ascertain this.

Th e Wise pattern keyhole is then placed over the new nipple position and the template traced de ning the vertical limbs. Th e vertical limbs vary between 5 and 9 cm with 77.5 cm being the most commonly used lengths. Th is describes the nipple-to-inframammary fold distance, which de nes the lower pole of the new breast. A lazy S shaped incision is drawn from the lat-eral vertical limb to where the breast mound seems to end laterally. Th e process is repeated medially.

Women with gigantomastia frequently have exces-sively large areolas. Th e NAC is marked with a template prior to harvesting the free nipple graft . Th is usually varies from 4.2 to 4.7 cm in diameter and is chosen according to the planned reduction size.

72.6Operative Technique: Free Nipple Grafting

Th e NAC is removed as a full thickness unit and thinned with a pair of scissors taking care to preserve the smooth muscle of the nipple and the dermis of the nipple and areola, as this is thought to more likely provide good postoperative projection and perhaps even erectility. It is then stored in a sponge moistened with saline.

Th e new nippleareolar site is de-epithelialized. Th e breast reduction is then carried out according to the pre-operative markings to fashion the skin envelope and the breast parenchyma reduced around the pedicle chosen.

Th e graft is positioned onto the recipient site with interrupted sutures and sutured into place with a run-ning suture peripherally. A tie-over bolster dressing made up of Xerofoam gauze and mineral oilmoistened cotton is secured over the graft and left in place for 710 days.

72.7 Complications

Any form of breast reduction involves signi cant scar-ring which the patient must be made fully aware of. Any hesitation on the part of the patient regarding this or any of the other complication must result in postpone-ment or cancellation of surgery until reassessment at a later date.

Criticism of the free nipple graft technique has fre-quently been directed at the seemingly greater postop-erative loss of sensation in the NAC when compared to maintaining the NAC on a pedicle. While this may seem a reasonable conclusion, given that the NAC is severed from its vascular and nerve attachments as a free graft , recent reports contradict these earlier ndings [1517].

Fig. 72.1 Identifying the transposed nipple position. Adapted from [33]

Fig. 72.2 Th e intersection of the two tapes is transposed onto the breast and describes the superior margin of the areola

558 72 Free Nipple Areolar Graf t Reduc tion Mammaplast y

Studies have shown that even patients with free nipple graft s have a reasonable recovery in sensation, with erectile function persisting in most patients [1820].

Th e recovery of sensation in the free nipple graft is likely multifactorial. Breast surgery by necessity divides some intercostal nerve bers decreasing the sensation. Postoperative nipple sensibility has been shown to be inversely proportional to the amount of breast tissue resected [21]. Patients requiring free nipple graft reduc-tion mammaplasty also tend to be older, which would also likely impair recovery in sensation [18].

Reinnervation from the intercostals and supraclavic-ular nerves probably explains why a large proportion of individuals regain some form of sensation aft er a free nipple graft [22, 23]. It has also been suggested that patients with gigantomastia have a chronic traction injury to the fourth intercostal nerve, relief of which contributes to improvement in sensation [24]. It is also noteworthy that the lack of sensation seems to bother the surgeon more than the patient.

Good recovery rates in erectile function of the nipple have also been demonstrated, which contradicts earlier conclusions by some authors that it was impossible to maintain erectile function in a free nipple graft . Th is could well be due to retaining a good amount of areolar smooth muscle when fashioning the graft [18, 20].

Nipple necrosis can occur with a free nipple graft , although partial loss is more common. Th is can be due to lack of vascularity of the parenchymal pedicle or improper harvesting and fashioning of the graft , or due to medical illnesses that limit vascularity as a whole. Partial nipple loss should be allowed to heal secondarily, with the patient warned about depigmentation. Nipple reconstruction should be planned for full nipple loss aft er allowing it to heal.

Hypopigmentation of the nipple is an unsightly com-plication which can occur even with good graft uptake. It has been well described in the literature [25] and seems more common in the darker areolas of patients of African origin. Tattooing of the hypopigmented patches is frequently unsatisfactory because of the dull-gray appearance it oft en takes despite the best e orts. Th e patient must be made aware of this and be accept-ing of the possibility of this complication.

Lactation is obviously compromised in a free nipple graft , as the lactiferous ducts are severed. Th e younger patient in whom the free nipple graft is indicated must accept this or have her surgery delayed till aft er childbearing.

All the other complications of breast surgery can also be encountered with a free nipple graft . Th ese include hematomas, seromas, infections, skin necrosis, fat necrosis, and other wound complications. Complications seen in any other type of breast reduction can obviously also occur, such as breast asymmetry, over- or under-resection, a high-riding nipple or bottoming out,

hypertrophic scarring, widening of scars at the T-junction, nipple numbness, and skin or nipple loss.

72.8 Aesthetic Considerations

Th e best breast reductions are performed with three main considerations:1. Pedicle design and position2. Area of resection3. Redraping or skin envelope design [26]

Creating an aesthetically shaped breast in a patient with a signi cant reduction has been one of the great surgical challenges in breast reduction surgery. Poor long-term projection is a very common complaint encountered by the surgeon [13].

Suction lipectomy has also been employed around the breast mound to enhance the appearance of the breast. Candidates for large reductions frequently tend to be overweight, and reducing the fat folds in the axilla and medial and lateral ends of the chest wall enhances the results of the surgery.

Inferior pedicle reduction mammaplasty with free nipple graft remains the technique most used by surgeons today. However, detractors of the technique cite the problem of bottoming out, in which the lower pole of the reduced breast descends gradually stretch-ing the skin of the lower pole, causing the nipple to ride up and point upwards. Bottoming out is thought to occur at a rate of 0.44 mm a year on average and needs to be considered in the preoperative planning and when fashioning and xing the inferior pedicle. Some sur-geons prefer to amputate the lower pole and fashion the breast mound over superior or medial pedicle aps to avoid this phenomenon. Others cite [27] vascular insuf- ciency of the lower pole to justify its amputation and the use of an alternative pedicle to the inferior one.

However, the sheer number of surgeons who still prefer and employ this method, some 74% of surgeons in one survey [13], suggests that the inferior pedicle technique o ers consistent results which are reproduc-ible with acceptable risks.

Th ere have been many suggestions, most of which are based on modi cations of the inferior pedicle tech-nique, to improve the shape and projection of the breast. Most solutions to this problem have centered around retaining a dermoparenchymal ap, which can be shaped to approximate the breast mound. Traction on the lateral ap provides most of the coverage of the resultant defect. Th is allows attening of the lateral pole and diminishes the need for the medial ap to be pulled excessively. Pulling the medial ap laterally in excess results in a breast that lacks the medial fullness of an unoperated breast.

72.8 Aesthetic Considerations 559

Koger et al. [28] suggested preserving an inferior dermoparenchymal ap with a tapering, oblique exci-sion of the glandular tissue to the muscle fascia to enhance the breast mound. In fashioning the ap, it is important to realize that in very large breasts frequently more than 90% of breast parenchyma is below the infra-mammary fold. Th erefore aps must be designed that can move cephalad and t under skin envelope [29].

Other surgeons have suggested staircasing the inci-sion and retaining glandular tissue along the excision line to help provide breast tissue for projection [30], as well as a keel-shaped excision of the keyhole to prevent excess attening [31].

Vertical pedicle aps are being increasingly used to shape the breast and to increase projection. A superolat-eral dermoparenchymal ap has been employed by Strauch et al. [25], in which the ap is rotated upwards aft er fashioning it to create a periwinkle e ect by cir-cular rotation [25] to increase projection from chest wall and create a more rounded contour (Fig. 72.3).

Hidalgo et al. [13] have suggested leaving de-epithe-lialized breast tissue below the 7-cm vertical limb to fold inwards to increase projection and then to bring in lateral and medial pillars to do the same.

Abramson [29] de-epithelializes the superior pedicle between the two vertical limbs of the Wise template while also maintaining an inferior dermal pedicle extending halfway between the inframammary fold and nipple. Th e lower ap is sutured to the pectoralis fascia and the supe-rior ap is the folded over it while bringing in the lateral and medial aps together (Fig. 72.4).

Ozerdem et al. [32] have also used a similar tech-nique and suggested preserving the area between the vertical limbs of the Wise pattern even in a nonfree nipple graft reduction so that both superior and inferior

dermoparenchymal aps can be fashioned if the viabil-ity of the NAC is called into question.

Casas et al. [33] have suggested suturing the lateral and medial pillars of a superior parenchymal ap together to increase projection in a throwback to the Lejour technique of vertical mammaplasty where the medial and lateral pillars are sewn together. Th ey also suggest intentionally creating a dog ear under the nip-ple to increase projection. However, projection and erectility are more likely a function of maintaining the areolar smooth muscle in the graft ed NAC.

Breast amputation with the horizontal scar modi ed to include a backfolded dermoglandular superior pedicle ap with a free nipple graft aft er amputation of the lower pole has also been described [34]. Despite the added burden of de-epithelialization of the ap, the authors spe-ci cally cite the ease and speed of the operation (average 81 min operating time) in advocating this method.

Th e medial pedicle has also been used albeit less commonly, citing preservation of blood supply from the internal thoracic vessels and innervation to NAC as the advantages of this ap [35].

However, the choice of operative technique is ulti-mately dependent on the training and familiarity of the surgeon with it. No one technique has been shown to be markedly superior to another. As surgeons are attempting larger and larger reductions without a free nipple graft , it must always be remembered that a good number of can-didates for a free nipple graft reduction mammaplasty are chosen to reduce the time spent intraoperatively. It is important not to compromise this by increasing the operative time spent by harvesting and de-epithelializing aps. Aesthetics, while very important, should come only secondary to safety and symptom relief which are paramount.

Fig. 72.3 (a-c) Th e ap is rotated upwards aft er fashioning it to create a periwinkle e ect by circular rotation [25] to increase projection from chest wall and create a more rounded contour. Adapted from [25]a cb

560 72 Free Nipple Areolar Graf t Reduc tion Mammaplast y

72.9 Current Controversies with Free Nipple Graft Reduction Mammaplasty

Th e decision to perform a free nipple graft rests not on a set of rules but rather on arbitrary guidelines based on experience and largely anectodal evidence. Limits for inferior pedicle reductions have been based both on reduction weights and other measurements.

Th e issue, of course, has been the viability of the pedicle; however, advances in the understanding of the vascular anatomy of the NAC and technical advances have challenged the limits set by the earlier experiences of surgeons.

Wise et al. [36] in a report detailing their experience with reduction mammaplasties in 1963 have recom-mended free nipple graft ing in all reductions of more than three bra sizes. Th is then increased from 1,000 g (Gradinger [14]) to 1,500 g (Robbins [37], Jackson et al. [38]) to 2,500 g (Georgiade [39]). Georgiade has subse-quently reported success without free nipple graft ing in reductions of up to 3,300 g, while Chang et al. [40] have successfully transposed reductions of up to 5,100 g with a very low NAC necrosis rate of 1.2% over a 7-year period.

Pedicle length is a very common consideration in considering graft ing over transposition of the nipple.

Common concerns are viability of the blood supply to the NAC and pedicle, folding and kinking of the pedicle, as well as excess tissue beneath and over the pedicle which can compromise it.

As with decisions based on the weight of the reduc-tion, the recommended inferior pedicle length over which free nipple graft ing should be considered has also increased over time from 15 to 25 cm [26]. Th is has been attributed to better handling of the pedicle, creating a pedicle with a wider base, and retaining the attachment of the base of the pedicle to the chest wall so as not to interrupt blood supply from the perforators.

Other authors cite the importance of the supraster-nal notch (SSN)-to-nipple distance as most important in recommending free nipple graft ing for distances exceeding 40 cm [25]. Th ere has even been a suggestion that since the inframammary fold-to-nipple distance, which determines pedicle length, remains relatively constant when compared to the increasing SSN-to-nipple distance in progressively larger breasts, the infe-rior pedicle technique with transposition of the NAC on the pedicle should be applicable to all breast reduc-tions regardless of size, rendering free nipple graft ing obsolete [38].

72.10 Conclusions

Th ere is little doubt that free nipple graft ing maintains its place as a therapeutic option especially when patient tness limits the operating time and when the NAC viability is called into question.

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a b

Fig. 72.4 (a,b) Th e superior pedicle between the two vertical limbs of the Wise template is de-epithelialized while also maintaining an inferior dermal pedicle extending halfway between the inframammary fold and nipple. Th e lower ap is sutured to the pectoralis fascia, and the superior ap is the folded over it while bringing in the lateral and medial aps together. Adapted from [29]

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Chapter 72Free Nipple Areolar Graft Reduction Mammaplasty72.1 Introduction72.2 History72.3 Indications72.4 Vascular Anatomy of the Breast72.5 Preoperative Markings72.6 Operative Technique: Free Nipple Grafting72.7 Complications72.8 Aesthetic Considerations72.9 Current Controversies with Free Nipple Graft Reduction Mammaplasty72.10 ConclusionsReferences