Early and accurate diagnosis and treatment of nipple–areolar complex (NAC) ischemia and necrosis are fundamental to the practice of breast surgery. Knowledge of breast anatomy, risk factors, and proper technique is not sufficient for avoiding this complication in all cases. Management of this situation is dynamic; it depends on the time of detection, and knowledge of different surgical maneuvers for NAC reperfusion. Management of this complication will continue to improve with technologic advances and research.
Key points
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The anatomy of breast circulation as a key element to prevent nipple–areolar complex (NAC) ischemia and necrosis.
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Ischemia detection during the operative procedure to enable reperfusion maneuvers is important.
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Reperfusion techniques are described as essential to revert NAC sufferance.
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NAC grafting as last option in salvage attempt, and as primary indication.
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NAC reconstruction with different techniques and with synthetic materials is described.
Video content accompanies this article at www.plastic.theclinics.com
Introduction
Partial or total nipple necrosis after breast reduction surgery can be a devastating complication for the patient and the surgeon ( Figs. 1 and 2 ). Frequent monitoring of the nipple–areola complex (NAC) and early identification of vascular compromise followed by appropriate action may prevent total NAC loss. Intraoperative pale appearance of the NAC complex can be the initial sign indicating that “something is wrong.”
Different maneuvers other than tissue resection that are performed during breast reduction surgery can alter NAC vitality and lead to ischemia and partial/total loss, areolar sufferance, nipple projection loss, and/or hypopigmentation. This situation can arise independent of the technique.
NAC necrosis has been reported in 2% of breast reduction cases and in 1% of mastopexy cases; epidermolysis with blisterlike formation owing to intradermal or subdermal edema may result in 5% to 11% of cases.
Introduction
Partial or total nipple necrosis after breast reduction surgery can be a devastating complication for the patient and the surgeon ( Figs. 1 and 2 ). Frequent monitoring of the nipple–areola complex (NAC) and early identification of vascular compromise followed by appropriate action may prevent total NAC loss. Intraoperative pale appearance of the NAC complex can be the initial sign indicating that “something is wrong.”
Different maneuvers other than tissue resection that are performed during breast reduction surgery can alter NAC vitality and lead to ischemia and partial/total loss, areolar sufferance, nipple projection loss, and/or hypopigmentation. This situation can arise independent of the technique.
NAC necrosis has been reported in 2% of breast reduction cases and in 1% of mastopexy cases; epidermolysis with blisterlike formation owing to intradermal or subdermal edema may result in 5% to 11% of cases.
Anatomic considerations
An important element for understanding the possibility of NAC ischemia and necrosis is awareness of breast and NAC vascular anatomy. Any surgical maneuver involving the breast parenchyma will alter not only its architecture but its blood supply as well. Detaching the parenchyma from the pectoralis fascia is not necessary during reduction procedures; this alters not only the vascularization but also the breast innervation, leading to unnecessary complications. Regardless of the chosen pedicle, the reduction technique, and resected breast parenchyma, the remaining breast tissue and NAC can be mobilized to the final position without detachment from the pectoralis fascia ( Video 1 ). This can be done with inverted pyramidal resections, thereby avoiding the remaining dead spaces.
Vascular Nutrition of the Breast
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Internal and external mammary systems ( Fig. 3 );
Fig. 3 Vascular anatomy of the breast. - •
Thoracoacromial artery with corresponding perforators;
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Intercostal perforator vessels;
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Lateral thoracic system; and
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Supraclavicular branches.
Another key element to keep in mind during breast reduction revisions is the patient history related to previous breast surgeries and access to surgical protocols (it is ideal if pictures are available). It is impossible to determine the surgical strategies previously used based only on the visible skin scar pattern alone; information on the surgery performed over the parenchyma related to the original breast size, resected tissue volume, selected NAC pedicle, original existing relations of the NAC, and surgery dates is fundamental to prevent NAC loss during a revision surgery ( Fig. 4 ).
Risk factors contributing to nipple–areola complex necrosis
NAC ischemia and necrosis occurs more frequently in cases involving large reductions (resection >1000 g), where a long pedicle is created to carry NAC perfusion, and folding during closure can stress the circulation.
Be Alert to
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Length of pedicle (>10 cm mobilization);
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Large reductions (>1000 g);
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Excessive pedicle folding, kinking, or malrotation;
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Excessive thinning of the pedicle;
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Dense gland pedicle (compression);
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Simultaneous augmentation, mastopexy, and reduction with implant compression; and
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Reoperative reduction or mastopexy with an unknown initial pedicle.
Associated risk factors
The following are individual conditions that can increase the risk of NAC necrosis:
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Body mass index >30 kg/m 2 ;
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Diabetes;
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Past history of poor wound healing;
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Heavy smoking;
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Simultaneous augmentation and mastopexy;
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Previous radiotherapy-chemotherapy;
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Steroid use;
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Previous scars around the NAC;
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Post–bariatric surgery malnutrition;
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Genetic predisposition to thrombosis; and
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Malignancies or immunomodulating medication.
Preoperative control
We believe that sometimes an augmented risk can be present associated with the patient’s personal history. To diminish the possibilities of NAC ischemia and necrosis, we suggest that the following items must be checked before surgery and be registered in every preoperative reduction mammaplasty patient.
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Nutritional state and serum albumin level;
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Hemogram;
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Recent weight loss or gain; and
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Pulmonary function.
Intraoperative evaluation
Vitality of the Nipple–Areola Complex During Closure Is an Important Factor to Be Checked in Every Mammaplasty Procedure
Vitality of the NAC can be preserved with appropriate care of the mentioned anatomic concepts during surgery; however, even with care taken regarding pedicle selection and a perfect technique, NAC vitality must be rechecked after surgical closure to avoid this complication. At this last moment, NAC vitality evolution is decided.
Excessive pedicle folding, compression, areolar tightening, or a bulky pedicle can stress the circulation; therefore, if NAC ischemia is suspected, incisions must be opened, sutures released, and the pedicle examined. In some cases, the pedicle must be reduced in volume, and the circulation must be reevaluated. If these maneuvers improve NAC perfusion, wound reclosure must be attempted, and the vitality reevaluated. If the circulation remains deficient, the pedicle might be trimmed further, and in some cases, the incisions may be left open ( Fig. 5 ).
Sometimes, alteration in NAC color may provide an indication regarding the problem and the required rescue maneuvers.
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Complete arterial insufficiency? White color.
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Incomplete arterial insufficiency? Grayish blue color.
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Vasospasm? Pale color; try warm irrigation.
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Venous congestion? Wine stain (dark red color).
Intraoperative nipple–areola complex perfusion evaluation
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Clinical judgment.
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Surgical instrument pressure/capillary refill monitoring ( Video 2 ).
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Abrading the edge of incision with gauze to check bleeding.
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Warm irrigation to improve vasospasm.
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Blood pressure elevation.
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Indocyanine green dye via intravenous injection (Spy Elite technology, Novadaq, Bonita Springs, FL; see Fig. 5 ).
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