Key points

Introduction

Necrosis of the nipple areolar complex (NAC) is an infrequent but dreaded complication of reduction mammaplasty and mastopexy. When there is significant loss of nipple and/or areolar tissue, it not only results in major cosmetic deformity but also may be a source of great angst for the surgeon and patients alike.

The manifestations of nipple areolar ischemia run the gamut from spontaneous, completely reversible nipple congestion ( Fig. 1 ) to total loss of the nipple ( Fig. 2 ) with extensive necrosis of subadjacent breast tissue ( Fig. 3 ). The appropriate response to nipple ischemia depends on the degree of circulatory compromise. The guiding principle is to avoid aggressive surgical therapy as long as possible to give the injured tissues the best possible chance to recover spontaneously.

Reversible ischemia of the right NAC 48 hours after reduction mammaplasty.

Complete necrosis of the left NAC 10 days after reduction mammaplasty.

Total loss of the NAC and extensive fat necrosis of subadjacent breast tissue.

Circulatory compromise of the NAC may be due to arterial insufficiency but is more commonly caused by venous congestion. Clinical signs of venous congestion include excessively brisk capillary refill, dark rapid bleeding on pinprick, and cyanosis and edema of the nipple. Venous congestion can occur for a variety of reasons: inadequate preservation of venous drainage, long pedicles, kinking or compression of the pedicle, excessively tight skin closure, or a hematoma. The risk of nipple areolar ischemia is increased with large-volume tissue removal, transposition of the NAC a great distance (more than 15 cm), and in cases whereby secondary mastopexy is performed in previously augmented patients. Systemic factors, such as obesity, diabetes, and cigarette smoking, may also increase the risk of ischemia.

The objectives of this article are to explain the mechanisms of injury that result in ischemia of the NAC, to offer recommendations about the management of this complication, and to illustrate reconstructive techniques that can be used to correct deformities arising from necrosis of the NAC. With these goals in mind, the remainder of this article is divided into 3 sections: (1) prevention of ischemia of the NAC, (2) management of the ischemic nipple, and (3) reconstruction after ischemic necrosis of the nipple and areola.

Introduction

Necrosis of the nipple areolar complex (NAC) is an infrequent but dreaded complication of reduction mammaplasty and mastopexy. When there is significant loss of nipple and/or areolar tissue, it not only results in major cosmetic deformity but also may be a source of great angst for the surgeon and patients alike.

The manifestations of nipple areolar ischemia run the gamut from spontaneous, completely reversible nipple congestion ( Fig. 1 ) to total loss of the nipple ( Fig. 2 ) with extensive necrosis of subadjacent breast tissue ( Fig. 3 ). The appropriate response to nipple ischemia depends on the degree of circulatory compromise. The guiding principle is to avoid aggressive surgical therapy as long as possible to give the injured tissues the best possible chance to recover spontaneously.

Reversible ischemia of the right NAC 48 hours after reduction mammaplasty.

Complete necrosis of the left NAC 10 days after reduction mammaplasty.

Total loss of the NAC and extensive fat necrosis of subadjacent breast tissue.

Circulatory compromise of the NAC may be due to arterial insufficiency but is more commonly caused by venous congestion. Clinical signs of venous congestion include excessively brisk capillary refill, dark rapid bleeding on pinprick, and cyanosis and edema of the nipple. Venous congestion can occur for a variety of reasons: inadequate preservation of venous drainage, long pedicles, kinking or compression of the pedicle, excessively tight skin closure, or a hematoma. The risk of nipple areolar ischemia is increased with large-volume tissue removal, transposition of the NAC a great distance (more than 15 cm), and in cases whereby secondary mastopexy is performed in previously augmented patients. Systemic factors, such as obesity, diabetes, and cigarette smoking, may also increase the risk of ischemia.

The objectives of this article are to explain the mechanisms of injury that result in ischemia of the NAC, to offer recommendations about the management of this complication, and to illustrate reconstructive techniques that can be used to correct deformities arising from necrosis of the NAC. With these goals in mind, the remainder of this article is divided into 3 sections: (1) prevention of ischemia of the NAC, (2) management of the ischemic nipple, and (3) reconstruction after ischemic necrosis of the nipple and areola.

Preventing ischemia of the nipple areolar complex

Clearly, preventing ischemic complications is greatly preferable to treating a necrotic nipple and areola. When performing reduction mammaplasty or mastopexy, care must be taken to select the operation that will likely produce the best outcome with the least risk of complications.

Understanding of breast vascular anatomy is crucial in preserving the arterial inflow and the essential venous drainage network of the nipple areola complex. Cadaveric dissection studies have shown that the most reliable blood supply to the nipple areola complex is from the internal thoracic–anterior intercostal system, supplying the NAC from the medio-inferior aspect. An additional collateral system composed of lateral thoracic and other minor contributors supplies the NAC from the superolateral aspect. Venograms of the breast have shown an extensive network of veins draining the NAC with the most reliable patterns located in the superomedial/medial and inferior pedicles.

A wide variety of techniques have been described for transferring the nipple in breast reduction and mastopexy. The most commonly performed procedure combines the Wise-pattern skin incision with an inferior pedicle for nipple transposition. This operation has gained popularity because of the reliability of the blood supply to the nipple, the relatively short learning curve, and the applicability of this method to reductions of all sizes. The main drawback to this approach is that aesthetic results are not always optimal. There may be a boxy contour to the breasts; it can be difficult to achieve desired breast projection; there is a tendency to pseudoptosis over time; and there is invariably a long scar in the inframammary fold. For these reasons, a variety of alternate pedicles and different skin patterns have evolved. In addition to the traditional inferior pedicle, the superior, superomedial, and central pedicle have all been successfully used in breast reduction and mastopexy. The reported rates of nipple necrosis vary with the use of different pedicles ranging from 0.8 % to 2.3% (0.8% with inferior pedicle, 2.1% total nipple necrosis with the use of superodermal pedicle, and 2.3% with superolateral pedicle). However, there are no randomized controlled trials comparing NAC necrosis rates for the different techniques.

In recent years, short scar techniques, including the vertical pattern and short-scar periareolar-inferior pedicle reduction (SPAIR) technique, have been introduced. Because there are so many possible combinations and permutations of skin pattern and vascular pedicle, it is difficult to objectively compare one technique with another. In a recent matched cohort study, the investigators compared superomedial pedicle vertical scar breast reduction with inferior pedicle Wise-pattern reduction and found there was no significant difference in complications between these two techniques. It is likely that adherence to the basic principles of plastic surgery is more critical than the particular surgical technique selected. Regardless of which approach is chosen, the surgeon must be careful to maintain a pedicle of adequate thickness, be cognizant of the length to width ratio of the pedicle, prevent kinking the blood supply when insetting the flap, and avoid excessively tight skin closure.

One group of patients especially at risk for ischemic complications of the NAC is previously augmented women with ptosis who present for mastopexy. These patients are at increased risk of circulatory compromise because of the inevitable changes in breast anatomy and physiology caused by implants. In many augmented patients, the soft-tissue envelope surrounding the implant becomes attenuated. Tebbetts observed: “The consequences of excessively large breast implants include ptosis, tissue stretching, tissue thinning, inadequate soft-tissue cover, [and] subcutaneous tissue atrophy.” These very same changes occur not just with “excessively large” implants as described by Tebbetts but with all breast implants to some degree over time. Most of the thinning and atrophy caused by implants occurs in the inferior pole of the breast. It is important to take this into account when selecting which pedicle to use in patients undergoing secondary mastopexy. A conventional Wise-pattern skin excision coupled with an inferior pedicle may be prone to ischemia because of thinning of the tissues of the inferior pole. In such cases, it may be prudent to preserve a superior pedicle as well (as in a traditional McKissock reduction mammaplasty) to ensure adequate arterial perfusion and sufficient venous drainage. Vertical mastopexy techniques are applicable in previously augmented patients; however, vertical techniques that depend on an inferior pedicle, such as the SPAIR mammaplasty may be relatively contraindicated. Procedures that incorporate a superior pedicle (Lejour, Lassus, Hall-Findlay) are probably safer in terms of preserving circulation to the nipple and areola.

When selecting the specific mastopexy operation for correction ptosis in augmented patients, there is a wide spectrum of procedures from which to choose. These procedures include crescent nipple lift, periareolar mastopexy, vertical lift, and finally the conventional Wise-pattern mastopexy. In general, the least aggressive mastopexy that will achieve the desired result is preferred. In secondary mastopexy patients, it is also critical to consider the effect of prior skin incisions on the blood supply of the nipple and the skin flaps and to avoid insertion of excessively large implants, which may cause compression of the vascular pedicle and lead to venous congestion.