Preoperative CT angiography to facilitate pedicle selection for high-risk breast reduction patients

Jessica Kierath,Richard Lewin,Mark Andrew Lee

doi:10.34239/ajops.v1i1.44

Abstract

Introduction: This study aimed to investigate the dominant vascular supply to the nipple areolar complex (NAC) using CTA and whether the preoperative CTA could change surgical planning and reduce the incidence of nipple necrosis after breast reductions for patients considered to be at a high risk of nipple loss.Methods: All female CT thoraces performed at a single centre between January and May 2013 were reviewed by a single cardiothoracic radiologist to find arterial sources, which intercostal space that was perforated, glandular/subcutaneous course and vessel entry point into the NAC of each breast. Preoperative planning CTA’s performed for the 28 cases of high-risk breast reductions of the 392 breast reductions between 2008 and 2014.Results: Analysis was performed on CTAs of 69 patient cases, involving 132 breasts. The dominant blood supply was the internal mammary artery (IMA) in 96 breasts, with long thoracic artery (LTA) in 21 breasts. A dominant vascular supply was identified in all cases. In 27 of the 28 cases, preoperative planning was undertaken as guided by the CTA. Of the 28 cases, there was one case of unilateral infection, one hematoma, and a single case of partial thickness areolar necrosis. No free nipple grafts were required.Conclusion: Preoperative CTA for large-volume breast reduction may be a useful surgical planning tool for high-risk patients. With CTA, pedicle design can be tailored to the specific patient’s blood supply in order to reduce the incidence of necrosis and avoid the need for free nipple grafts.

Highlights

Large volume breasts, and breasts with a long distance between the sternal notch and the nipple, have a higher risk of postoperative nipple necrosis after breast reduction surgery
In order to avoid both necrosis of the nipples and the use of free nipple grafts, we have investigated the use of angiographic computerized tomography (CTA) in the selection of the dominant blood supply in breast reduction pedicle selection
The second aim was to investigate whether the preoperative CTA could change surgical planning and reduce the incidence of nipple necrosis after breast reductions for patients considered to be at a high risk of nipple loss

Summary

Introduction

Breasts with a long distance between the sternal notch and the nipple, have a higher risk of postoperative nipple necrosis after breast reduction surgery. The technique of removing the nipple and replacing it as a full thickness graft is sometimes considered in these high-risk procedures.[5] free grafting is associated with disruption of the ductal system, reduction in sensation of the nipple areolar complex (NAC) and a generally less optimal aesthetic outcome. The vascular supply to the nipple is an essential consideration in surgical planning to avoid the complication of nipple necrosis.[5,9,10,11,12,13] Previous studies of the dominant vascular pedicle have been limited to a small number of cadaver dissections 10–12 and, more recently, MRI analysis.[13]

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