Nipple Graft Research Articles

Viability and sensation of the nipple-areolar complex after reduction mammaplasty.

Reduction mammaplasty with nipple-areolar transposition on a medial pedicle was designed as an alternative to amputation and free nipple graft for women with severe mammary hypertrophy. The purpose of this study was to review the viability and sensory outcome of the nipple-areolar complex (NAC) in 72 women (133 breasts) after medial pedicle and inferior pedicle reduction mammaplasty between 1996 and 2000. The medial pedicle was used for 41 women (79 breasts) with moderate to severe mammary hypertrophy. An inferior pedicle was used for 31 women (54 breasts) with mild to moderate mammary hypertrophy. Mean follow-up for all patients was 25 months. Total sensation of the NAC was obtained in 68 of 79 breasts (86%) after medial pedicle reduction mammaplasty and in 50 of 54 breasts (92%) after inferior pedicle reduction mammaplasty. Total viability of the NAC occurred in 74 of 79 breasts (94%) after medial pedicle reduction mammaplasty and in 53 of 54 breasts (98%) after inferior pedicle reduction mammaplasty. Quantitative sensory testing of the NAC using the pressure-specified sensory device demonstrated that static and moving sensory thresholds of the NAC are lowest in the inferior pedicle group followed by the control group and the medial pedicle group. It can be concluded from this study that the medial and inferior pedicle techniques are capable of supporting vascularity and innervation to the NAC. The medial pedicle technique for severe mammary hypertrophy is a good alternative to free nipple grafting. The amount of breast tissue removed does not correlate with sensory outcome for both inferior and medial pedicle techniques. The pressure-specified sensory device is an excellent means of assessing sensory outcome.

Two innovations of the star-flap technique for nipple reconstruction

Two innovations of the star-flap technique for nipple reconstruction are described. A combination of the star-flap technique and a contralateral nipple graft is indicated in patients with a large nipple and small areola on the contralateral side. It provides sufficient volume for the new nipple and improves the shape of the donor nipple. A combination of the star-flap technique and a banked costal-cartilage graft offers better nipple contour and projection than the conventional star-flap technique. Preparation of the cartilage graft is easy and does not result in additional scarring; the nipple projection can be expected to be maintained over a long period.

Breast reduction with use of the free nipple graft technique

In properly selected patients, the results of free nipple graft breast reduction may be equal or superior to a pedicle technique. A free nipple graft is clearly indicated for gigantomastia, but it is also useful in severe macromastia, when a large, bulky pedicle may impede adequate reduction and optimal contour, and in patients with fatty breasts and inverted nipples. Disadvantages include the loss of ability to breast-feed, loss of nipple sensation, and possible hypopigmentation in the nipple-areola. The author discusses patient selection and describes execution of this technique. ( Aesthetic Surg J 2001;21:261-271.)

Comparison of nipple and areolar sensation after breast reduction by free nipple graft and inferior pedicle techniques

Breast reduction with free nipple-areolar transplantation has traditionally been used for patients with gigantomastia. It is a widely held belief that there is little or no recovery of sensation in the nipple-areolar complex after this procedure. We set up a retrospective study to compare nipple-areolar sensation after free nipple grafting with that after breast reduction by the more commonly performed inferior pedicle technique. We reviewed 38 patients (17 free nipple grafts and 21 inferior pedicles) at least 1 year after breast reduction and measured the nipple and areolar pressure sensibility in each breast with Semmes-Weinstein monofilaments. We found some degree of recovery of sensation in all patients, with areolar sensation being similar in the two groups but nipple sensation being superior in the inferior pedicle group. In addition, we assessed the erectile function of the nipples in each group.

Vertical mammaplasty: early complications after 250 personal consecutive cases.

No surgeon likes to face complications. It takes effort to treat them personally and more effort to note, count, analyze, and demonstrate them. The author carefully followed 250 personal consecutive patients (476 breasts) who underwent vertical mammaplasties between 1990 and 1998; studying the complications and their relationship with the types of breasts and patients was very instructive. The main observations from this study follow. The most frequent benign complication was seroma (5 percent of breasts), which usually required one or two aspirations after surgery. Hematomas occurred in six patients (1.2 percent of breasts), who had all had mastopexies. Hematomas required immediate surgical evacuation. The major complication of breast reduction, i.e., areola necrosis, was rare (only two partial necroses occurred), but it left deformities that were difficult to correct. Infection without tissue necrosis was rare (two cases), and healing complications happened in only 5.4 percent of all cases. Healing complications were directly related to the size and fat content of the breasts. None occurred in mastopexy cases. For reductions, delayed skin healing was observed in 5 percent of cases and delayed breast tissue healing in 3 percent of cases. More healing complications occurred after liposuction of the breast, which was performed in the more fatty breasts. Delayed healing of skin and breast tissue was bothersome because healing was slow, but it left only a moderate deformity. In cases of delayed healing, frequent dressings, rinsing the wound with antiseptic solutions, giving antibiotics if needed, and refraining from early surgical intervention are the keys to success. Good personal contact with the patient, especially if healing is slow, is the best way of helping her and avoiding aggressive attitudes. In conclusion, this survey revealed few complications; however, it does show that the risk of delayed and slow healing is greater in larger breasts. In obese patients, a simpler operation may be indicated, such as liposuction with skin reduction alone or a free nipple graft, as long as the patient is not motivated to obtain the best possible result.

Repeat reduction mammaplasty.

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.

Increasing projection in patients undergoing free nipple graft reduction mammoplasty.

Reduction mammoplasty in patients with gigantomastia has traditionally been performed by a technique involving free nipple grafting. These patients usually have only a small amount of breast tissue above the inframammary fold and therefore this type of procedure has often left patients with an insufficient amount of superior pole projection. I have performed free nipple grafting in three patients with gigantomastia using a technique that utilizes two deepithelialized pedicles to increase projection. This technique is simple to perform, does not significantly lengthen the operative time, and results in a breast that provides significant projection.

Tailored infolding pattern (T.I.P.) procedure in reduction mammaplasty

This study was performed to determine whether an improved conical breast shape could be consistently accomplished without lower pole flattening, boxiness, or residual lower pole ptosis. Patients were evaluated before the surgery, at which time the true and ideal clavicle-to-nipple distances were measured. The tailored infolding pattern (T.I.P.) procedure, wedge base resection, or a combination of these two new techniques were used for breast reductions in 43 patients. In seven of the 50 patients, free nipple grafts were used. The average age of the patients was 37 years, and 16% were smokers. One patient had diabetes. The average change in true to ideal clavicle-to-nipple distances was 7.5 cm in those in whom the new techniques were used. Up to 1310 gm was resected with the T.I.P. procedure. Two of the 50 patients experienced complications; one occurred in a patient with a history of smoking and the other in the only diabetic patient. The goals of creating lighter breasts with an aesthetically pleasing breast shape and without residual lower pole ptosis or flattening were achieved with the use of the T.I.P. procedure, inferior base wedge resection, or a combination of these two techniques. The T.I.P. procedure is an easily adaptable technique that can be appreciated on the operating room table, thus avoiding a delay of weeks to months to achieve naturally shaped conical breasts. Immediate and long-term results are excellent, with a lower-than-average hypertrophic scar formation rate.

Nipple-areola reconstruction by tattooing and nipple sharing

In a reconstructed breast the nipple-areola complex can be restored by various techniques, most of which are complicated and may leave residual scarring at the donor site. The primary intradermal tattooing and nipple sharing technique for nipple-areola reconstruction is simple and can be done under local anaesthesia. We present our experience of 31 patients who had 32 areolar reconstructions using intradermal tattooing (one patient had bilateral breast reconstruction). Seventeen patients had a nipple reconstruction by the nipple sharing technique. At follow-up of 2 months to 4 years, 4 patients have required further tattooing because of fading of the pigment and 1 patient has a gross areolar colour mismatch. There have been no nipple graft failures and the reconstructed nipples have adequate projection.

Breast Reduction: The Inferior Pedicle as an Axial Pattern Flap

Mark R. Migliori, MD, Edina, MN , is a board-certified plastic surgeon. J. Bart Muldowney, MD, Edina, MN , is a board-certified plastic surgeon. The ideal breast reduction technique would allow for reliable and consistent transposition of the nipple areolar complex (NAC) with preservation of nipple viability, sensibility, and lactation potential. The ideal technique would also be applicable to all breast sizes. The blood supply to the breast is redundant, and its arterial anatomy has been well described.1 The arterial blood supply is from internal mammary, supraclavicular, lateral thoracic, and intercostal perforators. Three pairs of intercostal perforators exist from the fourth, fifth, and sixth intercostal spaces, respectively (Figure 1). The redundancy is evident in that multiple breast reduction techniques exist that rely on completely different components of this vascular anatomy to sustain the NAC. 2–6 The application of some of these techniques to the massively enlarged breast is questionable because of the unreliable viability of the NAC, and nipple grafting techniques are often recommended.7 Figure 1 Arteries and intercostal perforators through which blood is supplied to the breast. The inferior pedicle technique for breast reduction is well established as a reliable procedure. This technique has undergone several modifications. 8,9 Whereas the dermal …

Amputation/free nipple graft reduction mammaplasty

The amputation/free nipple graft method of reduction mammaplasty is used less frequently than the various pedicled reduction methods. Some valid reservations about this technique are decreased nipple-areola sensation, decreased breast-feeding capacity, diminished nipple erectile response, and the potential for nipple flattening and hypopigmentation. A suboptimal breast shape is another possible drawback. However, amputation and free nipple grafting offers improved safety compared with pedicled reduction mammaplasty, especially for those patients at high anesthetic risk. Some indications for amputation/free nipple grafting include gigantomastia, advanced age, systemic disease with poor microcirculation or poor wound-healing potential (eg, diabetes, chronic steroids, and so forth) and prior breast incisions that may limit pedicle or skin flap viability. Successful implementation of this method requires careful patient selection, and in general, it is not a good choice for those young patients concerned with breast-feeding capacity or nipple-areola sensation. Potential aesthetic liabilities of the amputation/free nipple graft technique can be minimized by attention to details of operative planning and execution. When appropriately used, amputation/free nipple graft reduction mammaplasty provides excellent patient safety and satisfaction.

Nipple-Areolar Perfusion and Reduction Mammaplasty: Correlation of Laser Doppler Readings with Surgical Complications

Clinical assessment of nipple-areolar perfusion by color, capillary refill, and temperature during and after reduction mammaplasty is generally satisfactory. However, the estimation of vascular perfusion in patients with very large breasts or dark-skinned women is difficult. If marginal perfusion of the nipple-areolar areas is undetected, necrosis is likely. To this point, no studies have tested the ability of the laser Doppler perfusion monitor to give absolute alarm values that would suggest marginal perfusion in the nipple-areola following reduction mammaplasty. We therefore completed a prospective study of areolar perfusion during surgery and for up to 24 hours following reduction mammaplasty. Fifty-four patients were studied and data collected from 104 breasts. Laser Doppler perfusion was measured with a LASERFLO BPM2 Blood Perfusion Monitor (Vasamedics, St. Paul, Minn.). Perfusion values were recorded for each breast following anesthesia but prior to the incisions, at the end of surgery, and every 2 hours for 24 hours. Patients were divided into three groups according to their follow-up results: no complications (92 breasts), minor complications (9 breasts), and patients with tissue necrosis (3 breasts). The no complications group had a perfusion of 4.8 ml/min/100 gm following the reduction procedure, while the minor complications and tissue necrosis groups had average perfusions of 1.4 and 0.8, respectively, immediately after incision closure. The average tissue removed from each group was 811, 1171, and 2118 gm for the no complications, minor complications, and tissue necrosis groups, respectively. The results from this study suggest that a laser Doppler perfusion monitor could prove useful for monitoring areolar perfusion following reduction mammaplasty, especially in patients with extremely large breasts and/or dark skin. Our studies have shown that laser Doppler perfusion values that consistently are in the range of 1.0 to 2.0 ml/min/100 gm indicate marginal perfusion, and the recovery of these patients should be followed closely. Furthermore, patients with consistent perfusion values equal to or less than 1.0 coupled with other clinical signs of low perfusion should be considered for suture removal and/or free nipple graft.

Outpatient reduction mammaplasty: a review of 338 consecutive cases.

Reduction mammaplasty is usually accomplished under general anesthesia, often with an overnight stay. With cost-containment pressures, the ability to perform this surgery in an outpatient setting would have obvious benefits. We present a series of 338 patients who have undergone bilateral reduction mammaplasty over a 3-year period. Two hundred eighty-six cases (84.6%) were performed on an outpatient basis and 52 (15.4%) were inpatients. Patient age ranged from 13 to 82 years. Significant differences were found between the two groups regarding average age (34.3 and 42.4 years, respectively) and average total resection weights (1,486.1 gm and 1,895.6 gm, respectively). The maximum total resection weight was 6,000 gm in the outpatient group and 7,140 gm in the inpatient group. Surgical techniques included inferior pedicle (N = 273), central mound (N = 54), and free nipple graft (N = 11). There were no substantial differences in the incidence of minor complications, including wound separation, seromas, hypertrophic scars, infection, and hypopigmentation. Autologous transfusion was utilized in 18 patients early in the series. Of the 175 patients (52%) who returned a follow-up questionnaire, all considered their outpatient experience a positive one. In addition, 33% of the inpatients who responded (N = 8/24) felt their hospital stay was unnecessary. Outpatient surgery resulted in a savings of $1,500 to $2,500 when compared to an overnight stay. Reduction mammaplasty can be performed safely in an outpatient setting and is not necessarily limited by age or extent of resection.

Nipple Placement in Simple Mastectomy with Free Nipple Grafting for Severe Gynecomastia

Severe gynecomastia with excessive skin is difficult to treat by only periareolar excision or suction-assisted lipectomy or both. In these patients, total mastectomy and free nipple grafting may be the best option. Placement of the nipple, however, has been arbitrary. With use of 20 "aesthetically perfect" men as models, standard nipple distances were identified. The average sternal notch-to-nipple measurement was 21 cm. In addition, two consistent ratios were identified. The nipple plane was located 0.33 times the distance from the sternal notch to the pubis, and the internipple distance was 0.23 times the chest circumference. With use of preoperatively obtained measurements of the sternal notch to pubis and chest circumference, accurate nipple placement can be accomplished.

Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty.

A vibrometer and Semmes-Weinstein monofilaments were used to delineate the sensory threshold for quickly and slowly adapting fibers in 13 women with gigantomastia (bra size D or greater) as compared with small-breasted women (bra size A or B). It was found that the mean thresholds for gigantomastia patients were significantly higher (i.e., they were less sensitive) for vibration (p < 0.001) and pressure (p < 0.02). After amputation and free nipple grafting (six patients) or a McKissock-type breast reduction (four patients), six patients had improved sensation, two patients were less sensitive, one patient was unchanged, and one patient was lost to follow-up. These results suggest (1) that preoperatively, there is a chronic traction injury to the fourth, fifth, and sixth intercostal nerves in women with gigantomastia (this is corrected after breast reduction, and sensation improves), (2) that breast reduction surgery itself divides some intercostal nerve fibers, the number dependent on the extent and type of skin and glandular resection (this decreases sensation), and (3) that postoperatively, reinnervation from intercostal and supraclavicular nerves occurs (this improves sensation with time). The postoperative sensory outcome of the breast depends on a combination of these factors; the majority of our patients with gigantomastia have improved sensation after breast reduction.

Reduction mammoplasty for macromastia.

Macromastia is a common cause of physical and emotional suffering. Reduction mammoplasty can provide relief from shoulder grooving, back and neck pain, intertrigo, and symptoms of ulnar nerve compression. Similarly, emotional well being is enhanced by improved self-image, increased capacity to participate in sports and work, and the ability to wear normal, attractive clothes. In the last three years, we have performed reduction mammoplasty using the inferior pedicle technique or free nipple graft in 75 patients. Preoperative symptoms typically included back pain, shoulder grooving, and a stooped posture. Fat necrosis was the most common complication and was associated with large resections. Patient satisfaction was high for both procedures.

Free nipple graft reduction mammoplasty.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

Stillen nach Mammareduktionsplastik und Mastopexie?

A certain amount of breast tissue remains connected with the nipple after aesthetic breast surgery, except in cases of free nipple grafting. Breast feeding is therefore possible. The obstetrician or the midwife are often with the question, whether breast feeding can be recommended. In this study we have investigated, whether lactation is adversely affected by breast surgery. 105 patients who had been operated for unilateral or bilateral mammahyperplasia or mammoptosis, were examined and questioned about breast feeding after operation. The operative techniques of McKissock, Pitanguy and Strömbeck had been used. Breast feeding attitude of our patients was compared with a corresponding collective without breast surgery from the 2nd University Clinic, Gynaecological Department. Five of 14 patients breastfed their babies. The remaining patients did not breastfeed, either after having been counselled not to breastfeed or because of admission of the newborn to a neonatal care unit. Only in two patients no lactation was observed. In our opinion, patients should be informed and encouraged, that breastfeeding is possible after aesthetic breast surgery.

Virginal breast hypertrophy at puberty; a case report

Plastic surgery reduction with free nipple graft was performed on an eleven and a half-year-old girl referred to us with massive bilateral macromastia. Hormonal studies revealed no abnormalities. Histopathological examination confirmed the diagnosis of virginal hypertrophy, an infrequent etiology in adolescent macromastia.

Intradermal tattoo as an adjunct to nipple-areola reconstruction.

Improving results in breast reconstruction have encouraged more authentic restoration of the lost nipple-areola. While recreation of nipple shape can be reliably achieved, appropriate color has remained elusive, except when a composite nipple graft has been harvested from the normal breast, often at a significant aesthetic, emotional, and oncologic cost. Extensive experience with intradermal tattooing of the nipple-areola in over 100 patients over a 5-year period has shown this technique to be exceptionally safe and effective. Both medical-grade and commercial machines are available at varying prices, and medical-grade pigments may be obtained in a variety of authentic flesh tones derived from titanium or iron oxides. In nearly every case, tattooing has helped with either nipple-areola color, size, shape, or position, without any significant complications. Some degree of tattoo fading is common, requiring occasional late touch-ups and, more rarely, complete retattooing.