Breast Reduction With Free Nipple Graft



Breast Reduction With Free Nipple Graft


Paul A. Ghareeb

Albert Losken





DEFINITION



  • Reduction mammaplasty is one of the most commonly performed operations in plastic surgery.


  • Free nipple graft reduction was first reported by Thorek in 1922.1


  • This technique is typically reserved for patients at high risk for nipple loss, in patients who wish to be smaller than what can be achieved by preserving the nipple on a pedicle, and in those who are at increased anesthetic risk.


  • The nipple may be preserved with the areola as a composite graft or may be harvested by itself with subsequent tattooing of the areola.


ANATOMY



  • Borders of the breast:



    • Superiorly: Clavicle


    • Medially: Sternum


    • Inferiorly: Superior border of rectus fascia


    • Laterally: Anterior border of latissimus


  • Blood supply:



    • Intercostal perforators


    • Internal mammary perforators


    • Lateral thoracic artery


    • Thoracoacromial artery


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Focused history:



    • Current brassiere size and desired size after mammaplasty is important to determine with the patient preoperatively.



      • Free nipple graft reduction is a good option in patients who wish to be smaller than what can be achieved with a pedicled reduction.


    • Symptoms of macromastia and any interventions should be documented.


    • History of breast-feeding and the desire to have further children are important to discuss.



      • Patients undergoing free nipple graft reduction should be counseled about the inability to breast-feed postoperatively, as this may affect their decision to undergo this procedure until childbearing is complete.


    • Mammographic history if applicable, as well as family history of breast disease or cancer.


    • A history of smoking should be discussed prior to any reduction, and patients should be counseled to stop smoking at least 1 month prior to reduction mammaplasty due to the significantly increased risk of wound healing complications.


  • Physical exam:



    • Examine the overall breast shape, asymmetries, previous scars, and estimate breast size in grams. Examine for breast masses and nipple sensation. Record breast measurements including sternal notch to nipple and nipple to inframammary fold distances.


    • Evaluate existing ptosis utilizing the Regnault classification.


    • Note any additional axillary tissue laterally that would not be resected with standard reduction mammaplasty. This area must be pointed out preoperatively so that patients understand where the limit of resection will be.


IMAGING



  • Mammography is recommended for women who meet screening criteria.


SURGICAL MANAGEMENT


Preoperative Planning



  • Patients who are good candidates for free nipple graft reduction include the following:



    • Patients who are at increased risk for nipple necrosis, including patients with gigantomastia (where greater than 2000 g of tissue per breast is expected to be resected)


    • Patients who would like to be smaller than what a pedicled reduction can provide


    • Patients with medical comorbidities who would not tolerate a longer operation, as the free graft technique is significantly shorter


    • Patients who are smokers or who have other comorbidities whereby breast amputation is safer than having undermined Wise pattern flaps


  • Furthermore, any breast reduction where the NAC is felt to be nonviable may be converted to a free nipple graft.


  • The surgical markings are performed in the preoperative holding area, with the patient standing and arms resting on each side.


  • We typically utilize a Wise pattern skin excision pattern when performing a free nipple graft procedure for optimal shaping of the skin envelope (FIG 1). Our technique for marking is described in detail in the Inferior Pedicle chapter.


Positioning



  • The patient is placed supine on the operating room table, with arms extended on arm boards and secured with soft roll. It is important not to extend the arms too far, as this may distort the breast shape.


  • The patient is positioned at the break of the bed, so that she may be placed in the upright position if necessary.







FIG 1 • Wise pattern skin excision markings.


Approach



  • The method of nipple graft to be performed is determined by the patient’s skin color and quality, scarring, and desires.



    • We feel that tattooing of the areola oftentimes produces superior results as compared with the free nipple-areolar graft, especially in patients with darker skin who are at risk for depigmentation. However, in patients who do not wish to undergo future tattooing, the areola should be grafted.


  • If the entire nipple-areolar complex is to be grafted, the nipple is marked with a cookie cutter at approximately 40 to 44 mm.


  • If the nipple is to be harvested with subsequent tattooing of the areola, then the nipple base is marked.


  • The standard Wise pattern markings are re-marked, with the inframammary fold incision marked at 1 cm above the actual fold. This is to preserve the dense attachments present in this area.


  • The resection pattern is based on breast amputation techniques, with the majority of the reduction specimen taken out as a wedge at the inferior pole of the breast.



    • Many other techniques have been described for resection of breast tissue, including the creation of dermoglandular flaps to provide improved projection. However, we feel that with a conservative resection and preservation of superior and central breast tissue with minimal undermining, adequate shape can be created.



TECHNIQUES

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Dec 6, 2019 | Posted by in Reconstructive microsurgery | Comments Off on Breast Reduction With Free Nipple Graft

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