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72.1
Introduction
Free nipple graft reduction mammaplasty describes a
breast reduction technique in which the nippleareolar
complex (NAC) is transposed as a free graft to ensure its
viability and to minimize complications. With advances
in surgical techniques coupled with a better understanding of the vascular anatomy of the breast and the
NAC, the limits at which free nipple grafting is preferred
over transposition on a pedicle have been pushed further and further. However, it is still an operation that
many surgeons turn to when faced with uncertainty
over the viability of the NAC.
72.2
History
Breast reduction techniques had been described as early
as the late nineteenth century, and Morestins [1] report
on transposing the nipple at the turn of the century. The
concept of maintaining the nipple on a dermoglandular
pedicle, as suggested by Strombeck in 1960 [2], revolutionized breast reduction surgery and still forms the
basis of all subsequent improvements and modications of the technique to this day. It was Thorek [3],
however, who popularized free nipple grafting in 1922.
Thorek combined the free nipple graft with lower pole
amputation and his technique continues to this day
albeit with a Wise pattern modication.
72.3
Indications
Size and Haste would aptly describe the most common indications for the free nipple graft reduction
mammaplasty. Gigantomastia, described as a breast that
requires resections in excess of 1,800 g per side, and the
high risk in surgical patients [4], e.g., the elderly and
those with medical comorbidities which limit the time
that can be spent safely under general anesthesia, are the
72.4
Vascular Anatomy of the Breast
The blood supply to the breast comes from six main
sources: the internal thoracic artery, the highest thoracic
artery, the anterior and posterior branches of the intercostal arteries, the thoracoacromial artery, the supercial
thoracic artery, and the lateral thoracic artery. Of these,
the internal thoracic vessels provide approximately 60%
of the blood supply, with the lateral thoracic vessels providing approximately 30%. The tributaries of these two
vessels form a rich anastomotic network around the
NAC [4]. The arterial anatomy of the NAC is complex as
M.A. Shiman (ed.), Mastopexy and Breast Reduction: Principles and Practice,
Springer-Verlag Berlin Heidelberg 2009
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1. Gigantomastia
2. High-risk surgical candidates
3. Threatened NAC viability intraoperatively
4. Patients with previous operative scars
5. Patients with severe gynecomastia
6. Male patients after massive weight loss, resulting in
severely redundant and inelastic skin
72.5
Preoperative Markings
a result of the contributions from six dierent sources.
Various sources have identied the internal thoracic and
the lateral thoracic arteries as the main blood supply
routes to the NAC [6]. The reliability of the internal thoracic artery [7] as the sole blood supply route to the NAC
has also been reported, as has the reliability of a lateral
thoracic arterybearing pedicle [8, 9].
The arterial supply around the NAC has recently
been described as split into a supercial and deep anastomotic network [10]. The supercial system comprises
tributaries of the internal thoracic, the highest thoracic
and the supercial thoracic arteries, whereas the deep
system is formed by the anastomoses of the lateral thoracic artery, the anterior and posterior branches of the
intercostals arteries, and the thoracoacromial artery.
This may seem to suggest that the medial and lateral
pedicles are the most reliable. However, the blood supply of the NAC described above fails to describe the
importance of the perforators of the anterior branches
of the intercostals arteries and the highest thoracic
artery from the rst to the fth intercostals spaces [10].
Indeed, the perforators of the fourth and fth intercostals vessels inferior to the NAC are remarkably consistent and of similar caliber to the internal thoracic and
lateral thoracic vessels [11, 12].
Pedicle thickness and adherence to the pectoralis
major muscle are also clearly important to the viability
of the NAC. This may reect on contributions from the
perforators of the pectoralis major, which has been
implicated in blood supply to the NAC. A thicker pedicle ensures that the vessels are enclosed safely within,
thereby ensuring their viability while enhancing the
reliability of the pedicle. An inferior pedicle with a base
width of 810 cm is thought to ensure adequate perfusion for a pedicle of up to 21 cm in length [4].
While it has not been conrmed, as has been suggested, that the integrity of the NAC rests solely with the
perforators rather than the subdermal plexi, there is little doubt that the perforators play an important role in
NAC viability as evidenced by the success of the inferior
72.7 Complications
72.6
Operative Technique: Free Nipple Grafting
The NAC is removed as a full thickness unit and thinned
with a pair of scissors taking care to preserve the smooth
muscle of the nipple and the dermis of the nipple and
areola, as this is thought to more likely provide good
postoperative projection and perhaps even erectility. It
is then stored in a sponge moistened with saline.
The new nippleareolar site is de-epithelialized. The
breast reduction is then carried out according to the preoperative markings to fashion the skin envelope and the
breast parenchyma reduced around the pedicle chosen.
The graft is positioned onto the recipient site with
interrupted sutures and sutured into place with a running suture peripherally. A tie-over bolster dressing made
up of Xerofoam gauze and mineral oilmoistened cotton
is secured over the graft and left in place for 710 days.
72.7
Complications
Fig. 72.2 The intersection of the two tapes is transposed onto the
breast and describes the superior margin of the areola
Any form of breast reduction involves signicant scarring which the patient must be made fully aware of. Any
hesitation on the part of the patient regarding this or
any of the other complication must result in postponement or cancellation of surgery until reassessment at a
later date.
Criticism of the free nipple graft technique has frequently been directed at the seemingly greater postoperative loss of sensation in the NAC when compared to
maintaining the NAC on a pedicle. While this may seem
a reasonable conclusion, given that the NAC is severed
from its vascular and nerve attachments as a free graft,
recent reports contradict these earlier ndings [1517].
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72.8
Aesthetic Considerations
The best breast reductions are performed with three
main considerations:
1. Pedicle design and position
2. Area of resection
3. Redraping or skin envelope design [26]
Creating an aesthetically shaped breast in a patient with
a signicant reduction has been one of the great surgical
challenges in breast reduction surgery. Poor long-term
projection is a very common complaint encountered by
the surgeon [13].
Suction lipectomy has also been employed around
the breast mound to enhance the appearance of the
breast. Candidates for large reductions frequently tend
to be overweight, and reducing the fat folds in the axilla
and medial and lateral ends of the chest wall enhances
the results of the surgery.
Inferior pedicle reduction mammaplasty with free
nipple graft remains the technique most used by
surgeons today. However, detractors of the technique
cite the problem of bottoming out, in which the lower
pole of the reduced breast descends gradually stretching the skin of the lower pole, causing the nipple to ride
up and point upwards. Bottoming out is thought to
occur at a rate of 0.44 mm a year on average and needs
to be considered in the preoperative planning and when
fashioning and xing the inferior pedicle. Some surgeons prefer to amputate the lower pole and fashion the
breast mound over superior or medial pedicle aps to
avoid this phenomenon. Others cite [27] vascular insufciency of the lower pole to justify its amputation and
the use of an alternative pedicle to the inferior one.
However, the sheer number of surgeons who still
prefer and employ this method, some 74% of surgeons
in one survey [13], suggests that the inferior pedicle
technique oers consistent results which are reproducible with acceptable risks.
There have been many suggestions, most of which
are based on modications of the inferior pedicle technique, to improve the shape and projection of the breast.
Most solutions to this problem have centered around
retaining a dermoparenchymal ap, which can be
shaped to approximate the breast mound. Traction on
the lateral ap provides most of the coverage of the
resultant defect. This allows attening of the lateral pole
and diminishes the need for the medial ap to be pulled
excessively. Pulling the medial ap laterally in excess
results in a breast that lacks the medial fullness of an
unoperated breast.
dermoparenchymal aps can be fashioned if the viability of the NAC is called into question.
Casas et al. [33] have suggested suturing the lateral
and medial pillars of a superior parenchymal ap
together to increase projection in a throwback to the
Lejour technique of vertical mammaplasty where the
medial and lateral pillars are sewn together. They also
suggest intentionally creating a dog ear under the nipple to increase projection. However, projection and
erectility are more likely a function of maintaining the
areolar smooth muscle in the grafted NAC.
Breast amputation with the horizontal scar modied
to include a backfolded dermoglandular superior pedicle
ap with a free nipple graft after amputation of the lower
pole has also been described [34]. Despite the added
burden of de-epithelialization of the ap, the authors specically cite the ease and speed of the operation (average
81 min operating time) in advocating this method.
The medial pedicle has also been used albeit less
commonly, citing preservation of blood supply from the
internal thoracic vessels and innervation to NAC as the
advantages of this ap [35].
However, the choice of operative technique is ultimately dependent on the training and familiarity of the
surgeon with it. No one technique has been shown to be
markedly superior to another. As surgeons are attempting
larger and larger reductions without a free nipple graft, it
must always be remembered that a good number of candidates for a free nipple graft reduction mammaplasty are
chosen to reduce the time spent intraoperatively. It is
important not to compromise this by increasing the
operative time spent by harvesting and de-epithelializing
aps. Aesthetics, while very important, should come only
secondary to safety and symptom relief which are
paramount.
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Fig. 72.4 (a,b) The superior pedicle between the two vertical
limbs of the Wise template is de-epithelialized while also
maintaining an inferior dermal pedicle extending halfway
between the inframammary fold and nipple. The lower ap is
sutured to the pectoralis fascia, and the superior ap is the
folded over it while bringing in the lateral and medial aps
together. Adapted from [29]
72.9
Current Controversies with Free Nipple
Graft Reduction Mammaplasty
The decision to perform a free nipple graft rests not on
a set of rules but rather on arbitrary guidelines based on
experience and largely anectodal evidence. Limits for
inferior pedicle reductions have been based both on
reduction weights and other measurements.
The issue, of course, has been the viability of the
pedicle; however, advances in the understanding of the
vascular anatomy of the NAC and technical advances
have challenged the limits set by the earlier experiences
of surgeons.
Wise et al. [36] in a report detailing their experience
with reduction mammaplasties in 1963 have recommended free nipple grafting in all reductions of more
than three bra sizes. This then increased from 1,000 g
(Gradinger [14]) to 1,500 g (Robbins [37], Jackson et al.
[38]) to 2,500 g (Georgiade [39]). Georgiade has subsequently reported success without free nipple grafting in
reductions of up to 3,300 g, while Chang et al. [40] have
successfully transposed reductions of up to 5,100 g with
a very low NAC necrosis rate of 1.2% over a 7-year
period.
Pedicle length is a very common consideration in
considering grafting over transposition of the nipple.
72.10
Conclusions
There is little doubt that free nipple grafting maintains
its place as a therapeutic option especially when patient
tness limits the operating time and when the NAC
viability is called into question.
References
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