Article

Preventing Venous Congestion of the Nipple-Areola Complex: An Anatomical Guide to Preserving Essential Venous Drainage Networks

Authors:
  • Xuzhou Medical University, College of Biomedical Sciences
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Abstract

Venous congestion leading to partial or total nipple necrosis is a relatively uncommon complication of breast reduction and mastopexy procedures but still occurs, particularly in larger reduction procedures. This is largely preventable if the surgeon has an understanding of the venous drainage to the nipple and carefully preserves it. An anatomical study was undertaken on 16 fresh female cadaveric breast specimens. The venous drainage of the breast was explored through vascular injection, radiographic, and cross-sectional studies. The venous drainage of the breast consists of an extensive network of vessels. The nipple-areola complex is drained by a superficial subareolar ring of veins that drains by means of medial and lateral veins. Laterally, superolateral and inferolateral veins drain into the subclavian veins, whereas medially, two veins drain into the internal mammary veins. An inferior vein drains the inferior quadrant of the breast in the midmammary line. Medially, the veins have a superficial course, whereas laterally, the veins follow a deeper course. The breast contains an extensive venous network. To avoid necrosis of the nipple-areola complex, this venous network should be preserved. The superomedial/medial and inferior pedicles contain the most extensive and more reliable venous drainage patterns.

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... After formation of the periareolar plexus, the cutaneous perforators travel within the subcutaneous tissue before reaching the NAC and after mastectomy the NAC relies solely on these cutaneous branches as the underlying breast tissue has been removed [1,26]. With respect to vascular outflow, the NAC is drained through a superior and inferior horizontal venous sling (Figure 4) [27]. After mastectomy, the NAC drainage relies heavily on the superficial, inferiorly coursing venous network [27]. ...
... With respect to vascular outflow, the NAC is drained through a superior and inferior horizontal venous sling (Figure 4) [27]. After mastectomy, the NAC drainage relies heavily on the superficial, inferiorly coursing venous network [27]. The cutaneous venous system is even more superficial than the arterial network and as such is more likely to be damaged during deepithelialization [27]. ...
... After mastectomy, the NAC drainage relies heavily on the superficial, inferiorly coursing venous network [27]. The cutaneous venous system is even more superficial than the arterial network and as such is more likely to be damaged during deepithelialization [27]. Necrosis of the NAC results from either arterial or venous insufficiency and the latter appears to be even more prevalent with larger breast resection volumes [13,[27][28][29]. ...
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Purpose Given the proposed increased risk of nipple-areolar complex (NAC) necrosis, nipple-sparing mastectomy (NSM) is generally not recommended for patients with large or significantly ptotic breasts. NAC preserving strategies in this subgroup include staged or simultaneous NSM and reduction mastopexy. We present a novel approach towards simultaneous NSM and reduction mastopexy in patients with large, ptotic breasts. Methods Literature pertaining to NSM for women with large, ptotic breasts was reviewed and a surgical approach was designed to allow for simultaneous NSM and reduction mastopexy in such patients. Results Eight patients underwent bilateral NSM with simultaneous reduction mammaplasty and immediate reconstruction. The majority of breasts demonstrated advanced ptosis (69% grade III, 31% grade II) and the average breast volume excised was 760 grams. In those patients without a history of smoking, NAC necrosis rates were 0%. In those patients with a history of smoking, 83% of breasts experienced NAC necrosis (60% total, 40% partial). One hundred percent of patients who smoked experienced some degree of NAC necrosis. Among breasts with grade II versus grade III ptosis, NAC necrosis rates were roughly equal. Conclusions Historically, patients with large, ptotic breasts were excluded from NSM due to the proposed increased risk of NAC necrosis. This study demonstrates a safe approach towards NSM and reduction mastopexy using an inferior, wide-based, epithelialized pedicle. While all patients eventually achieved satisfactory results, there was an association between smoking and NAC necrosis. Smoking cessation is paramount to the operation's success.
... Both systems merge by numerous channels and drain to the lateral thoracic, intercostal, or internal mammary veins. 38,39 Lateral veins drain to the axillary-subclavian route through the lateral thoracic system. The veins of the medial quadrant of the breast drain to the internal mammary vein and intercostal perforators. ...
... The veins of the inferior quadrant drain to the intercostal veins near the inframammary fold. 39 Either system seems sufficient for venous drainage of the NAC, provided the periareolar polygon-with all of its segmental drainage connections-is kept intact (Figure 3). ...
... Other than Cooper's classic text, 34 a detailed literature search revealed only 2 detailed anatomical studies that described the veins of the breast. 38,39 The other reports described only the most superficial vessels with infrared photography 35 or direct vision without any special aid. Thus, venous angiographic study was instrumental in revisiting and examining the anatomical pattern of the venous network. ...
Article
Successful breast reduction involves remodeling the breast parenchyma and creating a pedicle to maintain blood supply to the nipple-areola complex (NAC). Although vascular compromise is generally venous in breast reduction surgery, clear anatomical descriptions of the breast veins are lacking in textbooks. The author designed an NAC flap based on arterial and venous territories defined in a cadaver study and subsequently assessed the technique in a series of live patients. Dynamic venous angiography was performed on hemithorax specimens from 6 fresh female cadavers. A new septum-based pedicle (the "central pillar") was designed, which protected the periareolar vein polygon along with the breast septum. Sixty-seven patients underwent breast reduction with this technique between 2005 and 2010. The patients were followed for an average of 26.4 months. Sixty-two of the 67 patients underwent bilateral reduction. The average reduction in tissue per breast was 910.7 g (range, 440-1935 g), and the average nipple transposition was 9.6 cm (range, 6-17 cm). The most common complications were delayed healing of the vertical "puckered" suture line (16 patients), seroma (7 patients), hematoma (2 patients), and unilateral deepithelialization of the NAC following transient venous congestion (2 patients). The patient satisfaction rate was high. The central pillar technique is a promising alternative for young patients with glandular breasts that require gross reduction and high-transposition NAC, who are not good candidates for the "free nipple graft" technique.
... NAC necrosis most commonly occurs due to venous congestion. 1 The arterial system supplying the NAC courses deeper within the breast and is less likely to be disrupted during surgery than the more superficial venous network. 2 Outflow obstruction can also be caused by kinking of the pedicle, overly tight skin closure, or hematoma. Congestion of the NAC can be identified clinically by its dark or dusky appearance, excessively brisk capillary refill, and edema of the nipple. ...
... 1,13 The nipple is most reliably drained by the superomedial/ medial and inferior pedicles via superficial veins that course directly underneath the dermis. 2 As a result of its superficiality, the NAC's venous network is more likely to be disrupted during breast surgery, resulting in problems with outflow more often than inflow. 1 Venous obstruction can also be caused by kinking or compression of the pedicle, excessively tight closure, or hematoma. 3 Factors DMSO is a colorless liquid most commonly used for its polar, aprotic property, which allows it to dissolve a wide range of polar and nonpolar small molecules. ...
Article
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Necrosis of the nipple-areolar complex (NAC) is a major complication of breast surgery that most commonly results from venous congestion. Several conservative rescue therapies have been proposed for relieving NAC congestion, but each carries certain drawbacks, including cost and side effect profile. In this study, we evaluated the effectiveness of topical dimethyl sulfoxide (DMSO), an inexpensive compound with vasodilatory, free radical scavenging, and antiinflammatory properties in rescuing congested NACs. Methods: We conducted a review of all 15 patients treated with DMSO for NAC congestion at our institution between May 2019 and October 2020. DMSO was applied in liquid form on a soaked gauze pad in the hospital; patients were instructed to apply a DMSO cream to the NAC twice a day following discharge. Patient characteristics and data related to DMSO treatment and NAC healing were compared via univariate analysis. Results: Eighteen congested NACs from 15 patients who underwent mastectomy, breast reduction, mastopexy, or breast reconstruction were treated with DMSO. Of the 18 treated NACs, 15 healed with DMSO treatment alone. The average length of DMSO treatment was 9.4 ± 8.5 days (mean ± standard deviation); NAC healing took place over 9.9 ± 9.6 days. There were no complications related to DMSO treatment. Conclusions: This pilot study shows that DMSO may be an effective topical treatment for NAC congestion following breast surgery. Given its low cost, ease of application, and lack of side effects, future studies should prospectively compare DMSO against other topical treatments, like nitroglycerin ointment.
... However, this agreement is largely based on cadaver studies without magnification loupes dating back to 1840 (Cooper, 1840) and other studies lacking histological validation (Craig & Sykes, 1970;Eckhard, 1851;Farina, Newby, & Alani, 1980). In addition, some studies made conflicting statements about the existence of a subdermal neural plexus (Craig & Sykes, 1970;Farina et al., 1980;Jaspars et al., 1997;le Roux, Pan, Matousek, & Ashton, 2011;Pandya & Moore, 2011;Sarhadi et al., 1996). ...
... This suggests that some sensory nerves can be spared during a mastectomy, perhaps because they follow a superficial subcutaneous course (Cooper, 1840;Riccio et al., 2015;Schulz et al., 2017), which can sometimes be noticed during the procedure. However, other studies describe a deep course of the sensory nerves going over the pectoral fascia and then through the mammary gland (Craig & Sykes, 1970;Farina et al., 1980;Jaspars et al., 1997;le Roux et al., 2011;Sarhadi et al., 1996). These contradictory statements could be explained in terms of the wide variety of anatomical courses of the sensory nerves of the breast. ...
Article
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Introduction: Better sensation in the reconstructed breast improves quality of life. Sensory nerve coaptation is a valuable addition to autologous breast reconstruction. There are few publications concerning the sensory nerves of the breast and the nipple-areola complex and reports are contradictory, so it is unknown which nerve is best suited as recipient for coaptation. The current study serves as a proof of concept. Materials and methods: The areas innervated by the anterior cutaneous branches (ACBs) of the intercostal nerves (ICNs) were studied on two separate occasions in two healthy women. First, the ACBs of ICNs 2-5 were individually blocked using ultrasound. Next, the ACBs of all levels were blocked simultaneously. Sensation was measured using Semmes-Weinstein monofilaments. The numbed areas corresponding to the ICNs were drawn in a raster of 2 cm x 2 cm. Results: The largest area was supplied by the ACB of the fourth ICN, located in the upper (UIQ) and the lower (LIQ) inner quadrants of the breast. The second largest area was supplied by the ACB of the third ICN. Blockage of ACBs 2-5 affected sensation in the nipple and the areola. Conclusions: Blockage of all levels 2-5 partially affected sensation in the nipple-areola complex, suggesting innervation by a nerve plexus consisting of both ACBs and lateral cutaneous branches (LCBs). ACB4 supplied the largest area of the breast in the UIQ and LIQ and could be best suited for sensory nerve coaptation to optimize sensation in the autologously reconstructed breast. This article is protected by copyright. All rights reserved.
... Our preference of using a superolateral areolate pedicle flap is not due to the initial purposes described, namely for filling of the upper pole 9,10 ; as in the technique reported in this study, it is prepared with a thickness of 1.5-3.0 cm, which is sufficient to maintain skin vascularization 26 . This is mainly due to the extensive vascularization observed in this areolar segment (presenting as a dominant vascular pedicle with the perforating vessels of internal breast arteries/ veins and a higher risk of areolar necrosis 26,27 ) and the fact that it enables great areolar mobility, mainly in large and dense breasts, thus enabling the prevention of their tension and deformation 1 . ...
... cm, which is sufficient to maintain skin vascularization 26 . This is mainly due to the extensive vascularization observed in this areolar segment (presenting as a dominant vascular pedicle with the perforating vessels of internal breast arteries/ veins and a higher risk of areolar necrosis 26,27 ) and the fact that it enables great areolar mobility, mainly in large and dense breasts, thus enabling the prevention of their tension and deformation 1 . ...
Article
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Introduction: Several authors have reported on mammoplasty procedures using a pectoral muscle strap, but evaluated these techniques subjectively without a comparison group. In 2011, Swanson proposed a protocol including objective parameters that was based on standardized photographic measures for the aesthetic assessment of breast surgeries. Accordingly, this study aimed to evaluate the influence of the pectoralis major muscle strap compared to a technique that does not use a muscle strap as proposed by Swanson. Method: This retrospective cohort study included 18 women who underwent primary bilateral mammoplasty to correct breast ptosis and/or hypertrophy performed consecutively by a single surgeon between March 2010 and November 2012. Thirty-six breasts were divided in two groups (18 breasts in the group with a muscle strap, Group I; and 18 in the group without a muscle strap, Group II) and the outcome was assessed in a photometric study comparing the preoperative appearance to the 6-month-postoperative appearance. The results of each breast were analyzed using SPSS version 20 for Mac software. Results: The average percentage evolution of breast projection elevation in Group I was 15.32 ± 2.41% higher than that in Group II (p < 0.001, 95% confidence interval [CI], 10.41-20.22). The same result was observed for upper pole projection, which was 24.2 ± 3.71% higher (p < 0.001, 95% CI, 16.65-31.82) in Group I than in Group II. Conclusion: Use of the muscle strap effectively filled the upper pole of the breast and maintained its projection for a post-mammoplasty period up to 6 months.
... Venous congestion can occur because of inadequate preservation of the venous drainage, constriction of the pedicle because of an inset that is too tight, or hematoma. 3,4 In our patient, neither breast resection nor transposition of the nipple-areola complex was performed, so we can suppose that the cause of the congestion and consequent partial necrosis could be attributed to a reorganization of the tissues over time which led to a deficit in vascular surplus. ...
... It is impossible to determine the surgical strategies previously used based only on the visible skin scar pattern alone; information on the surgery performed over the parenchyma related to the original breast size, resected tissue volume, selected NAC pedicle, original existing relations of the NAC, and surgery dates is fundamental to prevent NAC loss during a revision surgery (Fig. 4). [16][17][18][19] Q9 RISK FACTORS CONTRIBUTING TO NIPPLE-AREOLA COMPLEX NECROSIS NAC ischemia and necrosis occurs more frequently in cases involving large reductions (resection >1000 g), where a long pedicle is created to carry NAC perfusion, and folding during closure can stress the circulation. 12,[20][21][22] Be Alert to Length of pedicle (>10 cm mobilization); Large reductions (>1000 g); Excessive pedicle folding, kinking, or malrotation; Excessive thinning of the pedicle; Dense gland pedicle (compression); Simultaneous augmentation, mastopexy, and reduction with implant compression; and 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 Reoperative reduction or mastopexy with an unknown initial pedicle. ...
Article
Partial or total nipple necrosis after breast reduc- tion surgery can be a devastating complication for the patient and the surgeon (Figs. 1 and 2). Frequent monitoring of the nipple–areola complex (NAC) and early identification of vascular compro- mise followed by appropriate action may prevent total NAC loss. Intraoperative pale appearance of the NAC complex can be the initial sign indicating that “something is wrong.”1–3 Different maneuvers other than tissue resection that are performed during breast reduction surgery can alter NAC vitality and lead to ischemia and partial/total loss, areolar sufferance, nipple projection loss, and/or hypopigmentation.4–6 This situation can arise independent of the technique.7–9 NAC necrosis has been reported in 2% of breast reduction cases and in 1% of mastopexy cases; epidermolysis with blisterlike formation owing to intradermal or subdermal edema may result in 5% to 11% of cases.1,10
... In the literature, there is still no consensus on the course of the sensible nerves of the breast. Some studies state that they run deep over the pectoral fascia and through the mammary gland [19,[27][28][29][30], others state that their course is superficial and close to the surface [31][32][33]. Since our results show a statistically significant better sensation in the medial part of all operated breasts, we hypothesize that the lateral branches of the medial intercostal nerves might have a superficial course close to the surface and that the anterior branches of the lateral intercostal nerves run through the mammary gland after they arise from the axillary line. ...
Article
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Purpose The aim of the study is to evaluate the level of sensible impairment after mastectomy or implant-based breast reconstruction (IBBR). In addition, factors influencing breast sensibility were evaluated. Methods A cross-sectional study was performed in Maastricht University Medical Center between July 2016 and August 2018. Women with unilateral mastectomy with or without IBBR were included. Objective sensory measurements were performed using Semmes–Weinstein monofilaments. Their healthy breast served as control, using a paired t test. Differences between mastectomy with and without IBBR were evaluated using the independent t test. Linear regression was performed to evaluate the association between patient characteristics on breast sensibility. The paired t test was used to evaluate in which part of the breast the sensibility is best preserved. Results Fifty-one patients were eligible for inclusion. Sixteen patients underwent IBBR after mastectomy. Twenty-three patients received radiotherapy and 35 patients received chemotherapy. Monofilament values were significantly higher in the operated group compared to the reference group (p < 0.001). Linear regression showed a statistically significant association between IBBR and objectively measured impaired sensation (p = 0.008). After mastectomy, the cutaneous protective sensation is only diminished. After IBBR, it is lost in the majority of the breast. The medial part of the breast was significantly more sensitive than the lateral part in all operated breasts (p < 0.001). Conclusion IBBR has a significantly negative impact on the breast sensibility compared to mastectomy alone. This study shows that the protective sensation of the skin in the breast is lost after IBBR. To our knowledge, this is the first study to evaluate the level of sensible impairment after mastectomy or IBBR. More research is necessary to confirm these results.
... On the other hand, venous congestion can occur because of inadequate preservation of the venous drainage, kinking or constriction of the pedicle due to an inset that is too tight. Le Roux [20] published an interesting anatomical guide to preserving essential venous drainage networks in breast surgery and the supero-medial/medial and inferior pedicles contain the most extensive venous drainage patterns. ...
Article
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Nipple-areola complex (NAC) loss is one of the most devastating complications of mastopexy or breast reduction, and it requires revisional procedures with poor aesthetic outcome. In high-risk patients, a free nipple graft could be a choice, but it is associated with the same aesthetic concerns for both patients and surgeons. We report our experience with the septum-supero-medial-based mammaplasty to treat 22 patients with severe breast ptosis (nipple-to-sternal-notch distance > 40 cm). No NAC loss was observed. The study highlights surgical technical details and discusses anatomical considerations to justify the successful result. Level of evidence iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
... With NSM, all glandular tissue is dissected from the NAC dermis, eliminating blood supply from the underlying breast and rendering the NAC dermis completely dependent on blood flow from the perioareolar subcutaneous plexus. 22 In this study, we found that MSFN frequency was higher with NSM and was specifically attributable to hypoperfusion of the NAC. Reported frequencies of NAC necrosis after NSM are in the range of 0-48 %. 23 This wide range may be due to real differences in outcomes and/or varying definitions of MSFN. ...
Article
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With increasing use of immediate breast reconstruction (IBR), mastectomy skin flap necrosis (MSFN) is a clinical problem that deserves further study. We propose a validated scoring system to discriminate MSFN severity and standardize its assessment. Women who underwent skin-sparing (SSM) or nipple-sparing mastectomy (NSM) and IBR from November 2009 to October 2010 were studied retrospectively. A workgroup of breast and plastic surgeons scored postoperative photographs using the skin ischemia necrosis (SKIN) score to assess depth and surface area of MSFN. We evaluated correlation of the SKIN score with reoperation for MSFN and its reproducibility in an external sample of surgeons. We identified 106 subjects (175 operated breasts: 103 SSM, 72 NSM) who had ≥1 postoperative photograph within 60 days. SKIN scores correlated strongly with need for reoperation for MSFN, with an AUC of 0.96 for SSM and 0.89 for NSM. External scores agreed well with the gold standard scores for the breast mound photographs with weighted kappa values of 0.82 (depth), 0.56 (surface area), and 0.79 (composite score). The agreement was similar for the nipple-areolar complex photographs: 0.75 (depth), 0.63 (surface area), and 0.79 (composite score). A simple scoring system to assess the severity of MSFN is proposed, incorporating both depth and surface area of MSFN. The SKIN score correlates strongly with the need for reoperation to manage MSFN and is reproducible among breast and plastic surgeons.
... 9 Venous congestion can lead to NAC necrosis or conversion to a free nipple graft, which reduces lactation and sensation viability. 10 Causes of congestion include inadequate preservation of venous drainage, pedicle constriction secondary to F I G U R E 1 Normal appearance of NAC immediately after surgery tight inset, or hematoma formation. Furthermore, typical comorbidities such as smoking, diabetes, and obesity increase risk for venous congestion. ...
Article
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Leech therapy is a safe, easy-to-use, cost-effective traditional treatment to save reattached body parts and flaps in reconstructive plastic surgery especially in cases with blood circulatory problems.
... The superomedial/medial and inferior pedicle techniques have been shown in cadaveric studies to have the most reliable and consistent venous drainage. 2 Treatment of NAC congestion starts with prevention, followed by assessment and optimization of intrinsic patient characteristics. Weight loss, smoking cessation, blood pressure optimization, and diabetic control all reduce the incidence of NAC congestion. 1 A free nipple graft should be considered on patients with body mass index of more than 35 kg/m 2 or a nipple to inframammary fold distance of more than 18 cm. ...
... 19 The preservation of the vascular supply to the nipple in the augmented patient is critical in order to avoid nipple necrosis. 8,[20][21][22] Having insight into the most frequently encountered perfusion patterns will help surgeons optimize safety when designing an approach during potentially risky secondary operations. Our study is unique because it is the first study to analyze changes to NAC perfusion in vivo using MRI technology in patients following implant based breast augmentation. ...
Article
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Background: Revision surgeries after breast augmentation are associated with an increased risk of complications (eg, nipple areolar complex [NAC]) necrosis. Consequently, maintaining perfusion to the NAC is a critical aspect of secondary breast surgery. Objectives: The purpose of this study was to examine in vivo changes in perfusion to the NAC after implant breast augmentation using magnetic resonance imaging (MRI) technology. Methods: High-resolution 3 Tesla MRI images of 10 women (20 breasts) with previous breast augmentation were compared to a control population of 15 women (30 breasts). Perforators from the internal mammary artery and lateral thoracic artery were examined for the diameter of the originating perforator, distance between the nipple and most distally visualized point of the medial and lateral perforator, and dominance pattern between the medial vs lateral perforators. Results: No difference was found in the caliber of the medial vessels in the implant group compared to the control group. In contrast, the caliber of the lateral blood vessels trended towards being 20% larger in diameter in the augmented breasts. The distances between the nipple and the medial and lateral vessels increased. The frequencies in the distribution of dominance were not significantly different between the implant group and the control group. Conclusions: Overall, medial and lateral blood supply to the NAC are preserved in the augmented patient. Our results suggest a slight delay effect that seems to increase the caliber of the lateral perforators. In addition, the tissue expansion provided by the implants effectively increases the length of both perforators. Level of evidence: 3 Therapeutic.
... The superomedial pedicle areolar flap is used in most cases. [4][5][6] At this point, the need for refinements, such as complementary liposuction, fat grafting, and resection of excess medial and lateral skin, is evaluated and performed (Fig. 9). The final sutures are placed in 3 layers: the parenchymal, subdermal, and intradermal layers. ...
Article
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Augmentation mastopexy is one of the most difficult challenges plastic surgeons face, especially concerning sustainability of upper pole fullness and lower pole ptosis correction. We describe our technique for augmentation mastopexy that provides inferolateral muscular support for the implant and standardizes a sequence of surgical stages to resolve multiple situations and present the outcomes of patients who underwent such an approach. Methods: Our technique proposes the following: (a) modified subpectoral pocket, with muscular inferolateral support for the implant; (b) independent approaches to the submuscular (implant) pocket and parenchymal resection/reshaping; and (c) pre-established 4-step surgical sequence. Data from office files of our private practice were collected for 266 patients who underwent the technique from October 2015 to January 2019. Patient perception about esthetic outcomes, photographs from multiple postoperative follow-ups, and surgical complications/reoperation rates were analyzed. Results: Overall mid-term and long-term results (39 months) were positive for lift and augmentation at single time mastopexy; >90% of patients reported satisfaction with their esthetic outcomes, including absence of ptosis. No major complications occurred. The total revision rate was 16%, but it became <5% in 2018 as the learning curve progressed. Conclusions: Augmentation mastopexy is complex, and the myriad of approaches and possibilities may cause confusion when selecting the most suitable one. The 4-step sequence provides a reliable option, offering a predefined execution plan, whereas inferolateral muscular support prevents recurrence of lower pole ptosis. Other surgeons' experience with lift and augmentation at single time mastopexy and further studies are necessary to validate these findings.
Article
Classically, the vertical-style reduction mammaplasty utilizing a superomedial pedicle has been limited to smaller reductions secondary to concerns for poor wound healing and nipple necrosis. The authors reviewed a large cohort of patients who underwent a vertical-style superomedial pedicle reduction mammaplasty in an attempt to demonstrate its safety and efficacy in treating symptomatic macromastia. A retrospective review was performed of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty. All procedures were conducted by one of 4 plastic surgeons over 6 years (JDR, MAA, DLV, DRA). The average resection weight was 551.7 g (range, 176-1827 g), with 4.6% of resections greater than 1000 g. A majority of patients (55.2%) concomitantly underwent liposuction of the breast. The total complication rate was 22.7%, with superficial dehiscence (8.8%) and hypertrophic scarring (8.8%) comprising the majority. Nipple sensory changes occurred in 1.6% of breasts, with no episodes of nipple necrosis. The revision rate was 2.2%. Patients with complications had significantly higher resection volumes and nipple-to-fold distances (P = .014 and .010, respectively). The vertical-style superomedial pedicle reduction mammaplasty is safe and effective for a wide range of symptomatic macromastia. The nipple-areola complex can be safely transposed, even in patients with larger degrees of macromastia, with no episodes of nipple necrosis. The adjunctive use of liposuction should be considered safe. Last, revision rates were low, correlating with a high level of patient satisfaction.
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Transient areolar ischemia occurs as a consequence of all breast lift/reduction procedures. Most commonly, it results in no complications or cosmetic consequences. Prolonged or more moderate ischemia results in cutaneous edema and epidermolysis in approximately 5–11% of patients. Complete full-thickness areolar necrosis has been reported to occur in approximately 0.5–7.3% of all cases of cosmetic, oncologic, or reconstructive breast surgery. Despite this unavoidable fact, there does not appear to be any literature focused on the diagnosis and management of this well-documented complication. We present this paper as a review of the current literature and as a way to establish a standard of management of areolar ischemia and necrosis.
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In “The Central Pillar Technique: A New Septum-Based Pedicle Design for Reduction Mammaplasty,” Dr Bayramicli1 used a cadaver model study to visualize a superficial venous drainage route from the periareolar venous plexus to the medial and lateral drainage veins and a deep venous system, which accompanies the deep arterial system. As the critical link between those 2 drainage routes, the author identified a hexagonal-shaped periareolar vein polygon and assumed that this polygon should completely be preserved in the new septum-based pedicle (“central pillar”) design. Le Roux et al2 recently explored the venous drainage of the breast by radiographic and cross-sectional studies. They demonstrated that the dominant veins communicate with the valveless superficial subareolar plexus of veins by reduced-caliber choke vessels or through true anastomoses. They stated that this network of oscillating veins allows the venous drainage to be redirected to the main draining veins, provided at least 1 of the main draining veins is maintained. Taylor et al3 examined full-body cadavers through radiography and dissection of the venous network. Within the breast, they found large directional veins draining the subcutaneous layer and smaller perforating veins draining the deep surface of the breast. Between these valvular veins, they found a rich network of oscillating valveless veins …
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Breast MRIs have become increasingly common in breast cancer work-up. Previously obtained breast MRIs may facilitate oncoplastic surgery by delineating the blood supply to the nipple-areola complex (NAC). The aim of this study was to identify and classify the in vivo blood supply to the NAC using breast MRI exams. Breast MRIs obtained over a one-year period were retrospectively reviewed. Patients with negative MRI findings (BI-RADS category 1) were included; patients with diagnoses of breast cancer or previous breast surgery were excluded. Twenty-six patients were evaluated. Dominant blood supply was determined by maximum filling at 70 s post-contrast. Blood supply to the NAC was classified into five anatomic zones: medial (type I), lateral (type II), central (type III), inferior (type IV) and superior (type V). Patient age ranged from 33 to 70 years. Fifty-two breasts were evaluated and 80 source vessels were identified (37 right, 43 left). Twenty-eight breasts had type I only blood supply, 22 breasts had multi-zone blood supply (type I + II, n = 20; type I + III n = 2), one breast had type II only blood supply, and a single breast had type III only blood supply. Anatomic symmetry was observed in 96% of patients. This study utilized MRI to evaluate in vivo vascular anatomy of the NAC, classify NAC perfusion ("NACsomes"), and assess vascular symmetry between breasts. Superomedial source vessels supplying the NAC were predominant. Preoperatively defining NAC blood supply may aid planning for oncoplastic procedures. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
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Since 1989, the authors have performed vertical scar reduction mammaplasty on over 3000 patients. In 2006, the authors described their technique. Since then, the authors have made several modifications that they believe have improved both the reliability of the procedure and the outcomes that they are able to achieve. Key modifications are described in this article and the accompanying video.
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Background: The superior thyroid artery perforator flap has been presented previously in this Journal as a locoregional flap that provides an excellent tissue match with minimal donor morbidity for lateral face and temple defects. In the current study, the authors aimed to describe the microvascular anatomy of this flap. Methods: The authors used in vivo computer tomographic angiography, cadaveric dissection, and ex vivo angiography in order to improve surgical safety and application of this technique. Results: The authors provide a detailed map of the microvasculature that is critical to success in this technique, in addition to useful surface anatomical landmarks for ready application in the clinical scenario. Further, the authors discuss the anatomical basis of this flap with reference to the angiosome concept and the critical presence of true anastomoses. Conclusion: The superior thyroid artery perforator flap has been shown to be an excellent technique for reconstruction of lateral face and temporal soft tissue defects, providing a thin, pliable, hair-bearing tissue with minimal donor morbidity.
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Objective – clarification of the nipple-areolar complex’s (NAC) angioarchitecture.Materials and methods: search for articles which include the description of the breast angioarchitecture, the description of the several NAC’s blood supply sources and substantiated anatomic data presentation was performed by continuous sampling method in scientific databases. In addition, the information in available anatomic and surgery books was analyzed without special criteria for the selection of used medical literature.Results. The NAC’s vascularity was grouped in three systems: the medial, which consists of superficial branches of a. thoracica interna and a venous system, which flows into v. thoracica interna system, the central deep system, which consists of perforators of a. thoracoacromialis and aa. intercostales, and the lateral vascular system, consisting of vessels which variably originate from a. thoracica lateralis, a. axillaris and a. thoracoacromialis.Conclusions. The using of the stable medial vascular system is anatomically substantiated. The central vascular system can be used as additive blood supply source. The lateral system can be used only after pre-examination.
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The objectives of this article are to explain the mechanisms of injury that result in ischemia of the nipple areolar complex (NAC) after reduction mammaplasty or mastopexy, 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 article is divided into 3 sections: prevention of ischemia of the NAC, management of the ischemic nipple, and reconstruction after ischemic necrosis of the nipple and areola. Necrosis of all or part of the NAC is a devastating complication after breast surgery. However, with properly timed and well-executed reconstructive procedures, it is possible in most cases to restore a natural-appearing NAC.
Article
Recurrent or persistent macromastia can occur after breast reduction. This may be due to inadequate primary volume reduction, poor postoperative shape, and breast or nipple-areola complex asymmetry. Postpartum breast changes, weight change, and aging can also contribute to recurrent macromastia. The concern in these cases is the altered blood supply to the nipple-areola complex and the safety of nipple-areola complex transposition. Literature on the safety of repeated breast reduction is limited with conflicting approaches. This article discusses an approach to recurrent or persistent macromastia and outlines a modified breast reduction technique that is safe in cases of repeated breast reduction.
Article
Background: Nipple-areola complex (NAC) necrosis, which is caused by local ischemia, remains one of the complications associated with nipple-sparing mastectomy. Obesity, smoking, diabetes mellitus, and immediate breast reconstruction have been identified as risk factors of NAC necrosis. The current study examined the correlation between NAC necrosis and nipple volume. Materials and methods: A total of 83 patients who underwent NSM for primary breast cancer from January 2016 to December 2019 were retrospectively analyzed. Nipple volume was determined using the formula: volume (cc) = length × width × height (mm), with measurements determined using contrast-enhanced magnetic resonance imaging. Total and partial NAC necrosis was defined as full-thickness necrosis requiring surgical procedures and epidermal necrosis managing local wound care, respectively. Results: NAC necrosis was observed in 30 patients (36%), with 3 and 27 patients having total and partial necrosis, respectively. Large nipple volume (56% vs. 24%, p = 0.006), as well as smoking and immediate breast reconstruction (57 vs. 28%, p = 0.017; 48% vs. 20%, p = 0.009, respectively), were significantly correlated with NAC necrosis. Multivariate analysis identified nipple volume as an independent risk factor for NAC necrosis (OR, 3.75; 95% CI, 1.23-11.44; p = 0.02). Smoking (OR, 4.68; 95% CI, 1.37-15.94; p = 0.014) and immediate breast reconstruction (OR, 3.43; 95% CI, 1.05-11.23; p = 0.042) were also independently associated with NAC necrosis. Conclusions: This study suggested that a large nipple volume could be one of the risk factors for NAC necrosis following NSM.
Chapter
Nipple-areolar complex (NAC) necrosis is a dreaded complication of reduction mammaplasty and mastopexy that can lead to prolonged morbidity and permanent cosmetic deformity. Preventing ischemic complications is greatly preferable to treating a necrotic nipple and areola. The guiding principle in surgical management of ischemic complications of the nipple-areolar complex is to avoid aggressive treatment until the tissues have “declared” themselves. With properly timed and well-executed reconstructive procedures, it is possible in most cases to restore a very natural-appearing nipple-areolar complex.
Chapter
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Chapter
The breasts are organs of great relevance to a woman’s female identity. Breast hypertrophy may cause psychological and physical distress. We describe our personal approach to this common finding in a plastic surgeon’s practice. We divide these patients in three groups: young adolescent, post-gestational, and women at menopause. Breast evaluation is carried out according to shape and size, skin texture, and tissues that constitute the breast, NAC position and mobility, and the submammary fold. The technique used by us shows the importance of the inferior pedicle and the supero-medial areolar flap, while stressing that in younger patients the horizontal scars should be shorter. We conclude that breast reduction has dramatic benefits for the patient. Achieving a nice cone shape is more important than reducing the scars and surgery result alters throughout the years, as the body ages.
Article
Background Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%.Materials and Methods We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients.ResultsFifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications.Conclusion Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising results.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Article
Full-text available
Reduction mammoplasty is a popular operation worldwide. Early complications include bleeding, wound dehiscence, and nipple-areolar complex (NAC) ischemia. Although uncommon, NAC ischemia can lead to necrosis of the NAC. NAC congestion is usually recognized intraoperatively or within a few hours of the operation. A 21-year-old woman with severe macromastia received bilateral reduction mammoplasty using a Wise-pattern reduction with a superomedial pedicle. NAC congestion of the left breast was identified 40 hours after the operation. Delayed venous congestion of the NAC after reduction mammoplasty has not been previously reported; in this case, delayed congestion may have been caused by partial venous obstruction aggravated by the progression of tissue edema near the pedicle. Through use of the delayed suture technique, application of nitroglycerin cream, intravenous administration of prostaglandin E1, and use of a portable negative-pressure wound therapy device, the patient’s NAC was salvaged with satisfactory nipple projection and minimal scarring.
Chapter
Understanding the anatomy of the breast is important to ensure positive outcomes in regard to function and aesthetic appeal. Throughout the embryogenesis of the breast, malformations in the anatomy can arise that may require surgical intervention. One of the most crucial tenets of breast anatomy is the blood supply to the nipple-areolar complex. When intervening on possible malformations and/or performing procedures on the breast, maintaining blood flow to the nipple-areolar complex is critical. Using the most robust pedicle increases the reliability of sustaining blood flow to the nipple-areolar complex. In addition to maintaining blood flow, nipple innervation must be maintained to help preserve sensual function and breastfeeding potential. During breast surgery the pectoralis major and minor muscles are normally involved, which requires an understanding of the blood supply, innervation patterns, and functional anatomy of these muscles as well. Additionally, a full comprehension of the position of the inframammary fold is important to produce the most aesthetically pleasing breast possible. The breast is a major part of the plastic surgery realm, and a thorough knowledge of its anatomy allows for the most successful outcomes.
Article
Background: Prepectoral breast reconstruction is being increasingly popularized, largely because of technical advances. Patients with ptotic breasts and active cancer require mastectomies through a mastopexy excision pattern to achieve proper pocket control in a prepectoral single-stage operation. This article presents a single-surgeon experience with direct-to-implant, prepectoral reconstruction following skin-reducing mastectomies. Methods: A retrospective chart review identified all patients undergoing prepectoral, direct-to-implant breast reconstruction following Wise-pattern mastopexy from June of 2016 to June of 2018. Surgical and aesthetic outcomes, including capsular contracture and revision surgery, were measured. The BREAST-Q was administered preoperatively, 6 months postoperatively, and 1 year postoperatively. Results: Eighty-four patients (121 breasts) were included. A widely based inframammary fold adipodermal flap was used in all cases, with acellular dermal matrix used in 77 breasts (63.3 percent), free nipple grafts in 42 breasts (34.7 percent), and postmastectomy radiation therapy in 31 breasts (26.5 percent). Operative complications included nipple-areola complex necrosis in six (5.1 percent), hematoma in four (3.4 percent), seroma in four (3.4 percent), implant exposure in three (2.6 percent), and infection in one (0.9 percent). Minor complications included cellulitis in five (6.0 percent) and minor wound issues in five (4.3 percent). In aesthetic outcomes, only two nonirradiated breasts experienced a grade 3 to 4 or grade 4 capsular contracture requiring capsulectomy. Rippling was visible in four breasts (3.4 percent). The BREAST-Q showed good satisfaction with the technique, with no significant differences between nipple-areola complex techniques. Conclusions: This cohort represents the largest single-surgeon, Wise-pattern, direct-to-implant prepectoral database in the literature. This report showed that surgical and aesthetic complications did not differ in terms of acellular dermal matrix use. This technique has shown, through patient-reported outcomes, to yield good patient satisfaction. Clinical question/level of evidence: Therapeutic, III.
Article
Background: Vascularity of the nipple-areolar complex (NAC) is altered after reduction mammoplasty, which increases complications risks after repeat reduction or nipple-sparing mastectomy. Objectives: To evaluate angiogenesis of the NAC via serial analysis of breast magnetic resonance images (MRIs). Methods: Breast MRIs after reduction mammoplasty were analyzed for 35 patients (39 breasts) using three-dimensional reconstructions of maximal intensity projection images. All veins terminating at the NAC were classified as internal mammary, anterior intercostal, or lateral thoracic in origin. The vein with the largest diameter was considered the dominant vein. Images were classified based on the time since reduction: <6 months, 6-12 months, 12-24 months, >2 years. Results: The average number of veins increased over time: 1.17 (<6 months), 1.56 (6-12 months), 1.64 (12-24 months), 1.73 (>2 years). Within 6 months, the pedicle was the only vein. Veins from other sources began to appear at 6-12 months. In most patients, at least two veins were available after 1 year. After 1 year, the internal mammary vein was the most common dominant vein regardless of the pedicle used. Conclusions: In the initial 6 months after reduction mammoplasty, the pedicle is the only source of venous drainage; however, additional sources are available after 1 year. The internal thoracic vein was the dominant in most patients. Thus, repeat reduction mammoplasty or nipple-sparing mastectomy should be performed ≥1 year following the initial procedure. After 1 year, the superior or superomedial pedicle may represent the safest option when the previous pedicle is unknown.
Article
This article examines outcomes following repeated breast reduction using vertical scar reduction mammaplasty. The results of performing repeated breast reduction in patients for whom operative records were available for the previous breast reduction were compared with those for whom these records could not be obtained. A retrospective review of all patients who underwent repeated breast reduction for recurrent symptomatic mammary hypertrophy, inadequate volume reduction during the primary operation, and significant postoperative breast volume asymmetry was performed. Twenty-five patients had repeated breast reduction. The initial technique was known in 13 patients and unknown in 12 patients. The average total reduction per breast (including liposuction) was 658 g (range, 30 to 1150 g). Liposuction was used more often in cases for which the initial technique was unknown (p = 0.000). No patients experienced necrosis of the nipple-areola complex, and there was no significant difference in the complication rates between patients for whom the previous pedicle was known versus those in whom it was unknown (p = 0.220). Using vertical scar reduction mammaplasty, repeated breast reduction is a safe procedure, even when the initial technique is unknown. A vertically oriented, inferior wedge excision of tissue can be safely excised, irrespective of the initial pedicle. For patients with ptosis in whom the nipple-areola complex needs to be transposed superiorly, a carefully planned and de-epithelialized superior pedicle should be used. In addition, liposuction is an important adjunct to achieve volume reduction, while limiting the amount of dissection during repeated breast reduction. : Therapeutic, IV.
Article
Full-text available
This prospective study followed patients who underwent breast reductions to determine the influence of smoking and the amount of tissue removed on postoperative wound infections. Patients who had received breast reductions were considered eligible for the study. The study excluded postbariatric patients and those with ongoing clinical infections, a recent antibiotic course, or systemic diseases that could impair tissue oxygenation. Smokers were instructed to quit smoking at least 4 weeks before surgery. By March 2004, the study had enrolled 87 patients. Postoperative infections were present in 24 cases (27.9%). Infections included 16 in smokers (37.2%), 8 in nonsmokers (18.2%; p < 0.05), 14 in patients with large resections (>0.85 kg; 70%), and 10 in patients with small resections (14.9%; p < 0.001). Significant differences were found between the patients who experienced infections and those who were infection free in terms of the overall estimated cigarettes smoked (mean, 146,000; range, 29,200-228,125 vs mean, 10,950; range, 9,125-54,750; p < 0.001), the number of pack years (mean, 20; range, 4-31 vs mean, 2; range, 1-8; p < 0.001), and the amount of tissue removed (mean, 0.9 kg; range, 0.5-2 kg vs mean, 0.5 kg; range, 0.2-1.4 kg; p < 0.001). The analysis for all the patients determined an odds ratio of 2.04 for smoking and 4.7 for the amount of tissue removed. Smoking and the amount of tissue removed are important issues in aesthetic breast surgery that need to be addressed accurately by the plastic surgeon. If future larger studies confirm these data, surgeons could have a simple and easy method for stratifying patients according to their risk for the development of wound infections and for prescribing specific preventive measures.
Article
The internal mammary artery perforator flap has been used in head and neck reconstruction. Although anatomical and perfusion studies with ink have been performed previously, the authors now use three- and four-dimensional computed tomographic angiography to precisely visualize vascular anatomy of individual perforators (perforasomes) and the axiality of perfusion. Eleven hemichest adipocutaneous flaps were dissected from cadavers. Measurements were recorded, such as the distance of each internal mammary artery perforator from the sternal edge, diameter of vessels, and number and location of internal mammary artery perforators per hemichest. Single internal mammary artery perforator injections with Isovue contrast were carried out, and the flaps were subjected to dynamic computed tomographic scanning. Static computed tomographic scanning was also undertaken using a barium-gelatin mixture. Images were viewed using both General Electric and TeraRecon systems, allowing the appreciation of vascular territory (three-dimensional), and analysis of perfusion flow (four-dimensional). Each hemichest flap had one to three internal mammary artery perforators, most commonly in intercostal spaces 1, 2, and 3. Twenty-six internal mammary artery perforators were dissected, and 19 perforator arteries and six perforator veins were injected with contrast. The internal mammary artery perforator in the second intercostal space had the largest mean diameter and a large vascular territory. Linking vessels, both direct and indirect, communicate between perforators and can enlarge perforasomes. Linking vessels were also found between internal mammary artery perforators and the lateral thoracic artery. Three- and four-dimensional computed tomographic angiography allows detailed analysis of vascular anatomy. Important information such as internal mammary artery perforator flap dimensions, linking vessels, and axiality of perfusion is elucidated, thus contributing to a better understanding of perforator flaps.
Article
The innovative technique of three- and four-dimensional computed tomographic angiography allows us to analyze the areas of perfusion in commonly used free abdominal flaps in breast reconstruction, such as pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps, full TRAMs, muscle-sparing TRAMs, and deep inferior epigastric perforator (DIEP) flaps. The authors compared the vascular territories in these flaps. A total of 11 lower abdominal flaps were obtained from nine cadavers and two abdominoplasty procedures. The authors simulated the perfusion of seven pedicled TRAMs, eight full TRAMs, eight muscle-sparing TRAMs, 14 DIEPs, and six superficial inferior epigastric artery flaps. For each simulated flap, the named artery/perforator was injected with Omnipaque contrast using a Harvard precision pump at 0.5 ml/minute, and the flap was subjected to dynamic computed tomographic scanning using a GE Lightspeed 16-slice scanner. Scans were repeated at 0.125-ml increments (every 15 seconds) for the first 1 ml, then at 0.5-ml increments (every 60 seconds) for the next 2 to 3 ml, thus giving progressive computed tomographic images over time. Images were viewed using both General Electrics and TeraRecon systems, allowing analysis of branching patterns and perfusion flow as well as measurements of vascular territory. This study shows that there are definitive differences in vascular territory based on flap type. The sequences of images also allow us to reappraise the classic Hartrampf zones of perfusion.
Article
An understanding of the vascular anatomy of the breast is paramount in breast reduction surgery in order to minimize vascular complications. While most vascular compromise in breast reduction is largely venous in nature, the venous anatomy of the breast has not been sufficiently explored in the literature, particularly the inferior pole of the breast. Developments in infrared photography have enabled the use of this noninvasive technique to evaluate the venous architecture of the breast. 32 voluntary participants (26 female, 6 male) underwent infrared photography of the superficial veins of the breast. Using a modified technique, the venous architecture of the breast, with an emphasis on the inferior pole veins, was evaluated. Infrared photography was able to clearly demonstrate the superficial veins of the breast in all cases. The subareolar plexus and pattern of venous radiation from this plexus were evident, with a predominant pattern of superomedial and inferior pole drainage seen. Although the dominant drainage route was via the third and fourth intercostal spaces, two patterns of drainage were noted: superomedial drainage to the 2nd and 3rd intercostal spaces (29 out of 29 cases) and lower pole drainage to the 4th and/or 5th intercostal space (27 of 29 patients - 93.1%). The venous architecture of the breast is demonstrated clearly with the techniques described, enabling the improved planning of breast reduction pedicles. Preservation of the superficial venous drainage as well as the arterial supply can help to mini mize the incidence of vascular complications.
Article
The Hall-Findlay superomedial pedicle technique is widely used for breast reduction, and, despite low complication rates, nipple-areola complex (NAC) necrosis and denervation are still the two most common complications, particularly when resection volumes exceed 600g. An understanding of the anatomy of the neurovascular pedicle of the NAC is paramount in avoiding these complications. An anatomical study was undertaken on 11 female cadaveric breast specimens (nine fresh and two embalmed). The neurovascular anatomy of the breast was explored through dissection, microdissection, radiographic, computed tomographic, photographic and cross-sectional studies. The superomedial pedicle was mapped out on each specimen, and the course of the relevant nerves and vasculature was identified. The arterial supply to the superomedial pedicle was found to originate from a single dominant vessel in each specimen, while the venous drainage was via an extensive branching network. Both vascular patterns traversed the pedicle in a superficial plane. The innervation of the pedicle was via intercostal branches, which coursed extremely superficially in the pedicle. De-epithelialisation or superficial thinning of the superomedial pedicle for breast reduction is at high risk for complications related to vascular compromise or denervation. Where greater resection is needed, this should be done from the deep surface or the base of the pedicle, contrary to previous descriptions.
Article
A number of breast reduction techniques have been developed over the years, but debate over which technique is better for patients continues to grow. The authors' goal was to survey members of the American Society of Plastic Surgeons to identify their preferences and practices and report their opinion regarding issues related to the various breast reduction techniques. In the fall of 2006, a one-page anonymous survey was sent to 5112 plastic surgeons who were members of the American Society of Plastic Surgeons. A follow-up survey was sent 2 weeks after the first mailing as a friendly reminder. The questionnaires were then collected over a 6-week period. Of the 5112 plastic surgeons surveyed, 2665 (52 percent) responded to the survey. The majority of the respondents (69 percent) use the inferior pedicle breast reduction technique. Ninety-two percent of the respondents use intraoperative deep venous thrombosis prophylaxis. Sixty-one percent of respondents performed over 75 percent of their cases on an outpatient basis and 97 percent of respondents use general anesthesia. Ninety-three percent of the respondents use preoperative antibiotics. Over 70 percent of the respondents do not think breast reduction should be a cosmetic procedure. In conclusion, the inferior pedicle technique has traditionally been the procedure of choice and remains so today. However, there has been an increase in the use of the newer techniques. Plastic surgeons are becoming more cognizant of the risk of deep venous thrombosis among their patients. The majority of breast reductions are now performed as outpatient procedures.
Article
Convinced of the importance of a precise understanding of anatomy in modern surgery, the author studied the arterial blood supply and venous and lymphatic drainage and re-evaluated the innervation of the mammary gland; 60 fresh cadavers, 350 thermographies and 5 in vivo arteriographies were analysed. Twenty years of surgical practice either supported or contradicted these anatomical findings. Schematically, the arterial blood supply is ensured by three plexuses: cutaneoglandular plexus, retroglandular plexus, intraglandular anastomotic plexus; the cutaneoglandular plexus corresponds to a combination of the dermal and the glandular blood supplies. The ectodermal embryological origin of the mammary gland clearly accounts for this common blood supply. This concept allowed the development of deepithelialised periareolar pedicle reduction mammaplasty and acts as a guide for subcutaneous mastectomies. The retroglandular plexus is supplied, in particular, by the musculocutaneous and, in this case, musculoglandulocutaneous arteries. This plexus ensures the blood supply of the remaining gland following posterior or inferior pedicle reduction mammaplasty techniques. The venous drainage was studied in particular detail. Two venous plexuses are present: one runs parallel to the arterial blood supply and the other is superficial, subcutaneous and anastomotic not only with the deep plexus, but also with the all of the surrounding regions. This plexus, quiescent under normal conditions, becomes functionally important in certain pathological conditions or after correction of mammary hypertrophy. The external and internal pathways of lymphatic drainage have been described for a long time. The authors describe the lesser known accessory pathways which nevertheless play an essential role in certain forms of metastatic spread or recurrence of breast cancer. Lastly, the authors describe the sensory innervation of the mammary gland which is an essential element for preservation of nipple sensitivity, in particular, following reduction or augmentation mammaplasty or even breast reconstructions.
Article
The medicinal leech, Hirudo medicinalis, played a central role in the evolution of medieval and folk medicine. Today, for the first time in history, the leech actually has a real and valuable purpose in medicine as a useful adjunct for the plastic surgeon: It provides relief of venous congestion. For over 2000 years, leeches were needlessly applied for a multitude of maladies as an adjunct to blood-letting. Their use in Europe peaked between 1830 and 1850, however, shortages led to a subsequent decline in leech application. Today there is a real clinical use for leeches which had led to a resurgence in their use in plastic surgery. Plastic surgeons use leeches in microsurgery to salvage congested flaps, whose viability is uncertain due to venous congestion. We present our experience with two patients where leeches were used to treat isolated venous engorgement of the nipple following breast surgery. Leech therapy is painless, well tolerated, and does not result in significant scarring. Prompt initiation of treatment is mandatory and produces dramatic resolution of venous congestion.
Article
The supply, consumption, and tissue tension of oxygen were studied in experimental bilateral myocutaneous island flaps in five control pigs and in eight pigs during progressive 1-hour intervals of flap ischemia. Progressive ischemia was obtained by partial to complete clamping of the artery in one flap, producing arterial insufficiency, and simultaneous clamping of the vein in the other flap, producing venous stasis. Blood flow was reduced to 50, 25, and 0 percent of baseline. In the arterial insufficiency flaps, the oxygen tension in subcutaneous tissue, muscle, and venous outflow was significantly reduced once blood flow was reduced to 50 percent of baseline. Oxygen consumption during partial vessel occlusion was lower in the venous stasis flaps than in the arterial insufficiency flaps when blood flow was reduced to 25 percent of baseline, suggesting either that cellular metabolism is reduced in the venous stasis flaps or that the oxygen which is delivered is unavailable for the cells. Increased presence of tissue fluid in the venous stasis flap inhibits the diffusion of oxygen through the interstitial tissue, and this may explain the lower oxygen consumption. During 3 hours of reperfusion, increased blood flow was observed in the arterial insufficiency flaps, whereas blood flow in the venous stasis flaps was sluggish. The arterial insufficiency flaps recovered more rapidly than the venous stasis flaps during the first hour of reperfusion, judged by the rate of increase in oxygen tension and the higher venous oxygen tension. Oxygen tension increased more rapidly in muscle than in subcutaneous tissue.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
In order to further improve the understanding of hemodynamic changes in the immediate postoperative phase after elevation of myocutaneous flaps, regional blood flow and arteriovenous (A-V) shunting were measured in rectus abdominis island flaps in 8 pigs. Radioactive microspheres of two sizes (15 and 50 micron) were used. Approximately half (53.4 +/- 6 percent) of the 15-micron microspheres and one-fourth (24.1 +/- 6 percent) of the 50-micron microspheres entering the flap appeared in the venous outflow. Compared with the control area, A-V shunting was significantly increased in muscle and substantially more pronounced in skin. Nutritional blood flow, total blood flow, and vascular volume were increased in muscle and unchanged in skin and subcutis. The lowest tissue hematocrit of 7 +/- 1 percent was found in skin as compared with a central hematocrit of 35 +/- 2 percent. Tissue hematocrit in flap muscle was decreased to 17 +/- 2 percent when compared with control muscle (22 +/- 3 percent), and the mean transit time for blood was correspondingly decreased. Thus vasodilation provided increased perfusion through muscular capillaries and through A-V shunts. Shunting of 15-micron microspheres appeared to take place not only in skin, but also in subcutis and muscle, which challenges the widespread belief that A-V shunting does not occur in muscle.
Article
Multiple techniques for breast reduction have been proposed. For carefully selected women with macromastia, the technique of choice may be amputation mammoplasty with free nipple-areolar grafting. These select groups include the following: the poor-risk elderly, women with systemic disease that could affect the vascularity of the skin flaps or impair wound healing, women with previous operative procedures in the breast affecting skin flap or pedicle vascularity, and women with indications for removal of tissue in the region of the inferior pedicle. Our experience demonstrates that in these high-risk women, amputation mammoplasty with certain technical refinements provides an aesthetic safe result without significant perioperative surgical or medical complications. A clinical series is presented with an average follow-up of 2.75 years.
Article
The venous architecture of the integument and the underlying deep tissues was studied in six total-body human fresh cadavers and a series of isolated regional studies of the limbs and torso. A radiopaque lead oxide mixture was injected, and the integument and deep tissues were dissected and radiographed. The sites of the venous perforators were plotted and traced to their underlying parent veins that accompany the source (segmental) arteries. A series of cross-sectional studies were made in one subject to illustrate the course of the perforators between the integument and the deep tissues. The veins were dissected under magnification to identify the site and orientation of the valves. Results revealed a large number of valveless (oscillating) veins within the integument and deep tissues that link adjacent valved venous territories and allow equilibration of flow and pressure throughout the tissue. Where choke arteries define the arterial territories, they are matched by boundaries of oscillating veins in the venous studies. The venous architecture is a continuous network of arcades that follow the connective-tissue framework of the body. The veins converge from mobile to fixed areas, and they "hitchhike" with nerves. The venous drainage mirrors the arterial supply in the deep tissues and in most areas of the integument in the head, neck, and torso. In the limbs, the stellate pattern of the venous perforators is modified by longitudinal channels in the subdermal network. However, when an island flap is raised, these longitudinal channels are disconnected, and once again the arterial and venous patterns match. Our venous studies add strength to the angiosome concept. Where source arteries supply a composite block of tissue, we have demonstrated radiologically and by microdissection that the branches of these arteries are accompanied by veins that drain in the opposite direction and return to the same locus. Hence each angiosome consists of matching arteriosomes and venosomes. The clinical implications of these results are discussed with particular reference to the design of flaps, the delay phenomenon, venous free flaps, the pathogenesis of flap necrosis, the "muscle pump," varicose veins, and venous ulceration.
Article
The 20-MHz ultrasonic Doppler probe was used to determine its efficacy as a continuous monitoring technique for microvascular anastomoses. A 1-mm2 piezoelectric crystal embedded in a soft silicone sleeve was sutured directly to the blood vessel distal to the anastomosis. Using the dog femoral artery, simultaneous measurement of velocity and blood flow with an electromagnetic flowmeter established a direct correlation between flow and velocity with a 14 percent error at maximum flow and an 18 percent error at minimum flow conditions. The probe was then implanted in the rabbit femoral artery for 1 week (n = 3) and 4 weeks (N = 6), demonstrating that a continuous tracing could be obtained without injury to the vessel. Our clinical study included 63 patients undergoing free-tissue transfers monitored with the implantable probe for 7 to 29 days (average 10.5 days). Twenty-three flaps were buried. Two patients experienced loss of arterial tracing due to malfunction of the probe (3 percent). Three patients had a venous thrombosis with a present arterial tracing. There were no flap failures per se. All probes were removed without mishap, and there were no complications related to the probe. We conclude that the 20-MHz ultrasonic Doppler probe holds promise as a useful monitoring method.
Article
A simple, inexpensive injectable substance is reported for analysis of the arterial circulation in fresh human or animal cadavers. The technique is a modification of that reported by Salmon in 1936 and utilizes lead oxide and gelatin. This combination is highly radiopaque; it perfuses the small radicles of the vascular tree and sets to a firm rubbery consistency to fascilitate dissection.
Article
It is not uncommon following reduction mammoplasty that the nipple-areola vasularity becomes compromised. If simple maneuvers do not restore circulation, then a free nipple graft becomes mandatory to minimize morbidity. Occasionally, nipple congestion that recurs as the areola is inset might best be managed by delayed closure. The advantages of this technique are described.
Article
A technique based on reflection spectrophotometry has been tested for use as a monitor of the cutaneous circulation in experimental skin flaps. A very rapid indication was given of either arterial or venous insufficiency in a previously healthy flap. Post-operative monitoring produced characteristic traces for successful and unsuccessful free flaps. The ability of this method to discriminate between a satisfactory flap, an arterial failure, and a venous failure was highly significant (P less than 0.001).
Article
Despite careful preoperative planning and accurate surgery, nipple necrosis may follow reduction mammaplasty. Impending nipple necrosis developed following translocation of the nipple and areola on a dermal pedicle in two patients. An excellent result was obtained by converting the nipple-areola complex to a full-thickness graft and removing the avascular portion of the breast. We recommend this technique to the surgeon whose patients develop impending nipple necrosis after reduction mammaplasty.
Article
Although endothelial cell injury and microcirculatory intravascular clotting have been implicated in the pathophysiology of skin-flap failure and various hematologically active drugs have been used to improve flap survival, the basic underlying pathophysiology has not been documented previously. In this study of venous ischemia in pig flaps, we focus on the accumulation and distribution of platelets and fibrinogen in the flap, on the morphologic changes in the flap microcirculation, and on changes in various coagulation factors in the venous effluent from the flap. Bilateral buttock skin flaps and latissimus dorsi myocutaneous flaps were designed and elevated on 12 pigs. All flaps had a primary ischemic insult (clamp application to the vascular pedicle) of 2 hours, followed by 2 hours of reperfusion, and then one side was subjected to a 6-hour period of secondary venous ischemia (clamp application to the dominant flap vein). In six animals, radioactively labeled autologous platelets and human fibrinogen were injected intravenously half an hour before termination of secondary venous ischemia. Flaps were weighed and counted for radioactivity. Flap biopsies and the buffy coat of venous effluent were processed for electron microscopy. In the other six animals, venous effluent was collected before secondary ischemia, upon immediate reperfusion, and at 4 and 8 hours after termination of secondary ischemia. Venous plasma levels of fibrinogen, von Willebrand factor, and antithrombin III were measured. Platelet and fibrinogen accumulation was increased in flaps with venous stasis when compared with control flaps at both time intervals studied; a twofold increase was seen prior to reperfusion, and a threefold increase was seen following 4 hours of reperfusion. Venous effluent could not be collected from buttock skin flaps because of slow reflow and clotting in the collecting system. In comparing the venous effluent of control flaps with that of venous ischemic latissimus dorsi flaps, hematocrit was significantly elevated. Blood samples collected for analysis of fibrinogen, antithrombin III, and von Willebrand factor could not be analyzed because of postcollection clotting. Electron microscopy showed extravasation of red blood cells and activated platelets, fibrin, and red blood cells in distended and partly disrupted capillaries. The venous ischemia reperfusion injury is associated with thrombosis in the microcirculation and alterations in consumption of coagulation factors. This study gives physiologic support for potential beneficial effects of treatment modalities that aim at counteracting the different components of thrombus formation.
Article
In extreme cases of breast hypertrophy, amputation of the nipple-areolar complex and transplantation during reduction mammaplasty has been advocated to avoid nipple necrosis. We report our experience with 172 patients having inferior breast pedicle reduction without amputation of the nipple-areolar complex. Mean total weight of resected tissue was 1,946 g (548 to 5,100 g), with a mean nipple-areolar transposition of 10 cm (0.5 to 23 cm). Dividing patients into four groups by weight of resection, we compared complication rates. In this series, where nipple-areola amputation was avoided, there was a 99.6% survival rate of the nipple-areolar complex with 97.1% retention of nipple sensibility. Patients with extreme breast hypertrophy (3,000 g resected tissue) experienced no increase in complications when compared to smaller reductions. In most cases of gigantomastia, amputation of the nipple can be avoided using the inferior breast pedicle technique. Size of breast resection alone should not determine the fate of the nipple.
Article
Studies of the gross anatomy of the lymphatic system are few and far between when compared with those of other vascular systems. Our knowledge of the anatomy of the lymphatic system is so limited that it seems vastly inadequate in explaining the clinical manifestations caused by its disorder. This study has developed an effective method to identify the lymphatics using hydrogen peroxide, to demonstrate the lymphatic vessels radiographically using a lead oxide suspension, and to dissect them out in adult human cadavers.
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Venous outflow obstruction is the most common cause of tissue failure after microvascular reconstructive surgery. If it is not recognized early, there is an increased risk of tissue damage and loss. Currently, however, there are no adequate models for the study of this clinical problem. The purpose of this study was to develop a partial congestion model for the study of skin flap physiology in response to varying levels of occluded venous outflow. Nine mixed-breed pigs were equally divided into three experimental groups (0 percent, 20 percent, and 50 percent venous outflow) to determine the effects of varying venous outflow on cutaneous flap color, oxygen tension, and edema. A cutaneous pedicle flap model and a partial congestion system were used to observe changes in variable venous obstruction. Only 0 percent venous outflow resulted in progressive color change across time. In addition, 0 percent venous outflow demonstrated significantly different oxygen tension levels relative to the other groups. Twenty percent venous outflow resulted in significant edema formation relative to the other groups. The 50 percent group showed an increase in oxygen tension from the second hour of venous obstruction to the end of the experiment. Tissue flap color is the clinical standard on which flap health is measured. After 8 hours, only complete venous occlusion resulted in significant color change. However, physiological changes that could affect tissue flap health were noted with only partial venous occlusion, including the development of edema formation. Accordingly, subtle color change could indicate partial venous congestion and may warrant intervention by the surgeon.
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Nipple necrosis is a potential complication of breast reduction and mastopexy procedures that can be prevented if the surgeon is acquainted with the arterial blood supply to the breast, particularly the nipple-areolar complex (NAC). A review of the latest research on this with its clinical application is given.
  • Hjortdal