579
Chapter 10 • Mastopexy-Augmentation
Because the capsule is attached to the breast, contracture will raise the breast
and make the glandular ptosis look “better.” When the capsule is released, how-
ever, the gland will drop back down.
This patient developed the type of bottoming out in which the implant pushes
the inframammary fold downward. (See pp. 572 through 575 for more photos
of this patient.) The fold will inevitably drop an average of 2 cm after a mastopexy-
augmentation. Bottoming out can be reduced by keeping the implant pocket
dissection high. This patient had three procedures to reduce her glandular pto-
sis, and the dissection allowed the implant to push down the inframammary fold.
580
Part II • Technique
This patient demonstrates how important it is to keep the dissection rom ex-
tending below the Wise pattern i at all possible. The f ngers shown above are
blocked by parenchyma. This maneuver can help prevent bottoming out o the
implant where it descends below the in ramammary old.
Puckers
Puckers occur less requently with a mastopexy-augmentation than with a breast
reduction or mastopexy, because the in ramammary old does not rise; it actu-
ally drops an average o 2 cm with a mastopexy-augmentation.
Puckers can be removed with either a horizontal or a vertical excision (see Chap-
ters 6 and 9). Usually a pucker in a mastopexy-augmentation patient can be
treated with a vertical skin excision, because there is o ten extra distance be-
tween the lower aspect o the vertical scar and the (lowered) in ramammary old
level.
581
Chapter 10 • Mastopexy-Augmentation
This patient illustrates how a mild pucker can be corrected with a small verti-
cal elliptical excision complemented with horizontal fat removal. Puckers are
often more a problem of excess subcutaneous tissue left behind than of excess
skin.
582
Part II • Technique
This woman had a superior pedicle vertical mastopexy-augmentation using
smooth-walled Style 15 339 cc responsive silicone gel implants placed in sub-
glandular pockets. She had 40 g of tissue removed from the inferior aspect of
the right breast and 30 g from the left breast. She is shown 1 year after surgery.
She has complete return of sensation. Her nipples were marked at 20.5 cm pre-
operatively and the suprasternal notch-to-nipple distance stretched to 22.5 cm
on both sides. H er suprasternal notch-to-inframammary fold distance has in-
creased from 21.5 cm and 22 cm to 23 cm and 24 cm postoperatively.
Analysis
The patient’s result is good, with an acceptable nipple position and
shape. She had a small amount of glandular ptosis, so it was important to re-
move a small amount of the inferior pole to achieve a good long-term result.
This patient is relatively low breasted. She is 5 feet 4 inches tall, and the dis-
tance from her clavicle to her upper breast border was 12 cm and 12.5 cm. The
implant raised the upper breast border by 2 cm, but it also lowered the lower
breast border (inframammary fold). Even with good patient education, she re-
turned asking for larger implants. Often patients hope that larger implants will
increase their upper pole fullness and raise the upper breast border, but even-
tually gravity wins, and the breast shape drops instead.
RESU LTS
583
Chapter 10 • Mastopexy-Augmentation
This woman had a superior pedicle vertical mastopexy-augmentation using Style
115 253 cc textured silicone gel implants. The implants were placed in a sub-
fascial pocket using the inferior fascia as a sling; 50 g of tissue was removed in-
feriorly from the right breast and 95 g from the left. She is shown 1 year post-
operatively. She has complete return of sensation. H er nipples were marked at
19.5 cm from the suprasternal notch preoperatively and they have stretched out
to 21.5 cm postoperatively.
Analysis
It is clear that the small amount of parenchyma removed helped pre-
vent recurrent glandular ptosis. An argument could be made that the result
would have been improved if a larger amount of inferior tissue were removed.
Note that the areola on the left breast is wider than on the right breast. When
the markings are reviewed, it is obvious that the skin opening for the areola had
a longer circumference on the left than on the right. Inevitable stretching oc-
curred. It is important to try to match the length of the skin opening to the are-
olar circumference.
584
Part II • Technique
This woman had a superior pedicle vertical mastopexy-augmentation with
smooth-walled saline implants f lled to 250 cc each. The implants were placed
in a subpectoral pocket. Only skin was removed in eriorly. She is shown 4 months
postoperatively.
Preoperative
4 months postoperatively
585
Chapter 10 • Mastopexy-Augmentation
She is shown 8 months and 2 years postoperatively. She has complete return o
sensation but is disappointed that her breasts have “dropped.” She also has pal-
pable rippling laterally and in eriorly.
Analysis
Even with extensive preoperative discussion with patients, they are
o ten disappointed that the upper pole is not higher. This patient was low
breasted, and it can be very di f cult to raise the upper breast border any higher.
In this patient the implants were placed subpectorally, and it is clear that plac-
ing the implants under the muscle has not provided support. Many patients
(and plastic surgeons) seem to think that the subpectoral location prevents the
implants rom bottoming out, but that has not been my experience. Sometimes
the implants heal in too high a pocket because o postoperative muscle spasm,
but as long as the implant settles into the intended location, the muscle can ac-
tually push the implants down and out.
8 months postoperatively
2 years postoperatively
586
Part II • Technique
This woman had a superior pedicle vertical mastopexy-augmentation using
smooth-walled saline implants placed in a subglandular pocket. The right im-
plant was f lled to 230 cc and the le t implant to 210 cc. Only skin was removed
in eriorly. She is shown 1 month a ter surgery.
Preoperative
1 month postoperatively
587
Chapter 10 • Mastopexy-Augmentation
She is shown again 1 year and 5 1⁄2 years a ter surgery. She has complete return
o sensation.
Analysis
This patient has a good result, but some parenchyma should have
been removed rom the in erior pole o the right breast, because it had a small
amount o glandular ptosis. In the le t breast, the problem was mainly nipple
ptosis. This patient series demonstrates that the shape will still change during
the f rst year; a ter 1 year the result is airly stable, but urther dropping out o
the implant is inevitable. H owever, the result a ter 1 year with a mastopexy or
a breast reduction is quite stable.
1 year postoperatively
51⁄2 years postoperatively
588
Part II • Technique
This patient had a superior pedicle vertical mastopexy-augmentation with
240 cc smooth-walled saline implants placed in subglandular pockets. A vertical
wedge of inferior pole tissue was excised, with 100 g removed from the right
breast and 125 g removed from the left. The intraoperative photos show how
important it is to place the implant before deciding how much skin to remove.
She is shown 2 years after surgery with a left capsular contracture (Baker III).
She has complete return of sensation.
Analysis
The good result on this patient was achieved because an inferior
wedge of lower pole was removed. Although it may seem counterintuitive, the
principle of the reduction-augmentation or minus-plus should be followed.
589
Chapter 10 • Mastopexy-Augmentation
REFLECTIONS
It is important to assess each patient or both glandular and nipple ptosis. Pto-
sis should be def ned in relation to the upper breast border, not in relation to
the in ramammary old. Regnault’s classif cation o ptosis is not particularly use-
ul in surgical planning.
Glandular ptosis needs to be treated; tightening the skin will not be e ective in
supporting ptotic breast tissue. The in erior wedge needs to be removed in a
mastopexy-augmentation, because it cannot be easily moved. The implant cho-
sen should be larger to compensate or the volume o in erior parenchyma that
is removed. The surgeon should assess the amount o glandular ptosis to de-
termine the amount o gland that needs to be removed.
Nipple ptosis is much easier to correct. Elevation o the nipple can be achieved
without changing the shape o the breast mound. I the shape is ptotic as well
(glandular ptosis), both nipple and glandular ptosis must be treated.
Pseudoptosis occurs when the in ramammary old drops. This type o bottom-
ing out can be very di f cult to treat, and the problem can be made worse when
an implant is added.
The concept o a minus-plus or reduction-augmentation is an important surgi-
cal principle in mastopexy-augmentation patients.
Concepts to Recall
• The upper breast border is the most important landmark or determin-
ing the new nipple position.
• Both nipple and glandular ptosis need to be assessed and corrected sepa-
rately.
• The surgeon cannot rely on skin to act as an e ective brassiere.
• The ptotic lower pole parenchyma needs to be removed rather than
pushed up and held with skin or dermis.
• The superior pedicle is the best choice in a mastopexy-augmentation pa-
tient, because the implant might damage the blood supply to the other
pedicles.
• The Wise pattern is a good design or visualizing the f nal breast shape.
• The breast base is narrowed and breast projection is improved.
• The implant will increase upper pole ullness and elevate the upper breast
border by 2 cm.
590
Part II • Technique
• There are three separate components to mastopexy-augmentation:
– Pedicle design and creation
– Implant pocket dissection and insertion
– Parenchymal and skin excision
• The key to preventing complications is to avoid tension on the pillar clo-
sure and on the skin closure.
• Wound-healing problems o ten indicate the presence o a low-grade
in ection.
BIBLIOGRAPH Y
Baroudi R, Lewis JR. The augmentation-reduction mammaplasty. Clin Plast Surg 3:301-
308, 1976.
Colwell AS, Slavin SA, May JW. Breast augmentation a ter reduction mammaplasty. Get-
ting the size right. Ann Plast Surg 60:372-374, 2008.
Kirwan L. Augmentation o the ptotic breast: simultaneous periareolar mastopexy/ breast
augmentation. Aesthet Surg J 19:34-39, 1999.
Owsley JQ, Simultaneous mastopexy and augmentation or correction o the small, ptotic
breast. Ann Plast Surg 2:195-200, 1978.
Perso MM. Vertical mastopexy with expansion augmentation. Aesthetic Plast Surg 27:13-
19, 2003.
Rancati A, Nava M, Tessari L. Simultaneous augmentation and periareolar mastopexy: se-
lecting the correct implant. Aesthetic Plast Surg 34:33-39, 2010.
Regnault P. Breast ptosis. Def nition and treatment. Clin Plast Surg 3:193-203, 1976.
Regnault P, Daniel RK, Tirkanits B. The minus-plus mastopexy. Clin Plast Surg 15:595-
600, 1988.
Spear SL. Augmentation/ mastopexy: “Surgeon, beware.” Plast Reconstr Surg 112:905-
906, 2003.
Spear SL, Boehmler JH , Clemens MW. Augmentation/ mastopexy: a 3-year review o a
single surgeon’s practice. Plast Reconstr Surg 118(7 Suppl):136S-147S, 2006.
Spear SL, Dayan JH , Clemens MW. Augmentation mastopexy. Clin Plast Surg 36:105-
115, 2009.
Spear SL, Giese SY. Simultaneous breast augmentation and mastopexy. Aesthet Surg J
20:155-164, 2000.
Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmen-
tation: a review o 321 patients. Plast Reconstr Surg 120:1674-1679, 2007.
Stevens WG, Spring M, Stoker D, et al. A review o 100 consecutive secondary augmen-
tation/ mastopexies. Aesthet Surg J 27:485-492, 2007.
Stevens WG, Stoker DA, Freeman ME, et al. Is one-stage breast augmentation with
mastopexy sa e and e ective? A review o 186 primary cases. Aesthet Surg J 26:674-
681, 2006.
Nipple Necrosis
Chapter11
591
G
r
a
c
e
,
N
i
k
o
l
H
a
s
k
o
v
a
N ipple necrosis may be one o the best-kept secrets in plastic surgery. We all
know that it occurs, and surgeons are proud when they can claim that it has not
happened in their practices. The reality is that i a surgeon per orms enough
breast surgery—breast reductions, mastopexies, mastopexy-augmentations,
revisions—nipple necrosis is an inevitable potential complication. I remember
Dr. Robert Goldwyn cautioning us at a meeting (Cutting Edge, New York,
1998) years ago that those o us who were smug about never having had a pa-
tient with nipple necrosis should be advised that eventually it would happen.
I was one o those surgeons—but I am no longer.
Why does nipple necrosis occur? Can we prevent it? Can we limit its extent?
How do we treat it when it does occur? Answers to these questions are the sub-
ject o this chapter, which ocuses on my approach to nipple necrosis. Fortu-
nately, over the years I have been airly obsessive about photographs and have
learned a great deal by reviewing and analyzing my results. When I used to per-
orm in erior pedicle inverted-T breast reductions, I would o ten comment on
how “gray” the nipples appeared at the end o the case. I made it a part o my
routine to do a postoperative check on nipple status or all o these patients and
ound that the nipples would usually become pink as the day progressed. But
what i they do not? We have all been cautioned to convert a nipple-areola com-
plex with inadequate blood supply to a ree nipple gra t. But that course o ac-
tion should not be taken lightly, because it has signif cant repercussions. Basic
questions to address include: Is there an adequate bed to gra t it onto? Will it
recover on its own, thereby avoiding inevitable problems with gra t take, poor
nipple projection, potential patchy hypopigmentation and lack o sensation?
What is the potential or uture breast- eeding? When a nipple-areola complex
looks dusky during the postoperative check, what should be done? Remove su-
tures? Take the patient back to the operating room? And what then?
Nipple necrosis is an invitation to possible litigation. My only lawsuit has been
related to a case o nipple necrosis where I ailed to take the patient back to the
operating room the next day. What could I have done di erently? Probably not
much at that late stage. The patient had a superior pedicle vertical breast re-
duction, and perhaps I should have taken her back to the operating room that
evening. But there was no evidence o venous congestion—just a dusky color.
My personal approach now is to intervene i there is obvious venous conges-
tion or i there is a question that the pedicle may have been kinked or com-
pressed during inset. I that is the case, the nipple may be saved by removing
sutures or returning the patient to the operating room and releasing any com-
pression—whether rom kinking or pressure rom an implant or hematoma. I
the nipple-areola complex is just dusky, I will leave it alone. I have been im-
592
Part II • Technique
593
Chapter 11 • Nipple Necrosis
pressed by how o ten it recovers and does well on its own. What is worse: los-
ing an edge, developing blistering, or converting to a ree nipple gra t? The an-
swer is not clear, and the decision is not easy.
Once it is obvious that some necrosis has occurred, I believe it is best to wait,
unless there is obvious compression or kinking that might still be relieved. De-
bridement should be delayed until the extent o the necrosis has been deter-
mined. The f nal result can be surprisingly good with no intervention. Areolar
skin is elastic with signif cant potential or stretching, which usually permits the
area to heal by secondary intention, thereby producing the best possible result
as seen in the patient shown below.
This woman had a medial pedicle vertical breast reduction with 650 g removed
rom the right breast and 630 g removed rom the le t breast. No liposuction
was per ormed. She is shown be ore her bilateral breast reduction and at
2 weeks, 6 weeks, and 3 months postoperatively. No debridement or revision
was per ormed.
Preoperative
2 weeks postoperatively
6 weeks postoperatively
3 months postoperatively
A statistical analysis o the incidence o nipple necrosis in my practice over a
14-year period is shown in the table below. Only vertical approaches are in-
cluded or breast reductions, mastopexies, and mastopexy-augmentations.
594
Part II • Technique
Incidence o Nipple Necrosis (Per Patient) Over a 14-Year Period
Total
Full
Partial
Edge
Procedure
Patients
Necrosis
Necrosis
Desquamation
Necrosis
Breast reduction
1500
8
10
2
8
Mastopexy
210
0
1
0
0
Mastopexy-
130
0
4
0
0
augmentation
Based on these data, the incidence in breast reduction surgery o ull nipple
necrosis per patient is 0.5%, partial nipple necrosis is 0.7%, and edge necrosis is
0.5%.
In the f rst 10 years o practice I per ormed inverted-T breast reductions almost
always with an in erior pedicle. My nipple necrosis incidence in these patients
was lower, with no cases o complete loss, but with two cases o partial loss
(0.5%) and two cases o edge necrosis (0.5%).
O the breast reductions, 2 patients had superior pedicles (total 73 patients,
145 breasts), 1 had a lateral pedicle (total 218 patients, 420 breasts), and 5 had
medial pedicles (total 1386 patients, 2740 breasts) (see the table below). These
numbers can be somewhat con using, because several patients had di erent pedi-
cles used on each breast, and one o the superior pedicle patients had necrosis on
both sides. This patient had very long pedicles, with 1050 g removed rom the
right breast and 975 g removed rom the le t breast. H er postoperative course
was complicated by respiratory problems, and she was trans erred to the ICU.
She recovered well medically, but she had almost ull necrosis on both sides.
Superior pedicles in a case such as this may be a poor choice, because the length
o the pedicle makes it di f cult to inset without kinking and compression.
Incidence o Nipple Necrosis (Per Breast) by Pedicle Over
a 27-Year Period
Pedicle
Breasts
Full
Partial
Desquamation
Edge
In erior
600
0
2
1
2
Superior
145
3
2
0
1
Lateral
420
1
0
0
0
Medial
2740
5
6
1
5
REVIEW OF TH E LITERATU RE ON NIPPLE NECROSIS
Every surgeon dreads having a patient who develops nipple necrosis. It can be
di f cult to assess the incidence o nipple necrosis, because surgeons ollow di -
erent def nitions. How “partial” is partial necrosis? Does this def nition include
cases with only some necrosis o the edge o the areola? Does loss o the nipple
constitute complete necrosis?
It was interesting (and humbling) when I reviewed all my cases o breast sur-
gery. I suppose we should all be grate ul that our memories are selective, but
my recollection o complications did not always match the numbers. The same
is true o nipple necrosis.
The reporting o partial or complete nipple necrosis is quite variable in the lit-
erature. These complications are probably inevitable in practices where a sur-
geon per orms a su f cient number o breast surgeries. I believe that although
a ew cases o nipple necrosis can possibly be prevented, most cases are unpre-
dictable. The problem is, essentially, that there are our main blood supplies to
work with, and (as is o ten the case in anatomy) only three are dominant; the
one chosen pedicle may be nondominant.
A meta-analysis by Daane and Rockwell reviewed several papers. Their f ndings
are presented in the ollowing table.
595
Chapter 11 • Nipple Necrosis
Overall Incidence o Nipple Necrosis in the Literature
Author
No. of Patients
Necrosis (%)
Pitanguy
2822
0.9
Skoog
149
1.3
McKissock
52
6
Mandrekas
371
0.8
Lejour
85
1.1
Lejour (no liposuction)
135
0.7
Data rom other studies are presented in the ollowing table.
596
Part II • Technique
Specif c Incidence o Nipple Necrosis in the Literature
Author
No. of Patients
Complete
Partial
(Pedicle)
Necrosis (%)
Necrosis (%)
Total (%)
Wallace
350 (In erior pedicle
0.5
4.0
4.5
inverted-T)
Makki
164 (71% in erior
Combined
Combined
8.0
pedicle)
Cruz-Korchin
105 (In erior pedicle
0.0
0.5
0.5
inverted-T)
Cruz-Korchin
103 (Vertical medial
0.0
0.5
0.5
pedicle)
Cárdenas-
112 (Lateral pedicle)
0.0
3.6
3.6
Camarena
H idalgo
251 (In erior pedicle
0.0
0.8
0.8
inverted-T)
Benelli
386 (Circumareolar)
0.0
0.0
0.0
Lassus
710 (Vertical superior
0.3
1.5
1.8
pedicle)
Lejour
250 (Vertical superior
0.0
0.8
0.8
pedicle)
Schnur
363 (In erior pedicle
0.0
0.6
0.6
inverted-T or bipedicle)
Davis
780 (85% in erior
Combined
Combined
6.0
pedicle inverted-T)
(Vertical superior
Combined
Combined
3.0
pedicle)
H ammond
98 (Vertical in erior
0.0
4.0
4.0
pedicle)
Berthe
170 (Vertical
7.0
25.0
32 .0
Series I
superior pedicle)
Berthe
138 (Vertical superior
0.0
2.2
2.2
Series II
pedicle)
Palumbo
100 (Vertical superior
0.0
0.5
0.50
pedicle)
Seidel
763 (inverted-T)
0.0
7.8
7.80
Ribeiro
1500 (Inverted-T
0.13
0.7
0.83
superior pedicle)
Ribeiro
400 (Lozenge)
0.0
0.0
0.00
Ribeiro
100 (Periareolar)
0.0
0.0
0.00
Scott
518 (In erior pedicle
0.4
0.4
0.80
inverted-T)
Lista
1501 (Vertical supero-
0.0
0.0
0.00
medial pedicle)
These reports demonstrate that nipple necrosis is a common complication. For
a proper assessment o the incidence o complete nipple necrosis, a large enough
patient population is required. Partial nipple necrosis is more common than
complete necrosis. This chapter will review prevention, diagnosis, and treat-
ment o nipple necrosis.
ANATOMY
A brie review o anatomy is important when discussing nipple necrosis. (See
Chapter 2 or a detailed discussion o anatomy.)
597
Chapter 11 • Nipple Necrosis
Superficial branches of the
internal mammary artery
Superficial branch of
the lateral thoracic artery
Thoracoacromial artery
2nd
3rd
Fourth deep branch of the
internal mammary artery
5th
6th
5
4
3
2
6
Lateral thoracic artery
(external mammary artery)
4th
Internal mammary artery
There are our main sources o blood supply to the breast: one deep supply at
the ourth intercostal space and three superf cial patterns. The deep system sup-
plies an in erior or central pedicle. The artery rom the ourth interspace con-
598
Part II • Technique
tinues under the intercostals and penetrates the breast on the deep sur ace
through the pectoralis muscle. It enters the breast medial to the breast merid-
ian just above the f th rib, and it o ten sends some branches laterally in the sep-
tum, as described by Würinger. It is the only system that has accompanying
venae comitantes.
The superf cial system comes mainly rom the internal mammary system, but
there is also the superf cial branch o the lateral thoracic artery, which supplies
a lateral pedicle. The superf cial system starts deep at the periphery o the breast
and then passes upward into the subcutaneous tissue, which is pushed outward
as the breast grows.
The internal mammary system sends branches around the sternum and through
the pectoralis muscle. These are deep initially and can be damaged when the
breast is undermined too much past its borders. The descending branch o the
artery at the second intercostal space (the artery continues on to supply a del-
topectoral ap) is a robust vessel that supplies a superior pedicle. By the time it
reaches the areola it is quite superf cial and is almost always just medial to the
breast meridian at the new areolar opening, and about 1 cm deep to the skin
sur ace. Doppler examination shows that a superior pedicle can be released quite
sa ely on both its medial and lateral borders (see Chapter 2, pp. 90 and 91).
The internal mammary system sends an artery or complex o arteries through
each interspace. The artery rom the third interspace turns superf cially and sup-
plies (usually) a medial pedicle. The artery rom the ourth interspace enters the
base o the breast; this composes the deep system and has accompanying venae
comitantes.
The internal mammary system sends arteries rom the f th (and possibly sixth)
interspaces, and these provide branches along the in ramammary old that then
travel superf cially to enter the breast. These vessels make an in erior pedicle sa er
than a central pedicle, because a central pedicle relies only on the deep system.
PREVENTION OF NIPPLE NECROSIS
Breast Reduction and Mastopexy
Nipple necrosis will occur when one o the internal mammary branches (sec-
ond through f th) or the superf cial branch o the lateral thoracic vessels is not
included in the base o the pedicle. We all know that excessive undermining or
surgical misadventure can damage the vessels, but I also believe that nipple
necrosis o ten occurs because o bad luck. There are our main arterial systems
that supply the breast, and, as with most areas o the body, perhaps only three
o the our are dominant. We cannot determine ahead o time which this will
be, and I suspect most cases o nipple necrosis are based on anatomic variation
and not surgeon error.
599
Chapter 11 • Nipple Necrosis
Second superficial
branch of the internal
mammary artery
Breast meridian
This photo depicts the usual position o the artery o the descending branch rom
the second interspace as it enters the areolar opening (red arrows). It can eas-
ily be marked with a pencil Doppler, but it is harder to f nd the other vessels.
The illustration on the right shows how the artery can be included in a true su-
peromedial pedicle.
Mastopexy-Augmentation and Mastopexy After Previous
Augmentation
It is important or surgeons to understand the anatomy when an implant is to be
used or when an implant has already been used. When an implant is placed ei-
ther in the subglandular or subpectoral location, the deep per orator system
(artery and vein) is damaged. The vessels are encountered during the dissection
just above the f th rib.
Both the in erior and central pedicles depend on the deep per orating system
or blood supply. The in erior ap used in mastopexy also depends on the deep
per orators. I an implant is to be used or i an implant has already been used,
600
Part II • Technique
the surgeon needs to be aware that an in erior pedicle or central pedicle is con-
traindicated. An in erior pedicle might have some vascular supply coming up
through the in ramammary old, but this should be regarded as tenuous.
When a surgeon per orms a mastopexy a ter a previous augmentation, the su-
perior pedicle is likely to be the best choice. The previous surgeon may have
damaged the medial arteries (and there ore a medial pedicle) when trying to
improve cleavage, and they may have damaged the superf cial branch o the lat-
eral thoracic artery (and there ore the lateral pedicle) when dissecting laterally.
This may be the case even i the f rst surgery was per ormed by the same sur-
geon. How many o us remember (or document) when we had to cauterize that
artery medially or when we had the same problem laterally? The descending ar-
tery rom the second interspace is cephalad enough and superf cial enough not
to be damaged.
Damage to the deep perforating system precludes using an inferior
or central pedicle if an implant has already been placed or will be
placed. Damage to the medial arteries and lateral thoracic artery
during augmentation preclude using a medial or lateral pedicle for
mastopexy.
This patient shows my mistake (previously, when I used only in erior pedicles
with inverted-T skin resection patterns) where I per ormed a mastopexy-
augmentation with an in erior pedicle. She actually had a subcutaneous mas-
tectomy with a submuscular saline implant. The insertion o the implant dam-
aged the blood supply to the in erior pedicle and nipple necrosis ensued.
RESU LTS
The ollowing patient examples demonstrate how di f cult it is to make
intraoperative or postoperative decisions about the health o the nipple-
areola complex. The decision as to what to do once necrosis is evident is
equally challenging. The f rst set o patient examples ocuses on the di -
f culty in diagnosing necrosis. The second set ocuses on treatment and
how it is o ten best to leave obvious necrosis to declare itsel f rst, with-
out intervention.
Diagnosis of Nipple-Areolar Necrosis
Medial Pedicle Vertical Breast Reduction With No Necrosis
601
Chapter 11 • Nipple Necrosis
This patient had 485 g o tissue removed rom the right breast and 490 g re-
moved rom the le t breast, with another 400 cc removed by liposuction. At
the end o this case, a surgeon might worry that the le t areola appears dusky
and the right areola looks patchy. Should something be done? These case pho-
tos show that the decision to intervene is not easy. This patient healed un-
event ully with no necrosis.
Medial Pedicle Vertical Breast Reduction With Edge Necrosis
602
Part II • Technique
The patient developed some edge necrosis on the left areola, but the area healed
well. The result is shown a few months later, with only conservative treatment.
Duskiness of the areola in surgery does not necessarily mean that the surgeon
should intervene.
This patient had a medial pedicle vertical breast reduction with 490 g of tissue
removed from the right breast and 500 g removed from the left breast. The left
areola was dusky, and the right areola looked normal. An additional 600 cc was
removed from her breasts with liposuction.
A medial pedicle vertical breast reduction was performed on this woman, with
335 g of tissue removed from the right breast and 375 g removed from the left
breast. H er left areola looked very dusky. The question to consider in this sit-
uation was whether something could or should be done? It would be easy, if
this patient had developed complete nipple necrosis, to look back on this photo
and criticize the surgeon for not intervening. But the postoperative result
showed that she only developed a small amount of edge necrosis. It may be bet-
ter to not intervene in most of these cases.
603
Chapter 11 • Nipple Necrosis
The patient developed some edge necrosis on the left areola. It healed un-
eventfully. She is shown 10 days and 6 weeks postoperatively.
Preoperative
Immediate postoperative result
10 days postoperatively
6 weeks postoperatively
604
Part II • Technique
Re-reduction After Inverted-T Reduction With Edge Necrosis
This woman underwent a re-reduction o an in erior pedicle inverted-T breast
reduction; 235 g were removed rom the right breast, and 280 g were removed
rom the le t breast. No new pedicle was created, but the area around the are-
ola was only deepithelialized, maintaining the pedicle on a random pattern blood
supply.
At the conclusion o the procedure, the le t areola looked quite dusky. Because
she did develop a small amount o necrosis in eriorly on the le t side, it could
be argued that some sutures should have been removed. But decisions can be
clear when the results are known—the rest o the areola did well. I ull necro-
sis had occurred, the surgeon could be criticized retrospectively. However, such
decisions are di f cult. I believe that surgeons should not intervene i the circu-
lation is questionable.
She is shown 2 weeks and 9 months postoperatively. A small area o edge necro-
sis resulted under the le t areola, but the f nal result was good. This patient ex-
ample shows that the skin was pulled too tightly in surgery, and eventually it
stretched with a good f nal result. Skin cannot usually be used e ectively as a
brassiere.
Superior Pedicle Vertical Mastopexy–Augmentation With Removal
o Calcif ed Capsules and Implants—No Necrosis
605
Chapter 11 • Nipple Necrosis
This 77-year-old patient developed severe, bilateral capsular contracture and
desired a mastopexy-augmentation. She had a superior pedicle vertical mastopexy
with removal o her calcif ed, ruptured silicone gel implants. The implants were
replaced with 335 g cohesive gel CML implants in the subglandular position.
The right areola looked quite dusky at the end o the procedure, but there was
good capillary return.
Preoperative
Immediate postoperative result
606
Part II • Technique
In the recovery room the areola still had a dusky appearance, but it improved
with time. I necrosis had occurred, retrospective evaluation could have been
harsh. But decisions can be very di f cult when the result is not known. I think
it is better not to convert to ree nipple gra ts.
The patient is shown 7 months and almost 2 years postoperatively. The nipple
and areola recovered completely. The result shows how di f cult it can be to ac-
curately position the nipples and make decisions about asymmetry in size when
marking a mastopexy with capsular contracture present.
During recovery
7 months postoperatively
2 years postoperatively
Medial Pedicle Vertical Breast Reduction With Desquamation
607
Chapter 11 • Nipple Necrosis
This patient had a medial pedicle vertical breast reduction with 600 g o tissue
removed rom the right breast and 625 g removed rom the le t breast. She had
an additional 475 cc o at removed with liposuction. At the end o surgery, the
color o the le t areola was not as good as that o the right breast. This case de-
veloped necrosis, but the intraoperative appearance was no di erent rom the
cases where the nipple did well. Such cases have not convinced me that it would
be worth conversion to ree nipple gra ts, because so many patients who would
have done well without this intervention would have to live with the conse-
quences o ree nipple gra ts—the possibility o poor take, patchy depigmenta-
tion, f attened nipples, poor symmetry, and the inability to breast- eed.
This patient is shown 3 days postoperatively with blistering and desquamation.
Preoperative
Immediate postoperative result
3 days postoperatively
608
Part II • Technique
She started to develop patchy pigmentation 2 weeks postoperatively. She is also
shown 3 months a ter surgery.
Sixteen months a ter her breast reduction she underwent a correction o her
le t nipple and areola. This f nal photograph shows her 8 years postoperatively.
The result was not ideal, but using ree nipple gra ts does not always give ideal
results either.
Caution is advised when conversion to a ree nipple gra t is con-
sidered, because the patient may have very serious adverse e ects,
including poor take, patchy depigmentation, f attened nipples, poor
symmetry, and the inability to breast- eed.
2 weeks postoperatively
3 months postoperatively
Corrective surgery 16 months postoperatively
8 years postoperatively
Re-reduction After Inverted-T Reduction With No Necrosis
609
Chapter 11 • Nipple Necrosis
A re-reduction o a previous inverted-T in erior pedicle breast reduction was
per ormed on this woman’s breasts. No new pedicle was created, but the are-
olae were deepithelialized because they were ar too large. They were di f cult
to inset during the re-reduction.
There was clearly good capillary return as shown by the imprint o the hemostat
handle (arrows) in the bottom le t photo. The patient did well postoperatively.
Medial Pedicle Vertical Breast Reduction With Edge Necrosis
610
Part II • Technique
This patient had a medial pedicle vertical breast reduction with 645 g of tissue
removed from the right breast and 545 g removed from the left breast.
At the conclusion of the procedure, both areolas looked good.
Preoperative
Immediate postoperative result
The patient is shown 1 month postoperatively (left), and clearly there was a
small aspect o necrosis on the right areola. Intervention would not have been
appropriate. The patient is shown 4-years postoperatively (right). No urther
surgery was per ormed.
611
Chapter 11 • Nipple Necrosis
She is shown 3 days a ter surgery with what could be either bruising or necro-
sis in the upper aspect o the right areola. At this point diagnosis was di f cult.
There was no evidence o a problem at the end o surgery, and the question
now was whether something should be done at this stage. I this dark area was
necrotic, there would probably be very little that could be done at 3 days. It is
best to leave it alone and await resolution.
3 days postoperatively
1 month postoperatively
4 years postoperatively
612
Part II • Technique
Medial Pedicle Vertical Mastopexy With Removal o Calcif ed
Capsules and Implants—No Necrosis
This patient had a mastopexy with removal o her silicone gel breast implants,
which were ruptured with calcif ed capsules. She also had 70 g removed rom
her right breast and 80 g removed rom her le t breast.
Although her right areola looked quite dusky at the end o the procedure, the
patient did well, with no necrosis. Not intervening with this appearance at the
end o surgery would be criticized retrospectively i nipple necrosis had occurred.
I think that intervention is rarely indicated, because so many o these patients
do well.
Mastopexy-Augmentation With Impending Nipple Necrosis
613
Chapter 11 • Nipple Necrosis
Sometimes the need for active intervention is obvious. For example, this pa-
tient had a mastopexy-augmentation. It became clear that her nipple-areola
complex was congested, so intervention was indicated.
Removal of several sutures 18 hours postoperatively helped to relieve the ten-
sion, and it appeared that at least some of the areola would survive.
The patient is shown 2 weeks after surgery, with the majority of the areola sur-
viving. The part that is still sutured did well.
2 weeks postoperatively
30 hours postoperatively
18 hours postoperatively
614
Part II • Technique
The patient is shown 6 weeks post-
operatively. No debridement was
per ormed, and it might have been
tempting to gra t the area to allow
closure. H owever, the areola was
stretched with delayed healing, and
the result was good even though
the whole areola was stretched.
Final closure was achieved by allowing the area to heal completely secondarily,
but it was clear that a revision was indicated. The scar was excised and the are-
olar widening reduced by adding a vertical excision to allow the skin circum-
erence to match a more ideal areolar circum erence. A Gore-Tex suture was
also added, because there was still too much tension. The patient is shown
8 months a ter revision.
She is shown 2 years a ter her revision,
with def nite—but not complete—
improvement.
6 weeks postoperatively
8 months after revision
7 months postoperatively
2 years postoperatively
615
Chapter 11 • Nipple Necrosis
Medial Pedicle Vertical Breast Reduction With Edge Necrosis
This patient had a medial pedicle vertical breast reduction with 900 g of tissue
removed from the right side and 1070 g removed from the left side.
Preoperative
Immediate postoperative result
At the end of the procedure, the right areola looked dusky. At this stage, re-
moval of the nipple and areola with conversion to a free nipple graft is not nec-
essarily a good solution. (I no longer perform any gathering or pleating of the
vertical incision.)
616
Part II • Technique
On the f rst postoperative day, the situation clearly did not look good. Although
a surgeon could be criticized or doing nothing, the patient did well without
intervention. My review o my other cases showed that intervention would usu-
ally not be a good choice in these cases.
The patient is shown 3 weeks postoperatively with only an area o edge necro-
sis. She is also shown 3 months postoperatively. She declined to have a scar re-
vision or a correction o the asymmetry.
1 day postoperatively
3 weeks postoperatively
3 months postoperatively
Medial Pedicle Vertical Mastopexy With Bilateral Partial Necrosis
617
Chapter 11 • Nipple Necrosis
This patient lost a signif cant amount o weight and underwent a medial pedi-
cle vertical mastopexy with a laterally based in erior ap rotated upward to re-
arrange the breast tissue.
Both nipples appeared to have adequate circulation at the end o the procedure.
(The postoperative photo o the le t breast was taken at a poor angle.)
Preoperative
Immediate postoperative result
618
Part II • Technique
Un ortunately, the patient developed signif cant edge necrosis on both areolae.
She is shown 10 days and 5 weeks postoperatively.
At the ollow-up, it was conf rmed that not intervening was a good choice. She
is shown just over 2 months a ter surgery and at 4 years postoperatively. She
continued to lose weight, resulting in urther loss o volume. (See a more in-
depth discussion about pedicle design in Chapter 9). The base o her medially
based pedicle may have been too low. I think that a true superomedial pedicle
may be sa er than a pure medial pedicle, but it can be more di f cult to inset. Too
much compression at the time o inset could also be a cause o nipple necrosis.
10 days postoperatively
5 weeks postoperatively
2 months postoperatively
4 years postoperatively
Medial Pedicle Inverted-T Breast Reduction With
Full Necrosis
619
Chapter 11 • Nipple Necrosis
This woman had a medial pedicle breast reduction with a T added to reduce
the excess skin envelope. Eight hundred twenty grams were removed from each
breast. An additional 660 cc was removed with liposuction. Both nipples looked
good at the end of the procedure.
Unfortunately, a full-thickness nipple necrosis occurred. She is shown 2 weeks
and 5 weeks after surgery.
Preoperative
Immediate postoperative result
2 weeks postoperatively
5 weeks postoperatively
620
Part II • Technique
The patient was taken to the operating room for debridement at 6 weeks, be-
cause it was clear that the necrosis was full thickness and involved much of the
pedicle itself. Fat necrosis is clearly visible in these intraoperative photos.
The patient is seen 2 months after the breast reduction. She is also shown
16 months after surgery, before reconstruction of the right areola and further
reduction of the left breast to compensate for the loss of volume that resulted
from necrosis of the pedicle.
Debridement 6 weeks postoperatively
2 months postoperatively
16 months postoperatively
Medial Pedicle Vertical Breast Reduction With Full Necrosis
621
Chapter 11 • Nipple Necrosis
This patient underwent a medial pedicle vertical breast reduction, with 1045 g
of tissue removed from the right side and 990 g removed from the left side. Al-
though the right areola looked slightly dusky, this appearance was not unusual
and did not raise any alarm.
This case demonstrates that making a diagnosis of nipple necrosis is far from
easy. Converting suspicious cases to free nipple grafts will result in a potentially
unsatisfactory result in many patients, because the postoperative result does not
reach the usual threshold for conversion.
Unfortunately, a full-thickness nipple necrosis developed that required de-
bridement. The patient is shown 1 week and 2 months following surgery.
Preoperative
Immediate postoperative result
1 week postoperatively
2 months postoperatively
622
Part II • Technique
Debridement was performed 4 months postoperatively, but it could have been
performed earlier, because the extent of demarcation was quite clear.
Treatment of Nipple Necrosis
Medial Pedicle Vertical Breast Reduction With No Necrosis
After a medial pedicle vertical breast reduction, this woman’s nipples both
looked a bit dark at the completion of surgery. (I no longer gather the vertical
incision.) She had 560 g removed from the right breast and 525 g removed
from the left breast.
4 months postoperatively
Preoperative
Immediate postoperative result
She is shown 10 days a ter surgery. The dark color in the upper hal o the le t
areola indicated that she may have developed nipple necrosis. It can be di f cult
to di erentiate between bruising and necrosis.
623
Chapter 11 • Nipple Necrosis
With time it became clear that she did not actually have nipple necrosis. It would
have been a mistake to intervene. Sometimes patients (and amilies) will insist
on treatment, and it can be di f cult to reassure them that it is better to wait.
10 days postoperatively
The patient is shown 1 year after surgery, with the markings for a revision.
624
Part II • Technique
Medial Pedicle Vertical Breast Reduction With Partial Necrosis
This patient underwent a medial pedicle vertical breast reduction. At her 3-week
postoperative visit it was clear that some nipple necrosis had occurred on the
right side. At this point, it is often tempting to proceed with debridement, es-
pecially when patients are urging you to act. But the following photos demon-
strate that this intervention would have been a mistake. H er nipple and areola
did amazingly well by allowing the area to separate on its own and heal by sec-
ondary intention.
Preoperative
3 weeks postoperatively
1 year postoperatively
625
Chapter 11 • Nipple Necrosis
She is shown 1 month after the revision.
This young woman had a medial pedicle vertical breast reduction with 330 g
of tissue removed from the right breast and 320 g removed from the left breast.
The markings show that there was an attempt to include visible veins in the base
of the pedicle.
1 month postoperatively
Preoperative
626
Part II • Technique
At the end o the procedure, the right areola looked dusky. H owever, many
other patients have looked worse at the end o the procedure and healed well.
Making a decision can be di f cult. The consequences o acting should be bal-
anced against the consequences o ailing to act. This is not a straight orward
decision. Removing the areola and gra ting it in all cases such as these would
lead to a signif cant number o patients with relatively at, insensitive nipples,
possible areas o hypopigmentation, and an inability to breast- eed on that side.
There would be def nite asymmetry, because nipple-areola complexes would
look di erent rom each other.
Un ortunately, there appeared to be almost complete necrosis, as seen 2 weeks
and 3 weeks postoperatively. It is still better to allow healing to proceed spon-
taneously.
2 weeks postoperatively
3 weeks postoperatively
Immediate postoperative result
The result shown at 8 months, with no intervention, would rival the result with
many free nipple grafts. Therefore one needs to determine whether it is worth
it to subject several patients to free nipple grafts or whether it is better to sub-
ject a few patients to debridement and reconstruction?
627
Chapter 11 • Nipple Necrosis
This patient underwent a medial pedicle vertical breast reduction. The area of
nipple necrosis was well demarcated 3 weeks postoperatively. Because there was
deep induration indicative of parenchymal necrosis, the decision was made to
proceed with debridement.
8 months postoperatively
Preoperative
3 weeks postoperatively
628
Part II • Technique
The area was left open, and was then closed 1 week later.
The patient is shown 9 months later
with a surprisingly acceptable result.
She chose not to undergo any form of
revision.
A medial pedicle vertical breast reduction was performed on this woman’s
breasts; 400 g were removed from the right breast and 550 g were removed
from the left breast. An additional 675 cc of fat was removed with liposuction.
9 months postoperatively
1 week postoperatively
Preoperative