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16 Breast Reduction withFree Nipple Graft Transfer
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Fig. 16.4 Position and draping of the surgical site with the large
breasts hanging on either side of the chest
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the areola which serves as a guide to make the incision using a number 15 blade (Fig.16.5c, d).
(b) Harvesting the NAC graft (Fig.16.6a–d)
Local anaesthesia is injected below the dermis in
the marked NAC.After 7min the NAC is harvested
using a number 10 blade. The level of tissue harvest
should be in the deep dermal plane as shown in
Fig.16.6 A.Care should be taken that there is no subcutaneous tissue in the graft. Smooth muscle elements are preferably maintained with the graft and
may provide some degree of an erectile response in
the grafted nipple (Sterodimas etal. 2008).
Fig. 16.5 (a) Marking of the NAC to be harvested using a cookie cutter (4.2–4.7cm). (b) Faint skin depression of the NAC is being seen. (c, d)
Incision being made using 15 number blade with the skin under tension
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M. Mammadli et al.
The harvest is relatively easy in the areolar area
but as we reach to the nipple, it becomes brous
due to the presence of the ducts entering the nipple
(Fig.16.6d). It is always advised to have the breast
skin held in tension by the assistant so that there is
counter traction during harvesting of the
NAC. Once the NAC has been completely separated from the breast it is checked for uniformity
of thickness. Any excess tissue is trimmed off
using a sharp iris scissor taking care that no button-hole takes place (Fig.16.6c). The entire nipple-areola complex is thinned enough to be
replaced as a thick split- thickness skin graft. The
harvested tissue is now kept safe in a wet gauge
soaked in cold saline. The assistant and the nurse
should be made aware of the tissue which has to be
kept safe and moist at all times as seen in
Fig.16.6d.
Fig. 16.6 (a) NAC being harvested as a full-thickness graft using 10 number blade. (b) Separation is tougher in the area of the nipple due to
brous tissue and ducts traversing the nipple. (c) Uniform thinning of the graft being undertaken. (d) Tissue being saved in a moist gauze
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2. Glandular excision (Fig. 16.7a–j): Incisions are now
made to create the medial and lateral aps along the premarked lines drawn in the standing position as seen in
Fig.16.3d. Incision is made using a number 15 blade to
score the superior edges of the excision as well as the
inferior edge of the excision (Fig.16.7a–d). The superior
incision is taken perpendicularly down deep to the loose
areolar tissue supercial to the pectoral muscle taking
Fig. 16.7 (a–d) Incising along the premarked ap design using a num-
ber 15 blade. (e) The central triangular ap is left attached to be incised
at a later part of the surgery. (f–i) Stages of gladular incision which is
always made perpendicular to the skin incision. (j) The completely
seperated glandular tissue from both sides which should be weighed
and sent for histopathology
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i
h
j
Fig. 16.7 (continued)
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care to not excise the central triangle marked as a shaded
area in Fig.16.7e. There should be no undermining of the
superior skin ap specially in the central triangle area
which will be involuted to add bulk behind the
nipple- areola. The inferior incision is completed taking
care to retain brofatty tissue in the inframammary are to
preserve the inframammary fold as seen in Fig.16.7f–j.
Also as much parenchyma as required can be left out in
the central area to achieve the predetermined breast volume. Once glandular excision has been completed, haemostasis is achieved.
Some authors (Stephen R Colen) advocate an inferior
‘tongue’ (akin to the inferior pedicle) which is then
turned inwards as well as slightly upwards and xed to
the chest wall (muscle or periostium) by means of one or
two nylon or prolene sutures (Stephen and Colen 2001)
(Fig.16.8a, b).
Fig. 16.8 (a) Creation of a
de-epithelized inferior tongue
of tissue which is based on
the same vascular pedicle as
the inferior pedicle for breast
reduction. (b) The tissue is
being xed to the muscle or
periosteum by nonabsorbable
sutures. (Images modied
from Stephen R.Colen, MD,
Breast Reduction with Use of
the Free Nipple Graft
Technique, Aesthetic Surgery
Journal, Volume 21, Issue 3,
May 2001, Pages 261–271,
https://doi.org/10.1067/
maj.2001.116439)
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3. Excision of the central triangular skin ap (Fig.16.9a–c)
The central triangular skin is excised with a thin layer
of fat so that most of the breast tissue is left intact and it
can be used to create bulk in the central breast area for the
mound.
4. Suturing of the Flaps
The skin aps remaining as lateral and medial pillars
of breast tissue are then sutured together as in the conventional inferior pedicle repair with the apex being formed
at the new nipple position (Fig.16.10a–e). The medial
and lateral aps are now advanced along with imbrication
of the central subcutaneous tissue using 2–0, interrupted
Vicryl sutures (Fig.16.10d). The key suture is placed at
the most inferior and posterior point of the pillar which is
then sutured to the pectoral fascia at the inframammary
fold (Fig.16.10c). This imbricated tissue along with the
central parenchyma and the moving in of the medial and
abc
Fig. 16.9 (a–c) The central triangular ap is being excised at a very supercial level so that sufcient soft tissue is left behind for imbrication
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d
Fig. 16.10 (a) The surgeon is seen moving the medial and lateral
breast parenchyma aps over the imbricated central triangle. (b, c) The
rst suture is being placed to hold the two aps in place on the inframa-
e
lateral aps provides the conical shape to the breast along
with the volume. The vertical limb is closed with a dog
ear at the upper end to prevent a at, nonprojecting nipple
(Fig.16.10e).
A suction drain is usually inserted either medially or
laterally before complete closure. Suction- assisted lipectomy can be used to contour the lateral aps and prevent
dog ears.
5. Suturing of the NAC (Fig.16.11a–h).
The new nipple position is marked with the inferior
areolar border at 5 cms from the inferior horizontal
incision. The new nipple has to be centred on the highest point of the breast mound. The cookie cutter is used
to mark the outline of the new NAC.The same size as
the harvest diameter is used to prevent traction on the
scar (Fig.16.11a, b). The recepient area is de-epithelized to have a very vascular bed for the nipple- areola
graft (Fig. 16.11c). The areola circumference is now
divided into quarters and interrupted sutures are used to
x the edge of the graft to the skin edges of the recepi-
mmary crease. (d) Schematic diagram showing the imbrication of the
tissue along with moving in of the medial and lateral skin aps. (e) The
completed closure with a very nice conical shape
ent site. Care should be taken to avoid overlapping of
the edges during suturing (Fig.16.11d–f). Saline ush
is used underneath the graft to ush out any blood clots
that may be present which may separate the graft from
the recepient site. Tie-over sutures are now placed to
hold the bolster dressing (Fig.16.11g). Figure 16.11h
shows the completed suturing of bilateral NAC which
awaits the bolster dressing for close approximation of
the graft to the recepient bed. This allows good nutrition of the graft through inosculation and development
of neo capillaries. Figure 16.11i shows the bolster
dressing in place after complete suturing. Sterodimas
etal. (Sterodimas etal. 2008) decided to perform a circular dermo- dermic round block using a 2–0 Mononylon
at the neo- areolar junction and claimed that this
increased the vascularity of the NAC due to pushing out
of the recepient tissue as well as reduced tension on the
suture line. This was based on the principle of the
perioareolar ‘round block’ described by Benelli (Benelli
1990).
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b
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Fig. 16.11
recipient site. (g) Tie-over sutures in place to accept a bolster dressing. (h, i) Completed graft suturing with bolster dressing in place
(a, b) Marking of the new NAC on the highest point of the breast mound using a cookie cutter. (c–f) Suturing of the NAC graft to the
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g
h i
Fig. 16.11 (continued)
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16.4 Postoperative Care
Intraoperative antibiotics are continued orally for 1 week
after surgery. Suction drains are removed on the rst or second postoperative day when the drainage has reduced to less
than 25cc. The dressing is removed on the third postoperative day, after which bacitracin ointment covered by gauze is
applied daily.
The bolster dressing on the nipple is removed on the seventh postoperative day, and the nipple-areola is dressed daily
with bacitracin and Telfa. The nipple-areola will appear at
immediately after removal of the pressure-bolster dressing
but will gradually regain normal contour in 1–2 weeks.
Frequently, the supercial layers of the nipple will slough
after removal of the bolster. A supercial eschar on the nipple may last up to 4weeks.
The patient is instructed to wear a surgical bra day and
night for 6weeks and to refrain from exercise and muscular
upper-body activities for 6–8weeks.
16.5 Risks
Despite its application in a higher-risk patient population, an
amputation/free nipple graft reduction mammoplasty is usually achieved with minimal wound complications, a high
degree of patient safety, and nearly complete survival of the
nipple-areola graft (Koger etal. 1994) (Figs.16.12 and 16.13).
The following complications may occur:
1. Skin ap necrosis: Major skin ap necrosis is extremely
rare. Minor skin loss at the T junction of the vertical and
horizontal incisions is more common and usually resolves
without any surgical intervention with just dressings.
2. Nipple-areola depigmentation: Unfortunately, nipple-
areola depigmentation is not uncommon in dark-skinned
patients; it is best treated by skin plugs from normal areolar skin or by tattooing. All patients of colour must be
warned about this potential risk.
3. Scars: Scar hypertrophy of the medial and lateral extensions of the inframammary incisions is not uncommon.
Every effort should be made to keep these incisions as
short as possible and well hidden in the inframammary
crease. Triamcinolone injections may be required to
improve the scars.
4. Nipple graft failure: Fortunately, complete nipple graft
failure is rare. Careful preparation of the graft and recipient site with adequate immobilization of the graft
postoperatively should minimize this risk. If the nipple
graft fails, nipple reconstruction techniques with the use
of full-thickness skin grafts may be required.
Pearls
1. Modied Wise pattern should be used to mark the skin
excision.
2. The angle of the two vertical limbs should be adjusted
according to the volume of breast tissue to be retained.
3. If the upper breast pole is completely at, then recruit the
triangular central tissue and also use part of the tissue
from the lower pole as a tongue ap and sutured to the
fascia, periosteum.
4. The cephalic end of the vertical suture line should be
closed as a dog ear to provide extra projection of the new
NAC.
5. The new nipple-areola complex should be centred on the
highest point of the breast mound in such a way that it is
7cm from the inframammary crease.
6. The new nipple-areola should be dressed with a tie-over
dressing followed by occlusive dressing until the areola
has even pigmentation and projection of nipple is maintained (about 3months).
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Fig. 16.12 (a, c) Presurgery photographs of a 40-year-old lady who underwent free nipple graft procedure along with a reduction mammoplasty.
(b, d) Photographs taken on table after the surgery
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