Managing of the Areolar Complex Following Reduction and

Neal Handel, MD*, Sara Yegiyants, MD

KEYWORDS  NAC necrosis  Reduction mammaplasty  Reduction mastopexy  Prevention  Management  Reconstruction of ischemic necrosis of NAC

KEY POINTS  Necrosis of the nipple areolar complex (NAC) is an infrequent but devastating complication of reduction mammaplasty and mastopexy. However, with strategic management and properly timed reconstruction, it is possible in most cases to restore a natural-appearing NAC.  To prevent necrosis of the NAC, it is most important to maintain a pedicle of adequate thickness, be cognizant of the length to width ratio of the pedicle, prevent kinking the blood supply when insetting the flap, and avoid an excessively tight closure, no matter what type of technique is performed. Especially in the case of secondary reduction mammaplasty or mastopexy in the previously augmented patient, great care must be taken because the anatomy and physiology has changed because of the previous procedures.  In the immediate postoperative period, the ischemic NAC can be transferred as a full-thickness graft. When it is elected to convert to a graft, all the circulatory changes have to be stabilized to confirm that the ischemia is irreversible and the recipient site is healthy enough to accept a graft.  The guiding principle in surgical management of ischemic complications of the NAC is to avoid aggressive treatment until the tissue necrosis obviously demarcates. When the missing part is small, the nipple can be reconstructed by composite grafting from the contralateral nipple. When a major part of the nipple is lost, reconstruction using a local flap can yield a favorable result.  The can be reconstructed using a full skin graft from the contralateral areola, the labia minora, or the upper inner thigh. Intradermal tattooing can be used to obtain a desirable color match.

INTRODUCTION only results in major cosmetic deformity but also may be a source of great angst for the surgeon Necrosis of the nipple areolar complex (NAC) is an and patients alike. infrequent but dreaded complication of reduction The manifestations of nipple areolar ischemia mammaplasty and mastopexy. When there is sig- run the gamut from spontaneous, completely nificant loss of nipple and/or areolar tissue, it not reversible nipple congestion (Fig. 1) to total loss

Division of , Geffen School of Medicine at UCLA, Los Angeles, CA, USA * Corresponding author. 22 West Pueblo Street, Suite A, Santa Barbara, CA 93105. E-mail address: [email protected]

Clin Plastic Surg - (2016) -–- http://dx.doi.org/10.1016/j.cps.2015.12.012

0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. plasticsurgery.theclinics.com 2 Handel & Yegiyants

Fig. 1. Reversible ischemia of the right NAC 48 hours Fig. 3. Total loss of the NAC and extensive fat necrosis after reduction mammaplasty. of subadjacent breast tissue.

of the nipple (Fig. 2) with extensive necrosis of The risk of nipple areolar ischemia is increased subadjacent breast tissue (Fig. 3). The appropriate with large-volume tissue removal, transposition response to nipple ischemia depends on the de- of the NAC a great distance (more than 15 cm),2 gree of circulatory compromise. The guiding prin- and in cases whereby secondary mastopexy is ciple is to avoid aggressive surgical therapy as performed in previously augmented patients.3 long as possible to give the injured tissues the Systemic factors, such as , , and best possible chance to recover spontaneously. cigarette smoking, may also increase the risk of Circulatory compromise of the NAC may be due ischemia. to arterial insufficiency but is more commonly The objectives of this article are to explain the caused by venous congestion.1 Clinical signs of mechanisms of injury that result in ischemia of venous congestion include excessively brisk capil- the NAC, to offer recommendations about the lary refill, dark rapid on pinprick, and management of this complication, and to illustrate cyanosis and edema of the nipple. Venous reconstructive techniques that can be used to congestion can occur for a variety of reasons: correct deformities arising from necrosis of the inadequate preservation of venous drainage, long NAC. With these goals in mind, the remainder of pedicles, kinking or compression of the pedicle, this article is divided into 3 sections: (1) prevention excessively tight skin closure, or a . of ischemia of the NAC, (2) management of the ischemic nipple, and (3) reconstruction after ischemic necrosis of the nipple and areola.

PREVENTING ISCHEMIA OF THE NIPPLE AREOLAR COMPLEX Clearly, preventing ischemic complications is greatly preferable to treating a necrotic nipple and areola. When performing reduction mamma- plasty or mastopexy, care must be taken to select the operation that will likely produce the best outcome with the least risk of complications. Understanding of breast vascular anatomy is crucial in preserving the arterial inflow and the essential venous drainage network of the nipple areola complex. Cadaveric dissection studies have shown that the most reliable blood supply to the nipple areola complex is from the internal Fig. 2. Complete necrosis of the left NAC 10 days after thoracic–anterior intercostal system, supplying reduction mammaplasty. the NAC from the medio-inferior aspect. An NAC Necrosis After Mammaplasty/Mastopexy 3 additional collateral system composed of lateral One group of patients especially at risk for thoracic and other minor contributors supplies ischemic complications of the NAC is previously the NAC from the superolateral aspect.1 Veno- augmented women with who present for grams of the breast have shown an extensive mastopexy. These patients are at increased risk network of veins draining the NAC with the most of circulatory compromise because of the inevi- reliable patterns located in the superomedial/ table changes in breast anatomy and physiology medial and inferior pedicles.4 caused by implants. In many augmented patients, A wide variety of techniques have been the soft-tissue envelope surrounding the implant described for transferring the nipple in breast becomes attenuated. Tebbetts8 observed: “The reduction and mastopexy. The most commonly consequences of excessively large breast im- performed procedure combines the Wise-pattern plants include ptosis, tissue stretching, tissue thin- skin incision with an inferior pedicle for nipple ning, inadequate soft-tissue cover, [and] transposition. This operation has gained popularity atrophy.” These very same because of the reliability of the blood supply to the changes occur not just with “excessively large” nipple, the relatively short learning curve, and the implants as described by Tebbetts but with all applicability of this method to reductions of all breast implants to some degree over time. Most sizes. The main drawback to this approach is of the thinning and atrophy caused by implants that aesthetic results are not always optimal. There occurs in the inferior pole of the breast. It is impor- may be a boxy contour to the ; it can be tant to take this into account when selecting which difficult to achieve desired breast projection; there pedicle to use in patients undergoing secondary is a tendency to pseudoptosis over time; and there mastopexy. A conventional Wise-pattern skin is invariably a long in the . excision coupled with an inferior pedicle may be For these reasons, a variety of alternate pedicles prone to ischemia because of thinning of the and different skin patterns have evolved. In addi- tissues of the inferior pole. In such cases, it may tion to the traditional inferior pedicle, the superior, be prudent to preserve a superior pedicle as superomedial, and central pedicle have all been well (as in a traditional McKissock reduction mam- successfully used in and masto- maplasty) to ensure adequate arterial perfusion pexy. The reported rates of nipple necrosis vary and sufficient venous drainage. Vertical masto- with the use of different pedicles ranging from pexy techniques are applicable in previously 0.8 % to 2.3% (0.8% with inferior pedicle, 2.1% to- augmented patients; however, vertical techniques tal nipple necrosis with the use of superodermal that depend on an inferior pedicle, such as the pedicle, and 2.3% with superolateral pedicle).1 SPAIR mammaplasty may be relatively contraindi- However, there are no randomized controlled trials cated. Procedures that incorporate a superior comparing NAC necrosis rates for the different pedicle (Lejour, Lassus, Hall-Findlay) are probably techniques. safer in terms of preserving circulation to the In recent years, short scar techniques, nipple and areola. including the vertical pattern5 and short-scar When selecting the specific mastopexy opera- periareolar-inferior pedicle reduction (SPAIR) tion for correction ptosis in augmented patients, technique,6 have been introduced. Because there there is a wide spectrum of procedures from which are so many possible combinations and per- to choose. These procedures include crescent mutations of skin pattern and vascular pedicle, nipple lift, periareolar mastopexy, vertical lift, and it is difficult to objectively compare one tech- finally the conventional Wise-pattern mastopexy. nique with another. In a recent matched cohort In general, the least aggressive mastopexy that study,7 the investigators compared superomedial will achieve the desired result is preferred. In sec- pedicle vertical scar breast reduction with inferior ondary mastopexy patients, it is also critical to pedicle Wise-pattern reduction and found there consider the effect of prior skin incisions on the was no significant difference in complications blood supply of the nipple and the skin flaps and between these two techniques. It is likely that to avoid insertion of excessively large implants, adherence to the basic principles of plastic which may cause compression of the vascular surgery is more critical than the particular surgi- pedicle and lead to venous congestion. cal technique selected. Regardless of which approach is chosen, the surgeon must be careful MANAGING ISCHEMIA OF THE NIPPLE to maintain a pedicle of adequate thickness, be AREOLAR COMPLEX cognizant of the length to width ratio of the pedicle, prevent kinking the blood supply when When circulatory compromise of the nipple and insetting the flap, and avoid excessively tight areola is recognized early, either in the operating skin closure. room or in the immediate postoperative period, 4 Handel & Yegiyants

urgent steps should be undertaken to reduce per- (Fig. 4). Release of the dermal and subdermal su- manent tissue loss. Recognition of irreversible tures around the periphery of the areola may result ischemia of the nipple may be hard to determine in dramatic improvement in venous drainage with by clinical criteria alone. Intravenous fluorescein transformation of tissues from a violaceous hue has been used to assess viability of the nipple.9 to a pink color within a matter of minutes. The Indocyanine green videofluorography10 is a newer application of Nitroglycerin Ointment USP, 2% technique that can be used to evaluate NAC (Nitro-Bid) may help by causing vasodilation and viability intraoperatively. Advantages of this tech- promoting drainage of blood. Steroids, such as a nique include repeated use during the same oper- methylprednisolone (Medrol Dosepak), have also ation and ability to evaluate both the arterial been recommended to reduce local tissue microcirculation and venous outflow. Intraopera- swelling and promote venous drainage. Leeches tive detection of NAC nonviability is an indication can also be used to improve venous drainage.12 to convert to a full-thickness graft. In cases Consideration should also be given to the use of whereby there is irreversible ischemia of the nipple, hyperbaric oxygen therapy.13 The mechanism of conversion of the nipple from a pedicle flap to a full- action of hyperbaric oxygen therapy is to increase thickness graft can result in a satisfactory aesthetic tissue oxygen tension, which results in production outcome.11 However, before making the decision of reactive oxygen species and reactive nitrogen to convert the nipple to a full-thickness graft, it is species that promote neovascularization and prudent to wait until the circulatory changes related improve postischemic tissue survival.14 to tissue cooling and the intraoperative use of The guiding principle in surgical management of epinephrine have subsided. If it is elected to ischemic complications of the NAC is to avoid convert to a graft, it is crucial that the recipient aggressive treatment until the tissues have site have an excellent blood supply. This require- declared themselves. It is often difficult early in ment precludes grafting onto breast tissue or fat; the acute phase to gauge which tissues will ulti- the graft must be affixed to a healthy dermal bed. mately prove viable and which tissues will necrose Conversion of the nipple to a graft is indicated (Fig. 5A–L). During the interim it is advisable to only rarely and in dire cases. In most circum- maintain patients on oral antibiotics to reduce the stances whereby ischemia of the nipple is identi- risk of . A wide variety of antimicrobials fied early, conservative measures are effective in are available and include drugs such as penicillin reversing or at least ameliorating the problem VK 500 mg every 6 hours or cephalexin 500 mg

Fig. 4. (A) Venous congestion of NAC 48 hours after reduction mammaplasty; (B) appearance of NAC 72 hours after removal of skin and subdermal sutures; (C) improved appearance of NAC at POD No. 7; (D) further improve- ment in circulation at POD No. 10; (E) fat necrosis of underlying breast tissue treated by surgical debridement and delayed primary closure; (F) appearance 18 months after procedure. 5

Fig. 5. (A) Preoperative view of patient with extremely pendulous breasts; (B) intraoperative photograph after reduction of right breast performed with central pedicel and Wise skin excision (nipple elevated approximately 20 cm); (C) appearance on POD No. 2; (D) appearance on POD No. 5; (E) appearance on POD No. 9; (F) appearance at 2 weeks; (G) appearance at 3 weeks; (H) appearance at 5 weeks; (I) appearance at 2 months; (J) appear- ance at 3 months; (K) appearance at 4 months; (L) appearance at 2 years: patient was offered further reconstruction of left NAC but declined addi- tional surgery; (M) appearance at 7 years without reconstruction.

every 6 hours. Consideration should be given aureus. In addition to systemic antibiotics, topical to adding trimethoprim and sulfamethoxazole antimicrobials may be used to further reduce the (Bactrim DS) twice a day to the regimen as prophy- chance of secondary infection. Several topical laxis against methicillin-resistant Staphylococcus agents are commonly used for this purpose, such 6 Handel & Yegiyants

Fig. 6. (A) Impaired circulation of right NAC 5 days after reduction mam- maplasty; (B) immediately following removal of skin and subdermal su- tures, color of NAC improved; (C) nitroglycerine ointment applied to ischemic NAC; (D) despite conserva- tive measures, NAC undergoes com- plete necrosis by POD No. 10; (E) appearance shortly after debride- ment of all nonviable tissue and closure of defect.

as neomycin-polymyxin B-bacitracin (Neosporin) attempted. It is critical to give the injured tissues triple antibiotic ointment or 1% silver sulfadiazine time to recover before proceeding with further (Silvadene cream). intervention. A waiting period of 3 to 6 months is Once the tissues have demarcated and it is usually adequate to allow for resolution of inflam- clear how much of the NAC will survive and how mation, improvement in local circulation, and much is necrotic, a decision can be made about maturation and softening of scar tissue. appropriate surgical management. If the area of nonviable tissue is limited (partial loss of nipple, RECONSTRUCTION OF THE NECROTIC NIPPLE subtotal loss of areola), allowing the necrotic tis- AND AREOLA sues to slough and the resulting defect to heal by secondary intention may be the most prudent After a suitable waiting period has transpired, approach. If the amount of necrotic tissue is reconstruction of the defect may commence. The more sizable, debridement and delayed primary appropriate reconstructive procedure depends closure may be indicated (Fig. 6). Regardless of on the nature of the deficit. In some cases, the whether the defect is allowed to close spontane- amount of missing tissue is negligible, which facil- ously or is closed surgically, there should be a itates reconstruction. For example, if only a portion delay before any reconstructive procedure is of the areola is absent, it may be possible to

Fig. 7. (A) Patient referred for reconstruction of left NAC lost following reduction mammaplasty; (B) appearance of reconstructed NAC 3 weeks after procedure, nipple was reconstructed with a modified skate flap and areola from full-thickness skin graft from upper inner thigh; (C) appearance 1 year following reconstruction, there has been some loss of projection of the reconstructed nipple, which is typical in these cases. NAC Necrosis After Mammaplasty/Mastopexy 7 8 Handel & Yegiyants

reconstruct the defect with a full-thickness graft It is important to remember that reconstruction from the contralateral areola. Likewise, if the are- of the nipple in patients who have had ischemic ola is intact but part or even the entire nipple has necrosis of the native NAC differs substantially been lost, a composite graft from the opposite from reconstruction of the nipple in nipple may be indicated (assuming there is patients. Unless mastectomy patients have been adequate tissue for sharing). In some cases there irradiated, the skin at the site of NAC reconstruc- is residual nipple and/or areola, but the degree of tion is generally in good condition; it is typically tissue damage or tissue loss is so extensive that supple, unscarred, and has a good blood supply. the best approach is to discard the remaining tis- This condition facilitates successful reconstruction sue and perform de novo nipple areolar recon- of the nipple with any of a variety of local flaps and struction. In such cases, or when the NAC has provides a well-vascularized recipient site for been completely lost, there are many excellent application of either full-thickness or composite techniques for recreating a natural-appearing grafts. Patients who have lost their NAC as a result nipple. of ischemic complications are more likely to have A host of operations have been described for scarred, poorly vascularized tissues at the site of reconstruction of the mammary papilla or nipple. the proposed reconstruction. When planning Composite grafts, such as the pulp of the toe15 nipple reconstruction, it is important to consider or the earlobe, have been used to reconstruct the quality of the local tissues in designing pedi- the missing nipple. However, even when these cles to ensure the best chance of flap survival grafts take successfully, they do not match the (Fig. 8). texture or pigmentation of a normal nipple. Com- With regard to reconstruction of the areola, the posite grafts from the contralateral nipple can most natural-appearing areola is created using a yield an excellent aesthetic result provided there full-thickness skin graft from the contralateral is adequate nipple on the intact side to serve as breast. The feasibility of using the opposite areole a donor site. More commonly, the papilla is re- as a donor site depends of course on how much constructed with local tissues. These procedures tissue is available for harvesting. Fortunately, the typically consist of some type of random flap, areola tends to be a very elastic structure; if a which is elevated and rotated or folded to create washer-shaped piece of pigmented skin is har- a projecting structure of the desired size and vested from the periphery of the intact areola, shape. Among the operations that have been the residual pigmented skin will usually stretch described are the star flap,16,17 the double enough so the donor areola maintains a reason- opposing tab flap,18 and the double opposing able size. Other sites that have been used for periareola flap.19 Most of these techniques are areolar reconstruction include full-thickness grafts derivatives of the skate flap,20 which has proven from the labia minora and the upper inner thigh. to be a safe and reliable technique for reconstruc- Although the early results of these grafts are often tion of the nipple.21 The skate flap is popular very pleasing, there is a tendency for the grafted because it is relatively easy to learn and results skin to lose pigmentation over time. Frequently are predictable. The skate flap has a hardy blood after an interval of 2 to 3 years following recon- supply, which ensures survival of the tissue and struction, the pigmentation has completely faded promotes maintenance of long-term projection and the only indication of areolar reconstruction of the reconstructed nipple (Fig. 7). is a circular scar around the periphery of the

= Fig. 8. (A) A 23-year-old woman who previously had bilateral augmentation mammaplasty and circumareolar mastopexy presents with dissatisfaction due to persistent breast ptosis and disfigured NACs; (B) design for vertical mastopexy with superior pedicle for transposition of nipple; (C) intraoperative view after nipple has been mobi- lized, note relatively short distance nipple needs to be raised and thick (3 cm) superior pedicle; (D) appearance of the breast at completion of procedure, both NACs appear viable; (E, F) appearance 4 days after procedure signif- icant venous congestion of NACs, right side worse than left side, dermal sutures released, and nitroglycerine paste applied; (G, H) appearance 10 days after procedure, necrotic eschar separating revealing partial survival of areola bilaterally; (I, J) appearance 24 days after procedure, central band of tissue on left side has survived but only tiny amount of tissue on right side is viable; (K) 6 weeks after procedure, open areas characterized by healthy granulation tissue, and patient undergoes delayed primary closure of bilaterally; (L) by 4 months after delayed closure, both breast have healed; (M) at 6 months tissues have softened and have matured, and patient is ready for reconstruction; (N, O) 3 months following bilateral NAC reconstruction, nipple has been created using a modified skate flap with care taken to incorporate residual pigmented tissue into recon- structed papilla, and areolae have been reconstructed from full-thickness skin grafts from upper inner thigh. NAC Necrosis After Mammaplasty/Mastopexy 9 reconstructed nipple. For this reason, intradermal (100 breasts): an outcomes study over 3 years. Plast tattooing has gained great popularity for areolar Reconstr Surg 2013;132(5):1068–76. reconstruction. Tattooing can be used either with 8. Tebbetts JB. The greatest myths in breast augmen- or without preliminary skin grafting.22 The tattooed tation. Plast Reconstr Surg 2001;107:1895–903. areola may also fade over time, but touch up tat- 9. Singer R, Krant SM. Intravenous fluorescein for evalu- tooing is a relatively easy way to restore the ating the dusky nipple-areola during reduction mam- desired pigmentation. When the nipple is recon- maplasty. Plast Reconstr Surg 1981;67(4):534–5. structed from local tissue (eg, skate flap or other 10. Murray JD, Jones GE, Elwood T. Fluorescent intrao- local flap), it does not match the color of the intact perative tissue angiography with indocyanine green: contralateral nipple. Tattooing of the papilla is the evaluation of nipple-areola vascularity during breast easiest way to achieve the desired color match. reduction surgery. Plast Reconstr Surg 2010;126(1): Because symmetry is such an important compo- 33e–4e. nent of successful nipple reconstruction, it may 11. Wray RC, Luce EA. Treatment of impending nipple be advisable to also tattoo the intact NAC to necrosis following reduction mammaplasty. Plast achieve the best possible color match between Reconstr Surg 1981;68(2):242–4. the two sides. 12. Pannucci CJ, Nelson JA, Chung CU, et al. Medicinal Necrosis of all or part of the NAC after reduction leeches for surgically uncorrectable venous conges- mammaplasty or mastopexy is a devastating com- tion after free flap . Microsur- plication. It is not only disappointing for patients but gery 2014;34(7):522–6. can also be disheartening for the surgeon. How- 13. Friedman HI, Fitzmaurice M, Lefaivre JF, et al. An ever, with properly timed and well-executed recon- evidence-based appraisal of the use of hyperbaric structive procedures, it is possible in most cases to oxygen on flaps and grafts. Plast Reconstr Surg restore a very natural-appearing NAC. 2006;117(7 Suppl):175S–90S. 14. Thom SR. Hyperbaric oxygen: its mechanisms and REFERENCES efficacy. Plast Reconstr Surg 2011;127(Suppl 1): 131S–41S. 1. van Deventer PV, Page BJ, Graewe FR. The safety of pedicles in breast reduction and mastopexy proce- 15. Klatsky SA, Manson PN. Toe pulp free grafts in dures. Aesthetic Plast Surg 2008;32:307–12. nipple reconstruction. Plast Reconstr Surg 1981; 2. Gravante G, Araco A, Sorge R, et al. Postoperative 68(2):245–8. after breast reductions: the role 16. Sierakowski A, Niranjan N. Star flap with a dermal of smoking and the amount of tissue removed. platform for nipple reconstruction. J Plast Reconstr Aesthetic Plast Surg 2008;32:25–31. Aesthet Surg 2011;64(2):e55–6. 3. Handel N. 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