Pedicle viability as the determinant factor for conversion to free nipple graft

Women with extremely large breasts have many complaints. Reduction mammaplasty improves shape and relieves physical symptoms and alleviates psychological complaints. Mammaplasty is a an evolving technique; no single method is ideal or suitable for all breasts. Many techniques are advocated for reduction mammaplasty, including the superior, vertical, horizontal, lateral and inferior (the most popular) pedicle techniques. Even after 60 years of development in breast reduction techniques, there are still reported incidences of nipple-areola complex (NAC) necrosis.

To assess the perioperative conversion to free nipple graft to prevent the complication of nipple necrosis when pedicle viability is grossly compromised.

Between January 2002 and March 2006, 66 patients (132 breasts) underwent reduction mammaplasty using the inferior pedicle technique. The patients presented with breast gigantism and required excision of more than 1000 g of breast tissue per side. The mean patient age was 34.81 years. Patients had neck, shoulder and back pain as well as psychological complaints. Data regarding sternal notch-to-nipple distances and inframammary fold-to-nipple distances were recorded preoperatively and postoperatively. The weights of the excised breast tissue from either side were recorded. Viability of the pedicle flap was carefully monitored through perioperative clinical observation of skin colour, temperature, capillary refill and bleeding characteristics, and reassessed after pedicle folding and placement inside the newly tailored skin envelope. Nonvital NAC, as evaluated by the surgeon during surgery, necessitated conversion to the free nipple graft technique.

During the course of the study, two patients (four breasts; 3.03%) exhibited impending gangrene to the NAC, and perioperative conversion to the free nipple graft was performed. In these two patients, the pedicle length ranged from 23 cm to 25 cm, and breast mass reduction ranged from 1950 g to 2250 g.

Perioperative conversion to a free nipple-areola graft is always a good and safe option when impending gangrene to the NAC is evident during mammaplasty by inferior pedicle technique.