Plastic Surgery Research Council
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Presenter: Saeed Chowdhry, BS
Co-Authors: Brooks R; Kelishadi SS; Tutela JP; Wilhelmi BJ
University of Louisville

Background: Since its inception, Reduction Mammoplasty has matured considerably. Primary evolution in clinical research and practice has focused on developing techniques to preserve tissue viability; breast parenchyma, skin, and nipples. However, surgery today involves not only preserving tissue viability, but also function in terms of sensation. The nipple serves as a sensate unit in erectile function and plays a large part in the physical intimacy of women. Nipple sensation has shown to be a valuable part of women s psychological and sexual health. The authors review the current literature of nipple innervation, perform anatomical studies, and apply their findings to the clinical setting to identify a safe zone for Reduction Mammoplasty to preserve nipple sensation.

Methods: 12 cadaver dissections were performed at the University of Louisville Fresh Tissue Lab. Circumareolar subcutaneous dissection were performed to identify the nerves from the chest wall to the nipple. Once the trajectory of the nerves to the nipple were identified, the practice of avoiding dissection in these areas was carried to the clinical setting. 56 patients (110) breasts underwent Reduction Mammoplasty with reductions ranging from 350g to 2500g using the Wise and Hall-Findlay techniques.

Results: Anatomical results identified 3-5 branches of the Fourth Intercostal Nerve to primarily innervate the nipple 80% of the time. On the Left side, the nerve travels toward the nipple at the 4 o clock position while it enters at the 8 o clock position on the right side. The nerve pierces the chest fascia above the 5th rib 3cm lateral to the border of the pectoralis major muscle and travels through the gland in an inferolateral position toward the nipple. Clinical results identified no loss of nipple sensation and one re-operation for wound dehiscence.

Conclusion: Preserving nipple sensation is a valuable goal in breast surgery. The innervation of the nipple is predictable based on anatomic findings. Clinical application of these findings demonstrates the possibility to reliably maintain the nipple as an esthetic and sensate unit.

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