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"Protect The Pigment": Alternative To Free Nipple Grafting In Women Of Color With Gigantomastia
Michael Tecce, DO, Jessica R. Cunning, MBA, Arturo J. Rios-Diaz, MD, Olatomide Familusi, MD, Monica Llado-Farrulla, MD, Cutler Whitely, BS, Robyn B. Broach, PhD, Joseph M. Serletti, MD, Paris D. Butler, MD, MPH.
University of Pennsylvania, Philadelphia, PA, USA.

Purpose: For women with gigantomastia undergoing reduction mammoplasty, surgical technique profoundly impacts aesthetic outcome, particularly the nipple areolar complex (NAC). The historically recommended technique is breast amputation with free nipple grafting (BA-FNG). However, the frequent NAC hypopigmentation resulting from BA-FNG is undesirable and becomes strikingly more apparent in women with more native pigment. Expanding techniques of pedicled reductions (PR) could provide an opportunity to dramatically improve NAC aesthetic outcomes in women of color with gigantomastia. We aimed to demonstrate aesthetic differences in NAC results in a series of non-Caucasian patients who underwent reduction mammoplasty for gigantomastia by type of technique. We also sought to estimate the number of patients at a population-based level that could potentially benefit from the extended PR approach.
Methods: Fifteen consecutive patients with gigantomastia (sternal notch to nipple distance >40cm) that underwent reduction mammoplasty in 2019 were identified. NAC aesthetic outcomes of BA-FNG and extended PR were photographically compared postoperatively. A patient who underwent right BA-FNG and left extended PR served as the internal control. For the secondary objective, data from the State Inpatient Database and the Statewide Ambulatory Surgery and Services Database for five states (FL, IA, NE, NY, UT) were analyzed to identify non-Caucasian patients undergoing reduction mammoplasty using procedure codes. Nipple grafts were identified using codes corresponding to skin graft. Patients with breast cancer, concurrent autologous breast reconstruction, or concurrent implant-based reconstruction were excluded. The number of reduction mammoplasty cases per year and the proportion of cases that underwent free nipple grafting were calculated.
Results: NAC pigmentation was dependent on surgical technique (Figure 1). The single patient that underwent BA-FNG experienced the classic hypopigmentation of the NAC (A). The 14 patients that underwent extended PR had no nipple ischemia and retained their natural NAC pigment (B,C). The internal control demonstrated both NAC aesthetic outcomes (D), with the extended PR on the left side leading to a more desirable result. Population-level analyses identified 43,228 reduction mammoplasty cases during the study period; 797 patients had a concurrent nipple graft. Overall, 39% of the patients receiving nipple grafts were women of color. Focusing on women of color, Figure 2 illustrates a downward trend of nipple graft utilization relative to reduction mammoplasty cases per year.
Conclusions: Women of color with gigantomastia can effectively undergo extended PR and obtain a superior NAC aesthetic outcome, reinforcing that one technique is not suitable for all. Our population-level analyses reveal that although BA-FNG is infrequent relative to the overall number of reduction mammoplasty procedures, there is still potential for improving hundreds of patients' lives. These findings suggest that it is time to revise antiquated treatment guidelines for gigantomastia to adjust for ethnic differences and ensure optimal results for all patients.


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