The most serious complication of breast reduction surgery is nipple-areola complex (NAC) or breast necrosis. Very large breasts and/or significant breast ptosis are the main reasons for such a disastrous complication, particularly in inexperienced hands. However, partial or total necrosis of the NAC can still occur in patients with high risk factors such as smoking, diabetes, or chronic corticosteroid therapy. Free nipple techniques in breast reduction are a viable alternative option for patients with large or ptotic breasts and should be considered and discussed early. Viability of the NAC depends more on adequate venous return than arterial input, with most cases of NAC necrosis being secondary to venous congestion. Methods to avoid later venous congestion include choosing of a suitable technique, appropriate design of the pedicle, avoidance of aggressive defatting of the pedicle especially under the NAC, suitable pedicle placement without kinking or over tight fixation, and judicious drain placement if there is a dead space behind the NAC.
If the NAC demonstrates venous insufficiency at the end of surgery,liposuction of the pedicle may provide instant relief of any tension. Should the NAC congestion persist, the surgeon is duty-bound to reopen the breast and resite the pedicle in a better position. Immediate postoperative edema and swelling may cause NAC venous congestion, too, and release of the periareolar stitches is recommended in this case. Manual massage of the NAC can help to improve the venous return but should be performed with care and propriety! Medicinal leeches are not recommended because of the increased risk of infection, which may result in total NAC necrosis. Despite all these measures, partial NAC necrosis can still occur and is often better treated conservatively. This usually produces a discolored scarred region, which can later be corrected by simple scar revision with or without tattooing.
A comprehensive approach to patient care and the potential pitfalls for the NAC, along with close communication with the patient, are essential throughout. Major or total NAC necrosis will necessitate a reconstructive procedure. Wound healing may be left to occur by secondary intention; however, surgical de-bridement is indicated if necrosis is accompanied by infection. Direct closure can be nicely achieved using a purse-string suture. Nipple-sharing techniques may be used in cases of large contralateral nipple. Modified star techniques for nipple reconstruction are recommended when only limited viable tissue is available. In association with tattooing, the aesthetic results are usually very acceptable.
Rearrangement of the breast skin envelope coupled with increased tension on the skin closure due to swelling or widened or hypertrophic scars may occur in the periareolar location. Purse-string closure can occasionally result in persistent wrinkling around the areola or a herniated or strangulated looking areola (Fig. 14.9). After the breast has completely settled and all the postoperative swelling has resolved,simple scar revision usually greatly improves the appearance of the NAC and can completely remove any widened or hypertrophic segments without fear of recurrence. Also, once the periareolar closure has stabilized, the tendency for the purse-string closure to form persistent pleats is very much reduced. As a result, persistent periareolar wrinkling can be eliminated with simple periareolar scar revision.
Where necessary, these revision strategies can be used in combination to correct postoperative defor
herniated looking nipple-areola complex due to the purse-string Gore-Tex stitch.A simple revision of the periareolar scar corrected this aspect without removal of the original suture mities and to improve the overall aesthetic result. Since the combined periareolar and vertical skin resections complement one another, they are readily used in combination to correct both scars and breast shape. The access provided by these incisions allows for adequate internal reshaping as required. Taken together, these maneuvers provide straightforward solutions to complications after vertical scar mammaplasty when they do arise.
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