Improving Nipple Survival in Large Volume Breast Reduction Using Negative Pressure Wound Therapy

Background: In large volume breast reductions, a primary concern is survival of the nipple areolar complex. Long pedicles can have unreliable vascular supply, leading to nipple ischemia and necrosis. Large volume breast reductions are therefore often managed with free nipple grafting onto a vascularized wound bed. Free nipple grafting presents its own disadvantages of loss of sensation, pilomotor function, and lactation. We present an alternative technique to free nipple graft for large volume breast reductions (>1000 g). In cases where vascular supply of a long pedicle was equivocal, incisional negative pressure wound therapy was applied over the pedicled NAC to improve blood flow and promote healing. NPWT has previously shown to be effective in reducing wound complications in reduction mammaplasties; however, focused on the inverted T incisions and not the NAC.Methods: Patients were included if >18 years of age, non smoking, no history of breast surgery, and preoperative sternum to nipple measurement >35 cm or nipple to inframammary fold measurement >20 cm. All patients underwent inferior pedicle technique with Wise pattern skin incision. The NAC was assessed for vascularity by clinical assessment of quantity and character of bleeding at the distal margin of the pedicle. In 12 cases this was equivocal. Rather than using free nipple graft technique, incisional negative pressure wound therapy was applied to the NAC for 7 days. Single use, portable pumps without exudate cannister (PICO, Smith and Nephew Medical Ltd., UK) were used (Figure 1C).Results: Table 1 highlights patients’ preoperative characteristics and operative measurements. None of the 12 patients (24 breasts) in this series experienced NAC ischemia or necrosis. Only 2 patients experienced delayed wound healing which was successfully managed by local wound care. Nipple sensation was maintained for 20/24 (83%) of breasts treated with negative pressure wound therapy.Conclusion: This study demonstrates the utility of NPWT in NAC survival for at risk patients. While FNG is often performed for large volume mammaplasty with long pedicles due to more reliable vascular supply, our case series suggests that using NPWT over the NAC in pedicled reductions may be a viable alternative. NPWT likely augments healing by limiting edema in order to improve tissue perfusion and remove inflammatory mediators.