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Nipple sensation following breast reduction and free nipple transplantation
NIPPLE SENSATION FOLLOWING BREAST REDUCTION AND FREE NIPPLE TRANSPLANTATION By P. L. G. TOWNSEND,~ B.Sc., M.B., B.S., F.R.C.S.(C.), F.R.C.S. Odstock Hospital, Salisbury, Wilts.
THERE are varying reports of how much sensation finally returns to the nipple and areola following free transplantation. Grenabo (1956) claimed that in 80 breasts repaired by Adams’ (1944) technique (full-thickness graft of nipple and areola on a deep dermal bed) only one had total loss of sensitivity [sic]; in 35 nipples the sensitivity was less than in the skin over the breast, in 25 the same and in 16 better than in the skin over the breast. Craig and Sykes (1970) studied 13 cases of transplanted nipples; 6 women stated that they had no sensation in the nipples and I that it was impaired; objectively, response to cotton wool and pin-prick was normal in 7 nipples, about half normal in 6 and absent in 13. Other authors, e.g. Lalardrie and Jouglard (1973), have criticised the operation because of the total loss of specific sensation which results. In the present series of 23 patients, the nipple and areola was removed by sharp dissection leaving the deep dermal layer behind and transplanted in the usual way to a deep dermal bed. Following this a wedge-shaped excision of the excess breast tissue was carried out with a minimum of undermining of the breast. At least I year had elapsed since operation in all cases. Fourteen control patients, all of whom had been admitted for breast reduction for mammary hypertrophy, were tested for nipple sensation pre-operatively. TABLE
Cotton wool Pin prick 2-point discrimination Erectility
I
in. or less
Controls 28 breasts % 93 100 38 100
Nipple transplants 46 breasts % 80 65 39 72
RESULTS
In only 8 breasts had no return of sensation been noted. Of the others, sensation was said to be enhanced in 2, normal in II and reduced in 23. In other words, in 82 per cent of breasts a return of sensation had been felt. The time at which sensation returned was variously stated at from 2 to 12 months. The objective findings are summarised in Table. The results are not quite so good as the overall figures suggest. Thus, of the 65 per cent who had sensation to pin-prick, about half responded in only a moderate or On the other hand, 2 of the transplanted nipples showed 2 point patchy fashion. discrimination of i inch; the best recorded for the controls was 9 inch, but it may well be that this was due to the stretched state of the nipple and areola. Unlike the cases of Craig and Sykes, 59 per cent experienced an erectile response and if one compares this with the objective findings where 72 per cent had some muscle present, it seems that even a small amount of muscle left in the transplanted nipple gives in most cases an erotic sensation. 1 Present address: Frenchay Hospital, Bristol. 308
NIPPLE
SENSATION
FOLLOWING
BREAST REDUCTION
309
She was seen 6 weeks post Only one patient has had a baby following operation. partum and although she had been warned that she would be unable to breast feed the baby, she reported vast quantities of milk in the left breast. Even after 6 weeks without any attempt at breast feeding, milk could be expressed from at least 7 ducts in the nipple (Figure). Strombeck (1964) carried out a number of mammagrams by injecting 30 per cent Urografin into the milk ducts. This revealed cross-connections
FIGURE.
Milk being expressed from transplanted nipple 6 weeks post partum.
between the lobes that had occurred following his operation. It is interesting to speculate on the number of anastomotic cross-connections that must have occurred in this patient. CONCLUSIONS When a nipple and areola is transplanted as a free graft, not only is it revascularised but it is re-innervated sufficiently to give reasonable sensation in about two-thirds of cases; even the lactiferous ducts appear to rearrange themselves to suit the new site of the nipple. I would like to express my thanks to Mr J. E. Laing, F.R.C.S., in the subject and zuhosepatients were made available for the study.
who stimulated my interest
BRITISH
310
JOURNAL
OF PLASTIC
SURGERY
REFERENCES M. (1944). Free transplantation of the nipples and areolae. Surgery, 15, 186-195. CRAIG, R. D. P. and SYKES,P. A. (1970). Nipple sensitivity following reduction mammaplasty. British Journal of Plastic Surgery, 23, 168-169. GRENABO,K.-J. (1956). In discussion of “Mammary plasty with free transplantation of of the International Society nipples and areolae” by Adams, W. M. “Transactions
ADAMS, W.
of Plastic
Surgery
First
Congress
Ig56”,
p. 375.
Baltimore:
Williams
and
Wilkins.
LALARDRIE,J.-P. and JOUGLARD,J.-P. (1973). “Plasties mammaires pour hypertrophie et ptose.” Paris: Masson et Cie. Acta STROMBECK,J. 0. (1964). Macromastia in women and its surgical treatment. Chirurgica Scandinavica Supplementurn, 341, rag-106.
THERE are varying reports of how much sensation finally returns to the nipple and areola following free transplantation. Grenabo (1956) claimed that in 80 breasts repaired by Adams’ (1944) technique (full-thickness graft of nipple and areola on a deep dermal bed) only one had total loss of sensitivity [sic]; in 35 nipples the sensitivity was less than in the skin over the breast, in 25 the same and in 16 better than in the skin over the breast. Craig and Sykes (1970) studied 13 cases of transplanted nipples; 6 women stated that they had no sensation in the nipples and I that it was impaired; objectively, response to cotton wool and pin-prick was normal in 7 nipples, about half normal in 6 and absent in 13. Other authors, e.g. Lalardrie and Jouglard (1973), have criticised the operation because of the total loss of specific sensation which results. In the present series of 23 patients, the nipple and areola was removed by sharp dissection leaving the deep dermal layer behind and transplanted in the usual way to a deep dermal bed. Following this a wedge-shaped excision of the excess breast tissue was carried out with a minimum of undermining of the breast. At least I year had elapsed since operation in all cases. Fourteen control patients, all of whom had been admitted for breast reduction for mammary hypertrophy, were tested for nipple sensation pre-operatively. TABLE
Cotton wool Pin prick 2-point discrimination Erectility
I
in. or less
Controls 28 breasts % 93 100 38 100
Nipple transplants 46 breasts % 80 65 39 72
RESULTS
In only 8 breasts had no return of sensation been noted. Of the others, sensation was said to be enhanced in 2, normal in II and reduced in 23. In other words, in 82 per cent of breasts a return of sensation had been felt. The time at which sensation returned was variously stated at from 2 to 12 months. The objective findings are summarised in Table. The results are not quite so good as the overall figures suggest. Thus, of the 65 per cent who had sensation to pin-prick, about half responded in only a moderate or On the other hand, 2 of the transplanted nipples showed 2 point patchy fashion. discrimination of i inch; the best recorded for the controls was 9 inch, but it may well be that this was due to the stretched state of the nipple and areola. Unlike the cases of Craig and Sykes, 59 per cent experienced an erectile response and if one compares this with the objective findings where 72 per cent had some muscle present, it seems that even a small amount of muscle left in the transplanted nipple gives in most cases an erotic sensation. 1 Present address: Frenchay Hospital, Bristol. 308
NIPPLE
SENSATION
FOLLOWING
BREAST REDUCTION
309
She was seen 6 weeks post Only one patient has had a baby following operation. partum and although she had been warned that she would be unable to breast feed the baby, she reported vast quantities of milk in the left breast. Even after 6 weeks without any attempt at breast feeding, milk could be expressed from at least 7 ducts in the nipple (Figure). Strombeck (1964) carried out a number of mammagrams by injecting 30 per cent Urografin into the milk ducts. This revealed cross-connections
FIGURE.
Milk being expressed from transplanted nipple 6 weeks post partum.
between the lobes that had occurred following his operation. It is interesting to speculate on the number of anastomotic cross-connections that must have occurred in this patient. CONCLUSIONS When a nipple and areola is transplanted as a free graft, not only is it revascularised but it is re-innervated sufficiently to give reasonable sensation in about two-thirds of cases; even the lactiferous ducts appear to rearrange themselves to suit the new site of the nipple. I would like to express my thanks to Mr J. E. Laing, F.R.C.S., in the subject and zuhosepatients were made available for the study.
who stimulated my interest
BRITISH
310
JOURNAL
OF PLASTIC
SURGERY
REFERENCES M. (1944). Free transplantation of the nipples and areolae. Surgery, 15, 186-195. CRAIG, R. D. P. and SYKES,P. A. (1970). Nipple sensitivity following reduction mammaplasty. British Journal of Plastic Surgery, 23, 168-169. GRENABO,K.-J. (1956). In discussion of “Mammary plasty with free transplantation of of the International Society nipples and areolae” by Adams, W. M. “Transactions
ADAMS, W.
of Plastic
Surgery
First
Congress
Ig56”,
p. 375.
Baltimore:
Williams
and
Wilkins.
LALARDRIE,J.-P. and JOUGLARD,J.-P. (1973). “Plasties mammaires pour hypertrophie et ptose.” Paris: Masson et Cie. Acta STROMBECK,J. 0. (1964). Macromastia in women and its surgical treatment. Chirurgica Scandinavica Supplementurn, 341, rag-106.