Breast Reduction Surgery Side Effects: Why Does Nipple Necrosis Occur?



Among the side effects of breast reduction surgery, the one people worry about most is, of course, 'nipple necrosis.'

However, nipple necrosis is often reported in a way that is overly exaggerated, and in terms of how often it occurs or how risky it is, it is frequently perceived differently from reality. So today, let’s take a closer look at this 'nipple necrosis.'

What does nipple necrosis mean?

When a certain area becomes necrotic, it means that blood does not reach that area, causing it to turn black, dry out, and eventually fall off.

Applied to the nipple, that is nipple necrosis.

In breast reduction surgery, tissue flaps are used to preserve blood flow to the nipple.

This flap refers to a long, board-like layer that contains the blood vessels heading toward the nipple.

If the blood vessels in this flap become twisted or damaged, that becomes the cause of nipple necrosis.

As you know, blood vessels can be divided into arteries and veins. Arteries are vessels through which blood flows in, and veins are vessels through which blood flows out. If an artery in the flap is damaged, the blood that should enter the nipple cannot get in, causing nipple necrosis. If there is a problem with the vein, the blood that should leave cannot drain, so blood flow in the nipple becomes congested, oxygen supply is cut off, and necrosis occurs.

In this way, nipple necrosis can occur if there is a problem with either the arteries or veins in the flap.

When there is a problem with the artery

If blood does not reach the tissue through the artery, necrosis occurs. When we say nipple necrosis, it is easy to think only of the nipple itself.

Strictly speaking, it is 'nipple-areola necrosis.'

If blood does not flow through the artery, it means no blood enters at all, so both the nipple and areola become necrotic and are completely lost, resulting in total necrosis.

The frightening nipple necrosis that many people are actually afraid of refers to this complete necrosis, where the nipple and areola are both lost due to interruption of arterial blood flow.

When there is a problem with the vein

The artery itself is fine, so blood does enter the nipple, but there is a problem with the vein and the blood cannot drain out.

This case is a bit more complicated.

To put it simply, the blood vessel structure of the nipple and areola can be imagined like an open umbrella. In other words, blood flows from the handle of the umbrella toward the tip, and finally drains out through the ribs of the umbrella into the surrounding area.

Arterial blood flows into the nipple, which is the tip of the umbrella, and the blood that reaches the tip then flows out toward the edge of the opened umbrella, that is, the areola.

However, if there is a problem with the blood flow draining out from the nipple and areola like this, a phenomenon called venous congestion occurs.

The arterial blood trying to enter continues to push in with high pressure, but the venous blood cannot drain out, so the blood cannot circulate and becomes stagnant.

In this case, the area affected first is not the nipple but the area around the areola.

Congestion and necrosis begin around the areola, and if the congestion continues, eventually the entire nipple may become necrotic as well. But that is very rare, and as collateral channels form and blood flow is gradually discharged, the necrosis is usually limited to the area around the areola.

This is called partial necrosis.

In most cases, this partial necrosis only causes the surface of the areola edge to peel off, so even if a side effect occurs, it usually remains limited to partial pigment loss.

In such cases, medical tattooing can be used to fill in the lost pigment along the edge of the areola.

Looking at the statistics, the incidence of areolar necrosis is about 3.6%, meaning it occurs in about 3 to 4 out of 100 people. Most of these are partial necrosis caused by venous problems and can be considered a mild side effect.

Pigment loss at the edge of the areola is a representative example.

In contrast, nipple necrosis caused by arterial problems results in complete necrosis and is a serious side effect, but fortunately it occurs very rarely.

That is because the breast is a tissue rich in blood vessels, and these vessels are connected like a network from above, below, left, and right around the nipple. So even if the breast tissue is shaped into a flap, it is rare for all the arteries leading to the nipple to be cut off.

Usually, rather than the blood vessels being cut off, the vessels inside the flap are bent during flap movement. Since arteries have high pressure, they can still flow in without much trouble even if they are somewhat bent, but veins are affected by bending because their pressure is relatively low.

Therefore, most cases of nipple necrosis are due to venous problems and usually appear in the form of partial necrosis.

Complete necrosis of the nipple and areola is reported to occur in less than 1% of cases.

This is because when there is a problem with the artery, blood does not flow in the flap and it can be detected immediately during surgery. When there is a problem with the vein, it appears somewhat later, but even then it can usually be identified within a few hours after surgery. So by the time the patient is about to be discharged, it can generally be recognized, and appropriate action can be taken before severe necrosis develops.

When does the rare case of complete necrosis occur?

First, a situation to keep in mind is when the breasts are very severely drooped.

In such cases, the flap becomes longer, which increases the possibility of blood vessel damage.

Also, from the surgeon’s perspective, if the flap is long, the remaining breast size becomes larger, so there is an attempt to overcome this by making the flap as thin as possible.

If the flap is made too thin, naturally the chance of blood vessel damage increases.

Therefore, in such cases, it is better to be somewhat less ambitious and give up the desire to make the breasts excessively small.

Another case is when the nipple is too medial, that is, when it has shifted too far inward in a drooped state.

In such cases, if the medial flap is used as usual, the flap becomes too short, increasing the likelihood of nipple necrosis due to bending of the blood vessels.

Another case where complete necrosis can occur is when reduction surgery and implant insertion are performed at the same time.

This occurred mainly in the past, when lower blood vessels were used more often. While performing reduction surgery, some patients also had an implant inserted at the same time to fill out the upper breast as well.

In such cases, the muscle layer has to be dissected to create an appropriate space for the implant.

At this time, unavoidable damage often occurs to the lower blood vessels that pass upward through the muscle from below. If reduction mammoplasty is then performed using a lower flap, serious problems arise in the arterial blood flow within the flap.

In the past, for this reason, complete nipple necrosis occurred frequently when reduction and augmentation were performed at the same time.

To prevent this, when an implant is inserted at the same time as reduction surgery, it is essential to use an upper flap.

The last situation to be careful about is when breast liposuction is performed during breast reduction.

In fact, liposuction is not a procedure that accurately looks inside the tissue directly while being performed. If the breast itself is liposuctioned in the name of reducing it as much as possible, the major blood vessels leading to the nipple may be damaged without notice.

In such cases, the blood vessels within the chosen flap may already be damaged while surgery continues, increasing the possibility of complete necrosis.

Therefore, to protect the blood vessels, breast tissue should always be removed directly in principle, and liposuction should only be used as an auxiliary method to smoothly connect the surrounding area with the breast.

Except for these cases, complete necrosis is a fairly rare side effect. Fortunately, the more common partial necrosis can be managed appropriately.

It is certainly true that nipple necrosis is the most frightening and serious side effect in reduction surgery.

However, if more careful attention is paid to the causes and management, I expect that you can overcome vague fear and achieve stable surgical results.