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Posts Tagged ‘nipple sensation after breast augmentation’

Breast Augmentation and Nipple Sensation

Monday, July 29th, 2013

 

A common question from many women considering breast augmentation is whether it will affect nipple sensation. Since there is surgery going into the breast and a medical device is being placed, this is a very logical question. For some women nipple sensation is an extremely important issue while for other women with little natural sensation it is of low to no priority.

The answer to breast neurological questions comes from looking at the anatomy of the nipple-areolar complex.  Although most agree that the nipple-areolar complex is innervated by the lateral and anterior branches of the intercostal nerves, controversy remains about which intercostal nerves are involved and what their anatomic course through the breast is.  The fourth intercostal lateral cutaneous branch is generally regarded as the most important nerve for nipple sensitivity.

Cadaveric studies have shown innervation appears to come from both the anterior and lateral cutaneous branches of the third, fourth, or fifth intercostal nerves.  Although there is some variation in the course of the nerves as they travel from the point where they perforate the deep fascia in the midaxillary line to the nipple, in the majority of patients the lateral cutaneous nerves pierce the deep fascia at the midaxillary line then travel in an inferomedial direction within the pectoral fascia or the pectoral muscle.  Once it reaches the midclavicular line, the nerves turn almost 90 degrees and continue though the gland towards the posterior surface of the nipple.

In a minority of cadaveric dissections, the lateral cutaneous nerves take a more superficial course and runs in the subcutaneous tissue close to the skin and reaches the nipple from the lateral side. This is exactly where the surgical dissection may be done for a breast implant so it is easy to see how nipple-areolar sensation may potentially be disrupted if the patient’s lateral cutaneous nerve anatomy should have this anatomic pathway to the nipple.

The anterior cutaneous branches are involved in medial innervation of the nipple-areolar complex. After piercing fascia in the parasternal line, they divide into a lateral and medial branch. The medial branch crosses the lateral border of the sternum while the lateral branch divides again into several smaller branches which then take an inferolateral route through the subcutaneous tissue. These branches then take a progressively more superficial course until they reach the breast skin or the areola at the medial border (8 to 11 o’clock on the left and 1 to 4 o’clock on the right). It is these nerves which may be at risk if a periareolar incisional approach is used to place the implants.

Does the location of the incision for putting the breast implants in affect the risk of loss of nipple-areola sensation? Several papers have been published in the past decade that have looked at nipple-areolar sensitivity after primary breast augmentation between different incision location, primarily between periareolar and inframammary approaches.  They found that there is n difference in sensation loss between inframammary and periareolar approaches. This is a little surprising given the nerve anatomy as previousliy described. Most likely this is because most breast dissection past the skin level is blunt and not sharp. (cutting)

Another factor in risk of nipple sensation loss is the size of the implant relative to the size of the native breast. Larger breasted women often have a natural decreased sensitivity of the nipple-areola complex, whether this is from traction neuropraxia of the sensory nerves or from the weight of the breast tissue causing  tissue expansion of this area resulting in decreased nerve fibers per surface area is not clear. This suggests that the more breast tissue one has, the less likely a perceived loss of nipple sensation may be.

The conclusion is that the risk of some loss of nipple-areolar sensation exists in every women undergoing breast augmentation. That risk is unavoidable given how the sensory nerves course through the breast to get to the nipple. Loss of nipple sensation, in my experience, is very low but may be more likely to occur in those women whose nerve anatomy places it in harm’s way. Unfortunately there is no way to make that anatomic determination before breast augmentation surgery.

Dr. Barry Eppley

Dr. Jane Namkung

Indianapolis, Indiana

The Risk of Nipple Sensation Loss After Breast Augmentation

Saturday, October 8th, 2011

While breast augmentation is largely about altering the size and shape of the breasts, there are other aspects of the procedure that are of interest. While women want many certain aspects of their breasts to change after surgery, feeling and function of the nipple-areolar complex is not one of them. While some women don’t have significant nipple feeling and are not concerned if it is lost, many women do and it is an important concern.

There is always some temporary loss of feelingof the skin after breast augmentation, largely restricted to the lower pole or the area between the nipple and the inframammary fold. This reflects the skin area of the breast that has been undermined the most so it is no surprise that it will be immediately numb. This usually completely resolves with time over two to three mnths after surgery. Nipple sensation and erection changes can also occur and can either be that of numbness to hypersensitivity. Similarly this usually revolves itself also but the risk of permanent loss of nipple feeling can occur.

It has long been conjured that the approach or incision used to place the breast implant influenced the potential for permanent loss of nipple sensation. Of the four incision options for breast augmentation, (nipple, fold, armpit and belly button), it is assumed that the nipple incision has increased risk of permanent nipple changes. While this seems intuitive, previous studies have shown conflicting results on this issue.

In the October 2011 issue of Plastic and Reconstructive Surgery, a study is reported that looks at the sensation of the nipple-areolar complex after breast augmentation. This was a retrospective study conducted over six years on 1,222 primary breast augmentation patients. Any other type of breast procedure, such as a lift, done with the augmentation excluded a patient from the study. They found that the only factor associated with changes in nipple-areolar sensation at six months after surgery was the type of skin incision used. The periareolar incision was associated with a three-fold increase in persistent nipple numbness and pain over an inframammary fold incision.

It is presumed that the periareolar incision in breast augmentation increases the risk of diminished nipple sensation by cutting the nerves that supply it. Stretching the nipple and the surrounding tissues in putting in the implant, particularly the larger silicone implant, is also not helpful. Nerve regeneration or recovery may also be limited by the scar tissue that forms under the nipple from the path of dissection downward.

While the risk is reasonably low, around 6% in this study, loss of some or all of nipple sensation is a potential issue that every breast augmentation patient should be aware. Since this risk is higher with a periareolar incision, I avoid its use completely. Now that prefilled silicone implants are used more commonly than saline in breast augmentation, it is harder to insert them through a small nipple that many small-breasted women have anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Nipple Sensation after Breast Augmentation

Monday, April 6th, 2009

There is always some concern that the sensation to the nipple may be decreased or lost after breast augmentation. Since the placement of a breast implant and the nerve that supplies the feeling to the nipple are in close proximity, breast augmentation always poses some threat of nerve injury. This is an issue which has been fairly well studied in the plastic surgery literature.

The feeling to the nipple of the female breast is derived mainly from the nerves that come out on the side of the chest wall between the 3rd to the 5th ribs. The nerves travel along the underside of the skin after coming out from between the ribs. In theory, these nerves can be injured by where the implant is placed (how far to the side it goes) and by what type of surgical incision is used. (does the incision location make any difference?)

Nipple and breast skin sensation changes after breast augmentation can cause either an increase or decrease of feeling in the breast area.  Changes can vary from extreme sensitivity to no sensation at all.  The physiological response to stimuli (sexual and non-sexual) and the ability to breastfeed can be adversely affected by nipple and breast sensation changes after breast augmentation.  These nipple and breast sensation changes may be temporary or permanent, depending upon the type of nerve damage or other injury caused during breast augmentation surgery.  

There have been a number of  studies that have looked at this sensation issue after breast implant surgery. The manufacturers’ statistics show that up to 10% of patients will experience decreased or permanent loss of sensation in the nipple. The lower pole of the breast skin can also experience numbness that can also be permanent in a small number of patients. Simple math would suggest that up to 20% of women will experience permanent changes in feeling after breast augmentation. In my Indianapolis plastic surgery practice, these numbers seem high in my experience particularly those with permanent loss of nipple sensation. It could be that my patients simply don’t tell me or that it is not a big issue for them. Either way, I can only count a handful of patients over the years that have ever mentioned it.

Does the type of incision used affect this nerve injury risk? Recent studies in the past few years have now shown that there is not really any difference in this regard in either the nipple, lower breast crease or through the armpit approach. In particular, a study published in 2006 showed that the periareolar (nipple) incision caused no more nipple numbness than any other type.

No formal studies have ever been done about the correlation between breast implant size and nerve injury. But it seems logical that larger implants, with more lateral position, are at greater risk for sensory nerve injury than smaller ones.

The location of the breast implant, above or below the muscle, may also affect nipple sensation.This seems more likely with subglandular (above the muscle) placement because the dissection of the breast implant pocket is more likely to interfere and damage the outer layers of the skin that are responsible for sensation.

In any case, every patient that undergoes breast augmentation must be aware of the risk of loss of nipple or breast skin feeling. While this risk does not seem to be large, a small number of patients will experience these irreversible nerve injuries and loss of some feeling. In my Indianapolis plastic surgery practice, I have had very few complaints about this problem but that doesn’t mean it does not occur.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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