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Sensational breasts: Research links sensation loss after augmentation surgery to incision approach

Article-Sensational breasts: Research links sensation loss after augmentation surgery to incision approach

Key iconKey Points

  • An inframammary incision performed during a breast augmentation procedure has been shown to produce more breast sensitivity loss compared with a periareolar incision
  • Even so, patients more commonly prefer the inframammary approach because of their apprehension with incisions made around the nipple-areolar complex

Dr. Shack
NASHVILLE, TENN. — For patients considering breast augmentation surgery, the prospect of potential breast sensation loss following an incision around the nipple is worrisome. Ironically, however, according to recent research, an inframammary approach to implant insertion more frequently results in loss of sensation compared with the periareolar incision.

PATIENT CONCERN "The issue that more patients are most concerned about when having a periareolar incision is that they will have a greater risk of an altered, [that is,] decreased nipple sensitivity — most likely because [of their perception that] the incision is too close to the nipple," R. Bruce Shack, M.D., professor and chairman of the Department of Plastic Surgery at Vanderbilt University Medical Center, Nashville, Tenn., tells Cosmetic Surgery Times .

"They're worried that a periareolar incision will interfere with the sensitivity of the nipple compared to an incision made someplace else."

Dr. Shack relates that inframammary and periareolar incisions are the two most common incisions and probably represent over 90 percent of all breast augmentation procedure surgical approaches in the United States. Typically, incision placement is a choice made by the surgeon and patient together after review of patient-appropriate approaches.

SENSATION STUDY According to Dr. Shack, data from previous studies related to sensory changes in the post-augmentation breast had been contradictory. His team's purpose was to apply a more sophisticated means of measurement in order to quantitatively compare established sensory endpoints both preceeding and following submuscular implant placement.

In this study in 33 micromastia patients, quantitative measurements were taken in all four quadrants of the breast, as well as at the nipple and the areola, using the pressure specified sensory device (PSSD). The PSSD is a unit that measures the onset of sensation at that point at which an individual begins to perceive sensation — both pressure sensation and moving, two-point discrimination.

The researchers found that women over the age of 35 had less sensation return and it returned more slowly compared with younger patients. This cohort of older women exhibited some diminished sensation pre-operatively as well, but whether this diminishment was related to previous childbirth or aging is unknown.

Data also showed that sensation in the lower pole of the breast was poorer following an inframammary incision as compared to a periareolar incision — in all study patients. Further follow-up showed that less than 10 percent of the women studied still had diminished sensation after six months — except in those patients who had received an inframammary incision. In these women, diminished sensation in the lower pole of the breasts persisted beyond the six-month period.

NERVE INSIGHTS By way of explanation, Dr. Shack notes that there are sensory nerves that reach to the lower pole of the breast that are at risk of being cut or stretched when an inframammary incision is made as compared to a periareolar incision, and that this finding is almost "expected." Expected, that is, to clinicians well-versed in anatomy. It is less axiomatic to patients nervously trying to assess their incision options and to project the post-surgical sensory ramifications of them.

"Patients are apprehensive concerning the periareolar incision," he says. "They almost fear that this approach may, in some way, interfere with their sexuality in terms of nipple erection or loss of nipple-areolar sensation."

But, as the study showed, this patient fear of sensory loss associated with a periareolar incision did not prove to be founded. The reason? Probably, he says, because, when a periareolar incision is made, most often the reduction in nipple sensitivity is not related to actual transection of the nerve, but rather to the nerve being stretched in the process of pocket dissection.

Further, he adds, the fourth intercostal nerve innervating the nipple comes in fairly far laterally, entering the breast parenchyma at the mid-axillary line from the fourth intercostal space. That is the primary sensation innervating the nipple-areolar complex.

"There are other nerves that supply the rest of the skin of the breast and what we found was that the sensation of the lower pole of the breast was less in women who had an inframammary incision, which makes sense because you are cutting through all of those nerves," he says.

According to Dr. Shack, even if the sensation is diminished, in neither of the two surgical approaches is nipple erectile function affected. "The nipple-erectile response is a local reflex arc," he explains, "so even if the nipple is totally numb and you stimulate it, it will become erect."

THE PATIENT CONVERSATION In his pre-operative consults, Dr. Shack says that he tells his patients that their nipple sensitivity will be the same regardless of which incision approach is chosen; however, there may be some diminished sensation in the lower pole of the breast after the surgery.

Nevertheless, according to Dr. Shack, most of his patients still choose the inframammary incision — even after being made aware that this approach will likely yield diminished lower pole sensation. They just do not like the idea of having an incision right around their nipple.

Reference

Okwueze MI, Spear ME, Zwyghuizen AM, et al. Effect of augmentation mammaplasty on breast sensation. Plast Reconstr Surg. 2006;117:73-83; discussion 84-5.

For more information
R. Bruce Shack, M.D.
[email protected]

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