Preoperative MRI to Prevent Nipple Areola Complex Necrosis and Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Photographic Essay

Goals/Purpose: Secondary mastopexy, or mastopexy in previously augmented breasts, presents unique challenges due to compromised blood supply to the nipple areola complex (NAC). Although prior operative reports may help determine the remaining blood supply, the surgeon often has to rely on clinical judgment and may perform a more conservative elevation of the NAC to minimize risk. Despite that, the risk of poor healing and nipple necrosis due to impaired blood supply persists. Magnetic resonance imaging (MRI) with contrast can be used to facilitate preoperative planning in both cosmetic cases and breast cancer patients. This paper describes the use of MRI to identify blood supply to the NAC in such cases and thereby decrease surgical complications and improve outcomes.

Methods/Technique: A consecutive series of secondary mastopexy augmentation procedures completed by the primary author was reviewed. The post-contrast MRI images portrayed the remaining blood supply to the NAC. An operative plan was formulated based on this information to optimize aesthetic outcomes and minimize the risk of wound healing complications. Preoperative and postoperative photographs were compared.

Results/Complications: Eight patients underwent secondary mastopexy augmentation. Approximately half of the patients had previously completed radiation therapy for breast cancer. In all eight patients, the NAC remained viable, and there were no incidences of partial thickness loss. There was minimal occurrence of delayed healing. Patient satisfaction was high.

Two case studies have been selected to demonstrate the utility of preoperative MRI for secondary mastopexy augmentation in patients with a history of breast cancer (Patient A) or cosmetic augmentation (Patient B).

Patient A

S: 73-year-old female with a history of bilateral Benelli mastopexy augmentation and right breast cancer treated with lumpectomy and radiation therapy approximately 20 years prior. Patient complained that the position of the right breast implant caused discomfort for her. Her goals were to have the implants exchanged and asymmetry corrected.

O: Inframammary fold and circumareolar scars were present bilaterally; a retracted lumpectomy scar was identified on the upper inner quadrant of the right breast. No prior operative reports were available. Preoperative maximum intensity projection MRI images demonstrated medial pedicles (red arrows) bilaterally and a small lateral pedicle on the right breast, which did not reach the NAC. The dermoglandular thickness was 1.4 cm at the location of the vascular pedicles (blue arrow). There was no evidence of malignancy.

A/P: Bilateral subglandular implants were removed and replaced with smaller silicone gel implants, and a secondary Wise pattern mastopexy was performed with a superomedial pedicle. The imaging allowed design of the medial pedicle and subsequent undermining to the most medial extent without impairing the blood supply to the NAC or medial breast skin. After viability of the NAC had been confirmed, revision of the right breast lumpectomy scar was performed to correct the concavity.

Patient B:

S: 49-year-old female with a history of bilateral breast augmentation and Benelli mastopexy. The patient was unhappy with the size and shape of her breasts, as well as the appearance of her nipples. Her self-reported bra size was 38DD/DDD, and her goal was 38C.

O: She had circumareolar scars and a sternal notch to nipple distance of 26 cm bilaterally. The dermoglandular flaps were thin, with the implant easily palpable beneath the skin. There was no prior operative report available. The MRI revealed a superomedial based blood supply to the NAC (red arrows). The dermoglandular flaps were as thin as 7 mm (blue arrow). On the MRI, a suspicious mass was detected and returned benign on biopsy.

A/P: Bilateral subglandular saline implants were removed and replaced with smaller silicone gel implants, and a secondary Wise pattern mastopexy augmentation was performed with a superomedial pedicle.

Conclusion: In patients undergoing secondary mastopexy, preoperative MRI enabled visualization of the dominant blood supply to the NAC and assessment of the dermoglandular flap thickness, which provided guidance for the undermining of breast skin. This reduced the risk of vascular compromise and tissue necrosis. The preoperative MRI can also be a unique opportunity to identify occult diseases of the breast.