Computed Tomographic Angiography-based Characterization Of Source Blood Vessels For Nipple-areola Complex Perfusion In Hypertrophic Breasts And Customized Breast Reduction

Background:Breast reduction is an important plastic and reconstruction surgery.Many patients needed to receive this operation every year,which exceeded 100 thousand cases in the United States only.However,a large number of excision of breast tissue during operation means that the most important aesthetic unit,which is nipple areola complex(NAC)under the risk of necrosis,and the key to reduce this risk is the sufficient blood supply.However,at present,the study on the blood supply of nipple areola complex were derived from the normal size of the breast,without any research about the patients with breast hypertrophy specially.Objective:Through the prospective study of consecutive cases,we characterized the distribution of blood supply of nipple areola complex in patients with hypertrophy,so asto provide anatomical basis for clinic.Then,customized breast reduction will be designed with the guidance of blood supply and analysis and discussion will be made for clinical application value.Methods:Three-dimensional digital reconstruction of the mammary arteries in 60 women(120 breasts)from November 2015 to February 2018 was performed by Computed tomography angiography.The distribution of the mammary arteries was observed and source blood vessels for nipple-areola complex perfusion were recorded(Definition of the dominant blood supply of the NAC: The detectable diameter threshold of blood vessels was set beyond 1.0 mm and entered the breast gland or reached the NAC).Then,the dominant blood supply of the NAC and its vascular sources were identified and sorted.Based on dominant blood supply of the NAC,50 patients(100 breasts)underwent customized breast reduction with related pedicles.The patients were followed up for at least 3 months to obtain the necrosis rate of the NAC and other possible complications.Results:In 60 patients(120 breast),a total of 163 dominant blood vessels were identified.The source arteries were traced as the internal thoracic artery(81,49.6%),lateral thoracic artery(46,28.2%),thoracoacromial artery(22,13.5%),brachial artery(7,4.3%),and axillary artery(7,4.3%).The intercostal artery was not identified as a dominant NAC supplying vessel in any CTA scan image.Sixty-nine breasts had only one dominant artery,whereas 47 breasts showed multiple dominant blood supplies.Four breasts showed no dominant blood vessels of the NAC,with diameters greater than the detectable threshold of 1.0 mm.Of the 50 patients(100 breasts)who received surgery,the mean breast resection weight was 468g(138-1010g).The average volume of the breast was 1210ml(546-2118ml)and the mean follow-up time was 6.4 months(3-19 months).No NAC necrosis,fat liquefaction or infection occurred,and only one breast had postoperative hematoma.Conclusion:The use of computed tomography angiography technique can obtain the knowledge of NAC perfusion with breast hypertrophy.Most of the dominant vessels were derived from internal thoracic arteries and lateral thoracic arteries,and a few from thoracoacromial arteries,brachial arteries and axillary arteries.This provided an anatomical basis for clinical application.Considering the complexity and diversity of blood supply patterns,customized surgery based on blood vessels may improve the safety of operation and reduce the incidence of postoperative NAC necrosis.