Commentary on: The Use of DCE-MRI to Evaluate the Blood Supply to the Nipple-Areola Complex: A Study in 245 Asian Women Free

In this paper,¹ the authors undertake a retrospective review employing a dynamic analytical approach to investigate the blood supply to the nipple-areola complex (NAC), evaluating their findings against the established literature, which has hitherto been mainly based on static anatomical studies. Limitations of past studies have included small sample sizes as well as being cadaver based.

Until now, the majority of anatomical studies have employed a variety of techniques but most rely on dissection of cadavers, usually with intra-arterial injections.² A similar methodology to this study was employed previously by Seitz and colleagues³ but with a significantly smaller sample size. The authors acknowledge the similarities of their studies and are to be commended for incorporating the findings of the 2 studies into their discussion

In summary, this study utilized dynamic contrast enhanced magnetic resonance imaging (MRI) images of 393 breasts from 245 women to investigate the orientation and origin of the source and feeding vessels to the NAC. It then allowed the utilization of 3-dimensional imaging to evaluate all the vessels supplying the NAC.

Different NACs demonstrated varying numbers of perfusion zones (comparable with Seitz’s NACsomes³), from single to 4 zones, the most frequently occurring being a single perfusion zone in over one-half of all cases.

Most perfusion zones were from the superomedial direction (termed Ia) (corroborating the findings of Seitz), followed by the medial and superolateral being next most frequent. Zone IIb (lateral) was the least frequently occurring orientation (in 0.5%), interestingly followed by zone V, directly superior. There was no significant difference between left and right sides.

This study principally referred to the relevance of its findings with respect to nipple-sparing mastectomies and the safety of incision planning. Past studies have recommended infra-mammary crease incisions to minimize the risk of NAC necrosis during nipple-sparing mastectomy (NSM); ⁴ however, this is not always desirable or feasible, so peri-areolar incision planning also needs to be considered. Furthermore, past studies have not always considered the precise orientation or location of a peri-areolar incision. In cases of NSM utilizing an areolar-based incision, the outcomes of this study strongly support the utilization of an incision caudal to the NAC. Suggested incision designs have been included in the paper.

As the authors have acknowledged, incision placement is not the only variable that can affect the survival of the NAC after NSM; other factors can have a significant influence, including thickness of skin flaps left behind, tumor location, smoking status, and tension on the skin, among others. However, it would seem prudent, as the authors recommend, to avoid cranial peri-areolar incisions whenever possible.

As mentioned above, this study was based on the concept of patients undergoing NSM but is actually much more widely applicable, particularly to the pedicles we may choose for mastopexy or reduction mammoplasty.

NAC necrosis is the most significant complication in reduction mammoplasty.⁵ Regarding the application of this study’s findings to reduction mammoplasty, it is interesting to reflect that many plastic surgeons still favor an inferior pedicle breast reduction^6,7 despite the evidence that the blood supply is less reliable,^1,3 the complication rate is higher, and the aesthetic outcomes have been noted to be more variable.⁸

Fortunately, the superomedial pedicle is increasingly becoming the preferred pedicle for breast reduction with many surgeons based on previous vascular anatomical studies,^8-10 and the current study serves to support this trend.

There are, of course, some limitations with this study as recognized by the authors. Due to the resolution of MRI, the vessels identified are likely to be the dominant vessels supplying the breast, suggesting that these vessels should be preserved during surgery whenever possible. From a clinical perspective, these vessels are the most important, and, although from a technical point of view the MRI resolution is a limitation, it might actually be interpreted as a useful limitation on a pragmatic level. A further speculative limitation, as the authors allude to, is whether the patients’ physiology changes according to their position; the MRIs being taken with the patients prone, however, I am not sure of the significance of this aspect.

I would like to congratulate the authors on a well-conducted study that provides a valuable addition to the vascular anatomical literature, extrapolating our previous understanding of this clinically relevant topic.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

References

Author notes