What Is Nipple Necrosis?

Nipple Necrosis – A Complication of Breast Surgery

Nipple necrosis is a rare but serious complication that can occur following breast surgery. As a patient considering or preparing for a breast procedure, it is important to be well-informed about potential risks and complications, including nipple necrosis. This blog post aims to provide you with a comprehensive understanding of what nipple necrosis is, its causes, and the breast surgeries associated with this complication. By equipping yourself with this knowledge, you can have more informed discussions with your plastic surgeon and make well-considered decisions about your breast surgery journey.

Causes of Nipple Necrosis

Nipple necrosis is a condition characterised by the death of tissue in the nipple-areola complex (NAC) due to inadequate blood supply. The nipple and areola rely on a network of blood vessels to provide oxygen and nutrients to the tissue. During breast surgery, some of these blood vessels may be disrupted or damaged, leading to a decrease in blood flow to the NAC. If the blood supply is significantly compromised, the tissue in the nipple and areola may not receive enough oxygen, resulting in tissue death or necrosis.

Several factors can contribute to the development of nipple necrosis. One of the primary causes is the surgical technique employed during the breast procedure. Certain incisions and tissue manipulations may inadvertently disrupt the blood supply to the nipple, increasing the risk of necrosis. Additionally, patient-related factors such as smoking, diabetes, obesity, and poor overall health can impair blood flow and healing, making an individual more susceptible to nipple necrosis.

The onset of nipple necrosis typically occurs within the first few days to weeks following breast surgery. Initially, the affected area may appear pale or discoloured, often turning darker or black as the tissue dies. Patients may experience numbness, tingling, or loss of sensation in the nipple and areola. In some cases, the skin may blister, peel, or develop open wounds. It is essential for patients to be vigilant and promptly report any concerning symptoms to their plastic surgeon, as early intervention can help prevent further tissue damage and promote healing.

Nipple necrosis can have a significant emotional impact on patients, as the nipple is an integral part of the breast anatomy and plays a role in both aesthetics and functionality.

While nipple necrosis is a concerning complication, it is important to note that advances in surgical techniques and pre-operative risk assessment have helped to minimise its occurrence.

Breast Surgeries Associated with Nipple Necrosis

Several breast surgeries carry a risk of nipple necrosis, although the likelihood of this complication varies depending on the specific procedure and individual patient factors.

Breast Reduction: Breast reduction surgery, also known as reduction mammaplasty, is a procedure designed to remove excess breast tissue, fat, and skin to alleviate physical discomfort and achieve a more proportionate breast size. During the surgery, the nipple-areola complex is often repositioned to maintain a natural appearance. However, the extensive tissue removal and repositioning of the nipple can potentially compromise blood flow, increasing the risk of nipple necrosis. The risk is higher in patients with very large breasts, as more tissue needs to be removed, and the nipple may need to be moved a greater distance.
Breast Lift (Mastopexy): A breast lift is a surgical procedure that aims to raise and reshape sagging breasts. During a mastopexy, excess skin is removed, and the remaining skin is tightened to create a more youthful and uplifted breast contour. The nipple-areola complex is typically repositioned higher on the breast mound. Similar to breast reduction, the manipulation of breast tissue and repositioning of the nipple can affect blood supply, potentially leading to nipple necrosis. The risk is higher in patients with significant ptosis (sagging) or those requiring extensive skin removal.
Nipple Repositioning: Nipple repositioning, also known as nipple correction or nipple-areola complex (NAC) repositioning, is a surgical procedure performed to address nipple asymmetry, inverted nipples, or nipples that are too high or low on the breast. This procedure involves moving the nipple-areola complex to a new position on the breast while preserving its blood supply. Although nipple repositioning is typically a smaller-scale procedure compared to breast reduction or lift, it still carries a risk of nipple necrosis due to the disruption of blood vessels during the repositioning process.
Breast Augmentation with Periareolar Incision: Breast augmentation is a surgical procedure that involves the placement of implants to increase breast size and enhance shape. While the risk of nipple necrosis is generally lower in breast augmentation compared to reduction or lift procedures, it can still occur, particularly when the periareolar incision technique is used. The periareolar incision is made along the border of the areola, allowing the implant to be inserted through this opening. If the incision is too close to the nipple or if the implant puts excessive pressure on the tissue, it can compromise blood flow and lead to nipple necrosis.

It is important to note that the risk of nipple necrosis is influenced not only by the type of breast surgery but also by various patient-related factors. Smoking is a significant risk factor, as it constricts blood vessels and impairs circulation, making the tissue more susceptible to necrosis. Nicotine and other toxins in cigarettes also interfere with the healing process. Patients who smoke are strongly advised to quit at least 4-6 weeks before and after breast surgery to minimise the risk of complications.

Diabetes is another factor that can increase the risk of nipple necrosis. Uncontrolled diabetes can lead to poor circulation, impaired wound healing, and a higher likelihood of infection. Patients with diabetes should work closely with their medical team to ensure their blood sugar levels are well-managed before and after surgery.

Obesity is also a risk factor for nipple necrosis, as excess body weight can put additional strain on the healing tissues and compromise blood flow. Patients with a high body mass index (BMI) may be advised to lose weight before undergoing breast surgery to reduce the risk of complications.

Other factors that can contribute to an increased risk of nipple necrosis include:

Poor overall health or nutritional status
Certain medications that affect blood clotting or circulation
Previous breast surgeries or radiation therapy to the breast
Autoimmune disorders or connective tissue diseases

You can take proactive steps to reduce your risk of nipple necrosis. In addition to following your surgeon’s pre-operative instructions, you should maintain a healthy lifestyle, eat a balanced diet, and stay well-hydrated to support optimal healing. After surgery, it is crucial to follow post-operative care instructions carefully, including wound care, activity restrictions, and wearing supportive garments as directed by the surgeon.

If you experience any signs or symptoms of nipple necrosis, such as skin discolouration, numbness, or delayed healing, you should promptly notify your plastic surgeon. Early detection and intervention can help prevent the progression of tissue damage and improve outcomes.

Symptoms and Signs of Nipple Necrosis

Recognising the symptoms and signs of nipple necrosis is important for patients undergoing breast surgery. Early detection and prompt intervention can help prevent further tissue damage and improve outcomes. Patients should be vigilant and closely monitor their breasts during the post-operative period, reporting any concerning changes to their plastic surgeon.

One of the earliest signs of nipple necrosis is a change in the colour of the nipple-areola complex (NAC). The affected area may appear pale, white, or greyish, indicating a lack of blood flow. As the tissue continues to deteriorate, the colour may progress to purple, blue, or black. These colour changes are a result of the death and decomposition of the tissue cells due to inadequate oxygenation.

In addition to discolouration, you may notice changes in the texture and appearance of the skin on the nipple and areola. The skin may become dry, flaky, or shrivelled, resembling a scab or eschar. In some cases, blisters or bullae may form, containing clear or blood-tinged fluid. These blisters can rupture, leaving open wounds or raw areas on the skin surface.

Nipple necrosis can also cause sensory changes in the affected area. Patients may experience numbness, tingling, or a complete loss of sensation in the nipple and areola. This is due to the damage or disruption of the nerve supply to the NAC during the surgical procedure. While some sensory changes may be temporary and resolve as healing progresses, others may be permanent, particularly in cases of severe necrosis.

As the necrotic process advances, you may notice a foul odour emanating from the affected area. This odour is caused by the presence of bacteria and the breakdown of dead tissue. In some cases, there may be visible signs of infection, such as redness, swelling, or discharge around the necrotic tissue.

The timeline of symptom development can vary depending on the extent of tissue damage and individual factors. Some patients may experience signs of nipple necrosis within the first 24 to 48 hours after surgery, while others may not develop symptoms until several days or weeks later. It is essential to be aware of the potential signs and symptoms and to communicate any concerns to your plastic surgeon promptly.

Treatment Options for Nipple Necrosis

When nipple necrosis occurs, prompt and appropriate treatment is essential to prevent further tissue damage, promote healing, and achieve the best possible aesthetic and functional outcomes. The specific treatment approach will depend on the extent and severity of the necrosis, as well as your circumstances and preferences. Hyperbaric Oxygen treatment may help prevent and treat Nipple Necrosis.

In cases of mild nipple necrosis, where only a small area of tissue is affected, conservative management may be sufficient. This typically involves wound care measures to keep the area clean, moist, and protected from further damage. The plastic surgeon may recommend the use of topical ointments or dressings to promote healing and prevent infection. You will be instructed on how to properly clean and dress the wound at home, and regular follow-up appointments will be scheduled to monitor progress.

If the necrosis is more extensive or if there are signs of infection, the plastic surgeon may prescribe oral or intravenous antibiotics to control the spread of bacteria and prevent systemic complications. In some cases, the surgeon may also recommend hyperbaric oxygen therapy (HBOT), which involves breathing pure oxygen in a pressurised chamber to increase the amount of oxygen delivered to the damaged tissues. HBOT can help stimulate the growth of new blood vessels, enhance collagen production, and promote healing.

When conservative measures are insufficient, or if the necrosis is severe, surgical intervention may be necessary. The first step is often debridement, which involves removing the dead and damaged tissue to prevent further deterioration and create a clean wound bed. Debridement may be performed at the bedside or in the operating room, depending on the extent of the necrosis and the patient’s comfort level.

After debridement, the plastic surgeon will assess the remaining tissue and develop a plan for nipple reconstruction. In some cases, it may be possible to preserve a portion of the original nipple and areola and use local tissue flaps to restore the shape and contour of the NAC. If the entire nipple-areola complex is lost, the surgeon may recommend a staged reconstruction using skin grafts or nipple-sharing techniques from the unaffected breast.

The timing of nipple reconstruction will depend on the individual case. In some instances, it may be performed immediately after debridement, while in others, the surgeon may recommend waiting several weeks or months to allow the tissues to heal and stabilise. You should have realistic expectations about the outcomes of nipple reconstruction, as the reconstructed nipple may not have the same sensation, texture, or projection as the original nipple.

FAQs about Nipple Necrosis

Can nipple necrosis occur in both male and female patients undergoing breast surgery?

Yes, nipple necrosis can occur in either male and female patients who undergo breast surgeries such as gynaecomastia surgery (male breast reduction), female breast reduction, or gender-affirming top surgery. The risk factors and preventive measures are similar for both genders.

Is it possible to breastfeed after experiencing nipple necrosis and undergoing treatment?

The ability to breastfeed after nipple necrosis depends on the extent of the tissue damage and the type of treatment received. In some cases, if the milk ducts and underlying breast tissue are preserved, breastfeeding may still be possible. However, if the necrosis is severe or if the nipple-areola complex is completely reconstructed, breastfeeding may not be feasible. It is important to discuss any breastfeeding goals with your plastic surgeon before and after treatment.

Can nipple necrosis recur after successful treatment?

The risk of recurrence after successful treatment of nipple necrosis is relatively low. However, it is essential to maintain a healthy lifestyle, avoid smoking, and manage any underlying health conditions to reduce the risk of future complications. If you undergo additional breast surgeries in the future, your plastic surgeon will take extra precautions to minimise the risk of nipple necrosis recurrence.

Are there any non-surgical alternatives to treat nipple necrosis?

In most cases, nipple necrosis requires surgical intervention, such as debridement and reconstruction, to remove the dead tissue and restore the appearance of the nipple-areola complex. However, in very mild cases or in the early stages of necrosis, conservative measures such as wound care, topical treatments, and hyperbaric oxygen therapy may be attempted before resorting to surgery. Your plastic surgeon will determine the most appropriate treatment approach based on the severity of your condition.