Plastic Surgery of the Breast: Keeping the Nipple Sensitive

Introduction: Since its inception, reduction mammaplasty has matured considerably. Primary evolution in clinical research and practice has focused on preserving tissue viability. Surgery involves preserving not only tissue viability but also function and sensation. The nipple serves as the sensate unit of the breast and is a valuable part of women's psychological and sexual health, making preservation of nipple sensation of utmost important. Studies regarding primary innervation to the nipple are few and often contradictory. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation. Methods: Circumareolar dissection of 22 cadaveric breasts was performed. Primary nerve branches to the nipple-areola complex were identified and dissected to their origin. Results: Three to 5 branches of the fourth intercostal nerve primarily innervated the nipple on 18 of 22 breast dissections. Two breasts received innervation from the third intercostal nerve and 2 from the fifth intercostal nerve. In half of the specimens, accessory innervation from the third and fifth intercostal nerves provided medial branches to the nipple. Conclusions: The fourth intercostal nerve provides the major innervation to the nipple-areola complex. Avoiding dissection in inferolateral quadrant “unsafe zone” of the breast during reduction mammaplasty and other breast surgical procedures can reliably spare nipple sensation and maximize patient outcomes.