title: Plastic Surgery of the Breast: Keeping the Nipple Sensitive.
abstract: BACKGROUND
  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.
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Riccio
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Zeiderman
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Saeed
authors.initials: S
authors.lastname: Chowdhry
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Brooks
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Shahrooz S
authors.initials: SS
authors.lastname: Kelishadi
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: John Paul
authors.initials: JP
authors.lastname: Tutela
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Joshua
authors.initials: J
authors.lastname: Choo
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: David V
authors.initials: DV
authors.lastname: Yonick
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, Ky.
authors.forename: Bradon J
authors.initials: BJ
authors.lastname: Wilhelmi
keywords: breast reconstruction; nipple; nipple innervation; nipple-areola complex; reduction mammaplasty