Aesthetic Plastic Surgery

, Volume 28, Issue 6, pp 393–398

The Blood Supply to the Nipple-Areola Complex of the Human Mammary Gland

Authors

    • Department of Anatomy University of Stellenbosch
Article

DOI: 10.1007/s00266-003-7113-9

Cite this article as:
van Deventer, P.V. Aesth Plast Surg (2004) 28: 393. doi:10.1007/s00266-003-7113-9

Abstract

The main sources of blood supply to the breast are described in textbooks as the internal thoracic, lateral thoracic, and posterior intercostal arteries. Textbooks, however, do not describe the contribution of each to the nippie-areoia complex (NAC), nor do they describe the pattern of supply.

To investigate this issue, 15 female cadavers were injected intraarterially with latex, and dissections were performed on 27 breasts.

The results were as follows:
  • In all the dissected breasts (27/27), the NAC received at least one or more vessels from the internal thoracic artery.

  • In 20 of 27 dissected breasts, the NAC received vessels from the anterior intercostal arteries,

  • In 19 of the 27 dissected breasts, the NAC received vessels from the lateral thoracic artery.

    Direct branches from the axillary artery supplied the NAC in 2 of the 27 breasts.

  • The posterior intercostal arteries supplied the NAC in only 1 of the 27 dissected breasts.

An underlying segmental pattern could be detected that can be explained by the embryological development. According to this study, the internal thoracic arteries are to be considered the main and constantly reliable source of blood supply to the NAC.

Keywords

Blood supplyMammary glandNippleNipple-areola complex

For successful breast surgery, knowledge of the blood supply to the breast, particularly the supply to the nipple-areola-complex (NAC) is of the utmost importance. Although the blood supply to the human mammary gland is well documented, the specific supply to the NAC still is obscure and not described in text books. Therefore, the complication of NAC necrosis still is found, even in the hands of the most competent surgeons.

Carl Manchot in 1889 [7] described the blood supply to the human mammary gland in great detail, and his work is to be considered a classic exposition on the subject. He described the vascularization of the breast via perforating branches of the internal mammary artery (internal thoracic artery), branches from the third to the seventh intercostal arteries, and branches from the lateral thoracic artery. Manchot also described a superficial Thoracic artery that runs downward on the lower border of the pectoralis minor muscle, supplying branches to the nipple, which is not the same as the lateral thoracic artery. This fact has not been assimilated in textbooks and is unknown to most anatomists and surgeons.

In 1934 Marcus [8] examined 33 human breasts, and finding great individual differences, came to the conclusion that it is possible to identify three major source contributions, with possible combinations:
  1. 1.

    Internal mammary artery plus the lateral thoracic artery

     
  2. 2.

    Internal mammary artery plus intercostal arteries

     
  3. 3.

    Supply by all three sources.

     
Marcus [8] described three basic patterns of blood supply to the NAC:
  1. 1.

    A ring anastomoses with the internal mammary artery as the dominant supplier (74%)

     
  2. 2.

    A loop anastomoses with the lateral thoracic artery as the dominant supplier (20%)

     
  3. 3.

    A radial pattern characterized by a lack of anastomoses in 6% of cases.

     
In 1939 Anson et al. [1] could not find any branches originating from the intercostal arteries to supply the breast. In 1943, Maliniac [5] summarized the findings of previous investigations and came to the conclusion that the blood supply came mainly from the internal and lateral thoracic arteries, and that the intercostal arteries are of secondary importance. He concluded that in 50% of cases, the breast is supplied by the internal thoracic and lateral thoracic arteries, in 30% by the internal thoracic and intercostal arteries, and in 18% by all three sources. Unfortunately, Maliniac [5] reported that Marcus [8] examined 53 breasts, instead of the documented 33 breasts (Marcus examined 23 female, 4 male, and 6 fetal breasts).

In 1977, Cunningham [4] reviewing work of previous investigators came to the conclusion that the main blood supply came from the lateral thoracic and internal thoracic arteries. These branches do not follow the duct system, but instead form a plexus in the anterior fat layer. Cunningham mentioned a posteromedial mammary artery originating from the internal thoracic artery, as reported by Salmon, which was confused by other workers with the anterior intercostal or perforating branches. The contribution of the pectoral branch from the thoraco-acromial artery and branches from the intercostal arteries was considered to be minimal.

In 1986, Palmer and Taylor [12] conducted radiographic studies on the vascular architecture of the anterior chest wall. They found that the dominant supply to this region is from the internal thoracic artery, with a concentration of large perforators along the inframammary crease arising from the anterior intercostal vessels.

In 1994, Nakajima et al. [11] investigated the arterial anatomy of the nipple-areola complex radiographicaily in five fresh cadavers and came to the conclusion that the main blood supply came from the external mammary (lateral thoracic) and internal mammary (internal thoracic) arteries.

In 1997 Elizabeth Wuringer et al. [14] examined 28 female breasts and described a horizontal septum extending toward the nipple that divided the blood supply into cranial and caudal networks. The first consisted of vessels from the thoraco-acromial artery and branches of the lateral thoracic artery, and the latter comprised branches of the anterior intercostal arteries with a contribution from the perforating branches of the internal thoracic artery.

Confusion exists about the blood supply to the NAC. This may be attributable to the scarcity of young female cadavers needed for research and the difficulty dissecting vessels. To contribute to and verify the findings of previous investigators, the author embarked on an anatomic study by dissecting latex-injected female cadaver breasts.

Materials and Methods

For this study, 15 adult female cadavers between the ages of 35 and 79 years (median, 52 years) underwent injection of latex into the right common carotid artery according to the method described by Thompsett [13]. Dissections of 27 breasts were performed. Arteries supplying the NAC were followed to their origin, and the pattern of supply was recorded. The contribution of each main source was determined by counting the number of arteries reaching the NAC

Results

The findings showed that blood is supplied to the NAC primarily by the internal thoracic artery (48.8%), via its perforating branches, as well as by the anterior intercostal arteries (24.4%) and the lateral thoracic artery (23.2%) (Table 1). In 2.4% of the cases in this study, the NAC was supplied by a branch originating from the axillary artery. This vessel, which is not identical to the lateral thoracic artery, is described by Manchot as the superficial thoracic artery. The posterior intercostal arteries were of less importance, contributing only 1.2% of the blood to the NAC (Table 1).
Table 1

Number of arteries reaching the nipple-areola complex

Main source

No. of arteries

%

Perforating vessels from the internal thoracic artery

40

48.8

Anterior intercostal arteries

20

24.4

Lateral thoracic artery (lateral mammary or external mammary artery)

19

23.2

Axillary artery/superficial thoracic artery of Manchot

2

2.4

Posterior intercostal artery

1

1.2

From the internal thoracic artery, perforating arteries 1 to 4 contributed the blood supplied to the NAC. The third perforator was the most important (47.5%), followed by the second perforator (25%) (Table 2).
Table 2

Perforating branches from the internal thoracic artery supplying the nipple-areola complex

Perforator

No. of arteries

%

1

6

15

2

10

25

3

19

47.5

4

5

12.5

Often, the perforating branches from the Internal thoracic artery coursed relatively parallel to each other in a lateral direction. They ran tortuously either above or below the nipple toward branches from the lateral thoracic artery (Figs. 1, 2, 3, 4, and 5). Rarely, they coursed medially and laterally to the nipple or inferiorly toward the submammary region. They sometimes anastomosed with the anterior intercostal arteries (Fig. 3, left breast). Branches from the lateral thoracic artery usually ran roughly parallel to each other on variable segmental levels, medially either above or below the nipple toward the perforating branches of the internal thoracic artery, to anastomose with these arteries arteries (Figs. 1, 2, 3, 4, and 5). Branches from anterior intercostal arteries 4 to 6 supplied the NAC inferiorly, sometimes more than one branch from the same intercostal artery (Figs. 1, and 3). The most important was anterior intercostal branch 4 (68.8%) (Table 3), which usually perforated the anterior chest wall at the fourth costochondral junction (Figs. 1, 3, and 4).
https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f1.jpg
Figure 1

The main sources of blood supply to the nipple-areola complex (NAC) and various patterns of supply. Perforating arteries of the internal thoracic artery indicated by numbers on the sternum. Branches from the lateral thoracic artery (LT) and branches from the anterior intercostal arteries (AI). Branches from the posterior intercostal artery (PI).

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f2.jpg
Figure 2

Basic segmental pattern of blood supply to the nipple-areola complex (NAC) by means of anastomoses between the internal and lateral thoracic arteries. Note that an inferior pedicle in the left breast would be considered a random flap.

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f3.jpg
Figure 3

Inferior input to the segmental pattern of blood supply to the nipple-areola (NAC) by means of ascending branches from the fourth anterior intercostal arteries. Note that a lateral pedicle in the left breast would be considered a random flap.

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f4.jpg
Figure 4

The superficial thoracic artery described by Manchot, originating from the axillary artery in the left breast, which is not identical to the lateral thoracic artery. The blood supply to the nipple-areola complex (NAC) from inferior in the left breast is via a branch from anterior intercostal artery 4, and in the right breast via an artery directly from the internal thoracic artery (posterior medial mammary artery of Salmon or nipple-areolar branch of the internal thoracic artery).

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f5.jpg
Figure 5

Anastomoses between anterior intercostal artery 6 and the lateral thoracic artery. Note that a medial, inferior, and lateral pedicle would be arterialized, but a superior pedicle would be a random flap.

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f6.jpg
Figure 6

Cadaver dissection. Lateral view of the right breast, illustrating the segmental blood supply pattern resulting from anastomoses between the perforators of the internal thoracic artery and branches of the lateral thoracic (LT) artery. The second perforator (P2) superior to and the third perforator (P3) inferior to the nipple. A branch from intercostal space 4 (NAIT4) ascends from the submammary area to join the inferior loop. These branches have their origin from the internal thoracic artery or could be branches from the anterior intercostal arteries.

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f7.jpg
Figure 7

Close-up view of the breast in Fig. 6 with the areola elevated to demonstrate the anastomoses. Note the branch from inferior (NAIT4) originating from the internal thoracic artery and traversing intercostal space 4 to join the inferior segmental loop in a T fashion.

https://static-content.springer.com/image/art%3A10.1007%2Fs00266-003-7113-9/MediaObjects/266_2004_7113_f8.jpg
Figure 8

Frontal view of a right breast. The nipple-areola complex (NAC) supplied from the inferior submammary region by means of a branch originating from the internal thoracic artery and traversing intercostal space 4 (nipple-areolar branch of the internal thoracic artery NAIT4).

Table 3

Anterior intercostal arteries supplying nipple-areola complex

Anterior intercostal artery

No. of arteries

%

4

11

68.8

5

4

25

6

1

6.2

Notably, in all the dissected breasts (27/27), the NAC received one or more perforating arteries from the internal thoracic artery (Fig. 1), the most important being the perforators 3 (47.5%) and 2 (25%) (Table 2). On the other hand, there was inconsistency in the blood supply from the lateral thoracic and anterior intercostal arteries, with neither supplying the NAC in 11 breasts. The latter two sources are thus not as reliable as the first.

A variable, asymmetrical pattern of blood supply from the main sources was found. In many cases the right breast pattern of supply to the NAC differed from that of the left breast in the same cadaver (Figs. 1, 2, 3 and 4).

Anastomoses between the main sources of blood were abundant (Table 4), and by examination of them, a basic pattern could be detected. Whereas various anastomoses were found, the most common were observed between the internal thoracic and lateral thoracic arteries, between the internal thoracic and anterior intercostal arteries, and between the anterior intercostal arteries and the lateral thoracic artery (Table 4). The most abundant anastomoses were between the internal thoracic and lateral thoracic arteries (50%), resulting in a transverse segmental pattern of blood supply (Figs. 1 and 2). Anastomoses between the internal thoracic and anterior intercostal arteries also were frequent (29.59%) (Figs. 1, 3, and 4), which added a vertical component from the inferior to the existing transverse pattern.
Table 4

Anastomoses around the nipple-areola complex between the main sources of blood supply

Anastomosis between main sources

No. of anastomoses

%

Internal thoracic and lateral Thoracic artery

22

50

Internal thoracic and anterior intercostal arteries

13

29.5

Anterior intercostal and lateral thoracic artery

6

13.6

Internal thoracic and axillary arteries (superficial thoracic artery of Manchot)

2

4.5

Internal thoracic and posterior intercostal artery

1

2.3

Other anastomoses were less abundant: between the lateral thoracic and anterior intercostal arteries (13.6%), between the internal thoracic and the superficial thoracic arteries (4.5%), and between the posterior intercostal arteries and the internal thoracic arteries (2.3%) (Table 4).

Discussion

Because the patterns of blood supply to the NAC are variable, the surgeon cannot predict the specific pattern of supply in the individual patient whose breast he or she subjects to surgery. However, this study indicates that the NAC always receives its arterial supply from the internal thoracic artery by means of its perforating branches 1 to 4. A pedicle containing these vessels can always be considered an arterialized flap and, therefore, safe to use. Nahabedian et al. [10] reported on 23 patients with severe mammahypertrophy for whom they performed medial pedicle reductions, removing a mean mass of 1604 g per breast, without any nipple necrosis. It also would be safe to use a medio-to-lateral bipedicle flap, a superomedial pedicle, or an inferomedial pedicle because of its medial component.

Conversely, this study also indicates that approximately one third of flaps using an inferior or lateral pedicle would be considered random, with the risk of poor blood supply to the NAC. Manderkas et al. [7] did inferior pedicle breast reductions for 371 patients and reported an 0.8% incidence of nipple necrosis. Blondeel et al. [2] reported partial nipple necrosis in 0.7% of patients who had breast reductions with a laterocentral pedicle. Cardenas-Camarena and Vergara [3] performed reduction mammaplasties with a superolateral dermoglandular pedicle in 213 breasts and reported partial nipple necrosis in five breasts.

In 21 of the 27 breasts dissected, the NAC did not receive blood vessels superiorly. Therefore, a superiorly based flap would, in most cases, be considered random. Blondeel et al. [2] reported incidences of 7.3% for partial nipple necrosis and 2.1% for complete necrosis of the NAC for patients in whom they used a superodermal pedicle.

According to Moore [9] the embryologic development of the arterial supply to the thorax is by means of dorsal intersegmental arteries arising from the dorsal aortas and passing between successive somites ventrally to form the intercostal arteries, thus creating a segmental pattern. The breast develops from the ecto- and mesoderm of the ventral chest wall and thus will have the same pattern of blood supply. It can be postulated that this segmental pattern can be enhanced by the developing mammary ridge, which adds a vertical component to the existing pattern. This development can explain the ascending branches from the anterior intercostal arteries that supply the NAC.

Confusion exists concerning the nomenclature of the blood vessels supplying the mammary gland. It is logical to name the branches from the internal thoracic artery the “medial mammary arteries” because they originate medially from the anterior intercostal spaces. The branches from the anterior intercostal arteries should be named the “inferior mammary arteries” because they ascend from the inferior submammary region toward the nipple. The branches from the lateral thoracic artery should be named the “lateral mammary arteries” because their origin is lateral.

The inferior branches supplying the NAC have their origin either from anterior intercostal arteries 4 to 6 or directly from the internal thoracic artery, directed toward the NAC, with no further contribution to the intercostal space (Fig. 3, right breast). In the latter case, the artery, running in the intercostal space, must be considered intercostal, but with a specific course toward the NAC, and leaving the intercostal space toward its destination. These vessels probably were named the posterior mammary arteries by Salmon. Although posterior mammary arteries seems to be appropriate for a name, they can simply be called the nipple-areolar branches of the internal thoracic artery.

According to this study, the internal thoracic artery is the main and constant contributor of blood to the NAC by means of its perforating branches 1 to 4 and anterior intercostal branches 4 to 6. The most important are the branches originating from intercostal spaces 3 and 4, and the author has used an inferomedial pedicle breast reduction technique including these vessels for the past 15 years, with great success.

Copyright information

© Springer Science+Business Media, Inc. 2005