Breast Surgery
Sensitivity of the Nipple-Areola Complex
and Sexual Function Following Reduction
Mammaplasty
Aesthetic Surgery Journal
2015, Vol 35(7) NP193–NP202
© 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
[email protected]
DOI: 10.1093/asj/sjv034
www.aestheticsurgeryjournal.com
Edgard S. Garcia, MD, MSc; Daniela F. Veiga, MD, PhD;
Miguel Sabino-Neto, MD, PhD; Flávia N.M. Beraldo Cardoso, PhD; Israel
O. Batista, MD; Renata M. Leme, MD; Isaias V. Cabral, MD; Neil F. Novo,
PhD; and Lydia M. Ferreira, MD, PhD
Abstract
Background: The sensitivity of the nipple-areola complex (NAC) is very relevant to female sexuality.
Objective: To evaluate NAC sensitivity and sexual function after breast reduction, and to assess whether altered NAC sensitivity is related to sexual
dysfunction.
Methods: The study included 80 patients, who were allocated to a control group with eutrophic breasts (CG, n = 20), a hypertrophy group without
surgery (HG, n = 20), or a mammaplasty group (MG, n = 40). The MG was assessed preoperatively and 6 months postoperatively. The HG and CG were
evaluated once. NAC sensitivity was assessed for touch, temperature, vibration, and pressure in four areola quadrants and the nipple. Sexual function was
assessed with the Brazilian version of the Female Sexual Function Index, which has six domains (desire, arousal, lubrication, orgasm, satisfaction, and pain)
and a total score that indicates the presence or absence of sexual dysfunction.
Results: Compared to the CG, the MG had worse sensitivity to temperature and pressure in the nipple and areola medial quadrants postoperatively
(P < 0.01). Compared to their preoperative assessment, the MG had reduced temperature and pressure sensitivity in the nipple and areola medial quadrants postoperatively (P < 0.05). Compared to the CG and HG, patients in the MG had higher postoperative scores of excitation (P = 0.0001), lubrication
(P = 0.0004), orgasm (P < 0.0001), and satisfaction (P < 0.0001). There was an association between sexual dysfunction and low NAC sensitivity to temperature and vibration (P ≤ 0.041) in the MG’s preoperative and postoperative scores, and to touch, temperature, and pressure across all three groups.
Conclusions: Breast reduction with a superomedial pedicle reduced NAC sensitivity but did not interfere with sexual function.
Level of Evidence: 3
Accepted for publication February 16, 2015.
Dr Garcia is a PhD Student in the Translational Surgery Graduate
Program at the Universidade Federal de São Paulo – UNIFESP, Brazil,
and a Medical Assistant Preceptor in the Division of Plastic Surgery at
the Universidade do Vale do Sapucaí – UNIVÁS, Pouso Alegre, MG,
Brazil. Dr Veiga is an Associate Professor in the Translational Surgery
Graduate Program at the Universidade Federal de São Paulo –
UNIFESP, Brazil, and a Medical Assistant Preceptor in the Division of
Plastic Surgery at the Universidade do Vale do Sapucaí – UNIVÁS,
Pouso Alegre, Brazil. Dr Sabino-Neto is an Associate Professor in the
Translational Surgery Graduate Program at the Universidade Federal de
São Paulo – UNIFESP, Brazil. Dr Beraldo-Cardoso is Psychologist and
PhD in Translational Surgery at Universidade Federal de São Paulo –
Therapeutic
UNIFESP, Brazil. Drs Batista and Cabral are Residents in the Division of
Plastic Surgery; Dr Leme is a Resident in the Division of Gynecology
and Obstetrics; and Dr Novo is a Full Professor in the Department of
Biostatistics of the Universidade do Vale do Sapucaí – UNIVÁS, Pouso
Alegre, Brazil. Dr Ferreira is a Full Professor in the Division of Plastic
Surgery and the Translational Surgery Graduate Program of the
Universidade Federal de São Paulo – UNIFESP, Brazil.
Corresponding Author:
Dr Daniela Francescato Veiga, Rua Napoleão de Barros,
715–4° andar - CEP 04024-002, São Paulo, Brazil.
E-mail: [email protected]
NP194
The distribution pattern of the breast nerve branches has
begun to attract increased attention, particularly regarding
surgical techniques that preserve the nerve branches to
facilitate the recovery of skin sensitivity after surgery.1
Different nerve branches contribute to the sensitivity of the
nipple-areola complex (NAC). Among these branches, the
most frequently cited are the medial and lateral branches of
the fourth intercostal nerve. The lateral branch is present in
all anatomic studies. The lateral nerve branch pierces the
fascia of the serratus anterior muscle and runs toward the
lateral margin of the pectoralis major muscle, turning at a
right angle to penetrate the breast tissue to the NAC.2-4
Other branches of the intercostal nerve, such as the second,
third, fifth, and sixth, as well as branches of the cervical
plexus, form a microscopic subdermal plexus below the
NAC and contribute to the ability of the NAC to perceive
stimuli.2,5
Increasing evidence suggests that cutaneous sensitivity
can impact the affective aspects of touch, including sexual
function, which is recognized as an important dimension
of personality that influences quality of life.6-8 Changes in
sexuality have been reported in patients undergoing breast
reduction, but very few studies have comprehensively evaluated the effects on sexual satisfaction and function.9-11
Moreover, although studies have assessed female sexual
function after breast reduction, to our knowledge no study
has quantitatively analyzed the relationship between postoperative changes in breast sensitivity and female sexual
function.11-14 Therefore, we undertook a prospective controlled study to assess the sensitivity of the NAC and sexual
function after breast reduction, to determine whether
changes in NAC sensitivity were associated with sexual
dysfunction.
METHODS
The study protocol for this single-center, prospective, controlled, and nonrandomized trial was approved by the
Ethics Committee of the Universidade Federal de São
Paulo. All protocols followed the ethical guidelines of the
Declaration of Helsinki and all participants signed an informed consent form. The study was carried out between
January 2012 and February 2014.
A total of 80 patients were selected from a plastic
surgery outpatient unit at the Hospital das Clinicas Samuel
Libanio, Universidade do Vale do Sapucaí, Brazil. Patients
were allocated to three groups: the control group (CG,
n = 20) consisted of women without breast hypertrophy;
the breast hypertrophy group (HG, n = 20) consisted of
women with breast hypertrophy who did not desire to
undergo breast reduction; and the mammaplasty group
(MG, n = 40) consisted of women with breast hypertrophy
who underwent reduction mammaplasty. The women included in the study were between 18 and 50 years of age,
Aesthetic Surgery Journal 35(7)
had body mass indexes of 19 to 30 kg/m2, were not postmenopausal, and were sexually active. Women were excluded
if they had previous breast surgery, breast asymmetry, or
any breast pathology; smoked or had stopped smoking less
than one month before the study; had given birth or were
breastfeeding less than one year before the study; had any
neuropathy or uncontrolled comorbidity; or were undergoing psychiatric treatment. Breast hypertrophy patients and
candidates for reduction mammaplasty were allocated to
the MG according to the hospital’s schedule. Patients with
breast hypertrophy who did not desire the operation were
allocated to the HG.
A patient was considered to be a study loss if she did not
attend the return visits, became pregnant during the study,
or did not engage in sexual activity during the study period.
Patients in the MG group underwent reduction mammaplasty with standard techniques using the superomedial
pedicle for the rise of the NAC.15-18 All procedures were
performed by the same surgical team. In the MG, skin sensitivity tests and the Female Sexual Function Index (FSFI)
were administered at the time of hospital admission and
6 months postoperatively.8 Patients in the CG and HG did
not undergo any surgical procedure, thus they were not admitted to hospital during the study. They were assessed
once, after giving informed consent, immediately after their
medical consultation at the outpatient plastic surgery unity
of the university hospital.
Skin sensitivity tests were performed by the same examiner in a quiet environment. During the test, patients lay
on a comfortable bed with their eyes blindfolded. The
areola was divided into four quadrants, and the nipple was
considered an additional point, for a total of five regions
(Figure 1). In each region, four sensory modalities were
tested: light touch, temperature (hot and cold), vibration,
and pressure.19,20
Figure 1. Points corresponding to the four areolar quadrants
(P1–P4) and the nipple (P5), in right and left breasts. P1,
areola superolateral point; P2, areola superomedial point; P3,
areola inferomedial point; P4, areola inferolateral point; P5,
nipple.
Garcia et al
NP195
Figure 2. Instruments used to assess cutaneous sensitivity.
From left to right: wad of cotton wool, thermometer, tube for
hot and cold water, vibrating tuning fork, and
Semmes-Westein filaments.
Figure 3. This 37-year-old woman’s superomedial pedicled
flap, containing the nipple-areola complex, is rotated 90° intraoperatively.
Sensitivity to light touch was tested using a wad of
cotton wool passed smoothly over the skin. Temperature
sensitivity was tested with tubes containing water heated at
60°C and crushed ice, respectively, placed on the skin for
two seconds. Vibration sensitivity was evaluated using a
tuning fork vibrating at 128 vibrations per second placed in
contact with the skin for two seconds (Figure 2). Pressure
sensitivity was measured using Semmes-Weinstein filaments (SORRI, BAURU, SP, Brazil, INPI.7.102.105), corresponding to threshold/potential skin pressure values of
0.05, 0.2, 2, 4, 10, and 300 grams (Figure 2). The monofilament was used to exert pressure until it bent, and the pressure was maintained for 5 seconds. The perceived pressure
value was recorded.
The NAC was rotated 90° (Figure 3) as a standard procedure during the operation. During postoperative sensory
testing, the areolar points were adjusted as well to ensure
that the same points in the NAC were compared pre- and
postoperatively. Breasts were randomized to determine
which side (left or right) of each patient was included in
the statistical analysis. The random sequence was computergenerated (Bioestat 5.0, Instituto de Desenvolvimento
Sustentável Mamirauá, Belém, PA, Brazil).
To evaluate sexual function, we used the validated
Brazilian version of the FSFI, which comprises 19 questions
on the sexual activity of patients during the last four
weeks.8,21 Patient responses are grouped into six areas to
obtain the scores: desire (items 1 and 2), excitation (items
3–6), lubrication (items 7–10), orgasm (items 11–13), satisfaction (items 14–16), and discomfort/pain (items 17–19).
Earned points are multiplied by a correction factor for each
independent domain, generating the corresponding scores.
Final scores can range from 2 to 36, and higher scores indicate better sexual function. A total score less than or equal
to 26.55 reflects sexual dysfunction.8,21
Statistical Method
Due to the nature of the data, non-parametric tests were
applied. The Kruskal-Wallis test was used to compare age
and body mass index (BMI) among groups and the chisquared test was used to assess the relationship between
the resected weight and sexual function. Either Fisher’s
exact test or the chi-squared test was used, as appropriate,
for intragroup (MG: pre- and 6 months postoperatively) and
intergroup (CG, HG, and MG: 6 months postoperatively)
comparisons of categorical variables related to cutaneous
sensitivity (light touch, vibration, and temperature). Tests
were applied independently for each evaluated point.
For numerical variables ( pressure sensitivity and scores
of FSFI), the Wilcoxon test was used for intragroup and
the Kruskal-Wallis test for intergroup comparisons. The
chi-squared test was used for intra- and intergroup comparisons regarding the presence of sexual dysfunction.
To determine whether there were associations between
categorical variables related to changes in skin sensitivity
(light touch, vibration, and temperature) and sexual dysfunction, Fisher’s exact test was used to compare within
the MG group and the chi-squared test to compare among
groups. Tests were applied independently for each evaluated
point. Associations between changes in pressure sensitivity (values above the median) and sexual dysfunction
were analyzed in the same manner. For all analyses, the
level of rejection of the null hypothesis was set at 5%
(α ≤ 0.05).
RESULTS
All 80 patients completed the study; there were no losses or
exclusions. Women in the three groups were matched for
age (CG: mean, 34.5 years; range, 21–50 years; HG: mean,
Aesthetic Surgery Journal 35(7)
NP196
Table 1. Age and BMI Values, and Statistical Comparison Among Groups
Groups
BMI (kg/m2)
Age (Years)
Range
Median
Mean ± SD
Range
Median
Mean ± SD
CG
21–50
33
34.5 ± 8.8
19.9–29.5
HG
20–50
36
35.8 ± 9.8
20–30
25.5
25.5 ± 2.7
MG
18–50
30.5
30.5 ± 9.9
21.2–30
25.8
25.6 ± 2.4
CG vs. HG vs. MG
(Kruskal-Wallis test)
24
P = 0.273
24 ± 2.9
P = 0.076
BMI, body mass index; CG, control group; HG, hypertrophy group; MG, mammaplasty group; SD, standard deviation.
Table 2. Frequency of Patients with Abnormal Sensitivity to Superficial Touch and Vibration and Statistical Comparison Intra-group (Fisher Test) and
Inter-groups (Chi-square Test)
Groups
Superficial Touch n (%)
Vibration n (%)
P1
P2
P3
P4
P5
P1
P2
P3
P4
P5
CG
–
1 (5)
–
–
3 (15)
–
1 (5)
–
–
–
HG
6 (30)
6 (30)
10 (50)
9 (45)
7 (35)
–
–
–
–
–
–
2 (5)
6 (15)
7 (18)
8 (20)
–
–
1 (3)
MG PO 6 months
3 (8)
5 (13)
39 (98)
5 (13)
8 (20)
1 (3)
1 (3)
–
1 (3)
1 (3)
MG Pre vs. MG PO
6 months
(Fisher test)
P = 0.120
P = 0.216
P = 0.241
P = 0.378
P = 0.601
P = 1.000
P = 1.000
P = 1.000
P = 0.615
P = 1.000
CG vs. HG vs. MG
(PO 6 months)
(Chi-square test)
P = 0.006*
P = 0.071
P = 0.000*
P = 0.000*
P = 0.275
P = 0.603
P = 0.600
P = 1.000
P = 0.603
P = 0.603
MG Pre
3
–
CG, control group; HG, hypertrophy group; MG, mammaplasty group; P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point;
P5, nipple; Pre, preoperative; PO, postoperative. *Statistically significant.
35.8 years; range, 20–50 years; and MG: mean, 30.5 years;
range, 18–50 years) and BMI (Table 1). However, the proportion of patients with sexual dysfunction was lower in
the MG: prior to the operation, 15 patients (37.5%) in the
MG presented with sexual dysfunction, while 19 (95%)
and 20 (100%) patients in the CG and HG did, respectively
(P < 0.001).
In the MG, the weight of resected breast tissue resected
ranged from 255 to 2720 g (median: 830 g; mean ±
standard deviation: 914.7 ± 529.6 g). There were no relations between the resected weight and sexual dysfunction
(P = 1.00). Tables 2-4 report the results of the sensitivity
analyses and the intra- and intergroup comparisons.
Compared to the CG, the MG had worse sensitivity to temperature and pressure in the nipple and areola medial quadrants postoperatively (P < 0.01). Compared to preoperative
analyses, the MG had reduced temperature and pressure
sensitivity in the nipple and areola medial quadrants postoperatively (P < 0.05).
Table 5 shows the related domain scores of the FSFI
results in the three groups and the intra- and intergroup
comparisons. Compared to the CG and HG, patients in the
MG had higher scores of excitation (P = 0.0001), lubrication (P = 0.0004), orgasm (P < 0.0001), and satisfaction
(P < 0.0001) postoperatively.
Finally, Tables 6-8 summarize the associations between
patients with sexual dysfunction and changes in skin
sensitivity. There was an association between dysfunction
and low NAC sensitivity to temperature and vibration
(P ≤ 0.041) in the MG when comparing pre- and postoperative scores, and to touch, temperature, and pressure when
comparing all three groups.
DISCUSSION
Preserving the sensitivity of the NAC and breast skin during
mammaplasty is essential to helping patients achieve better
postoperative outcomes.22,23 There is some controversy
Garcia et al
NP197
Table 3. Frequency of Patients with Abnormal Sensitivity to hot and Cold Temperature and Statistical Comparison Intra-group (Fisher Test) and
Inter-groups (Chi-square Test)
Groups
Hot Temperature n (%)
Cold Temperature n (%)
P1
P2
P3
P4
P5
P1
P2
P3
P4
P5
CG
2 (10)
–
–
–
1 (5)
–
–
–
–
–
HG
4 (20)
1 (5)
1 (5)
2 (5)
1
1 (5)
–
1 (5)
–
–
MG Pre
1 (3)
2 (5)
1 (3)
1 (3)
2 (5)
2 (5)
1 (3)
1 (3)
1 (3)
–
MG PO 6 months
3 (8)
7 (18)
4 (10)
10 (25)
8 (20)
3 (8)
8 (20)
6 (15)
7 (18)
8 (20)
MG Pre vs. MG PO
6 months
(Fisher test)
P = 0.308
P = 0.078
P = 0.180
P = 0.004*
P = 0.044*
P = 0.500
P = 0.0144*
P = 0.542*
P = 0.0284*
P = 0.003*
CG vs. HG vs. MG
(PO 6 months)
(Chi-square test)
P = 0.345
P = 0.041*
P = 0.309
P = 0.029*
P = 0.041*
P = 0.454
P = 0.012*
P = 0.121
P = 0.022*
P = 0.012*
CG, control group; HG, hypertrophy group; MG, mammaplasty group; P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point;
P5, nipple; Pre, preoperative; PO, postoperative. *Statistically significant.
Table 4. Median Values of the Pressure for Each Assessed Point and Statistical Comparison Intra-group (Wilcoxon test) and Inter-groups (Kruskal-Wallis test)
g/mm2
Groups
P1
P2
P3
P4
P5
CG
4
4
4
4
9
HG
27
27
27
27
9
MG Pre
9
9
9
9
9
MG PO 6 months
4
27
27
27
27
MG Pre vs. MG PO 6 months
(Wilcoxon)
P = 0.489
P < 0.000*
P = 0.326
P = 0.000*
P < 0.000*
CG vs. HG vs. MG (PO
6 months) (Kruskal-Wallis)
P = 0.050
P = 0.000*
P = 0.053*
P < 0.000*
P = 0.011*
CG, control group; HG, hypertrophy group; MG, mammaplasty group; P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point;
P5, nipple; Pre, preoperative; PO, postoperative. *Statistically significant.
Table 5. Median FSFI Scores and Statistical Comparisons Intra-group (Wilcoxon Test) and Inter-groups (Kruskal-Wallis Test)
Domain
Control
Hypertrophy
Mammoplasty Group
Pre
PO 6 months
CG vs. HG vs. MG
Pre vs. PO 6 months
Desire
3.00
3.60
3.60
4.00
P = 0.110
P = 0.145
Excitation
2.00
2.25
4.05
3.95
P = 0.001*
P = 0.285
Lubrification
3.45
3.60
4.80
4.50
P = 0.000*
P = 0.230
Orgasm
2.80
2.80
4.80
4.00
P < 0.000*
P = 0.369
Satisfaction
1.80
3.60
4.80
4.00
P < 0.000*
P = 0.483
Discomfort/Pain
5.00
5.60
5.40
5.00
P = 0.600
P = 0.383
19.95
22.20
27.90
26.50
P < 0.000*
P = 0.135
Escore Total
CG, control group; HG, hypertrophy group; MG, mammaplasty group; PO, postoperative. *Statistically significant.
Aesthetic Surgery Journal 35(7)
NP198
Table 6. Frequency of Patients with Abnormal Sensitivity to Superficial Touch and Vibration Variables That Presented Sexual Dysfunction and Statistical
Comparisons Intra-group (Fisher Test) and Inter-groups (Chi-square Test)
Groups
Superficial Touch n (%)
Vibration n (%)
P1
P2
P3
P4
P5
P1
P2
P3
P4
P5
CG
–
1 (5)
–
–
1 (5)
–
1(5)
–
–
–
HG
6 (30)
6 (30)
10 (50)
9 (45)
7 (35)
–
–
–
–
–
–
2 (13)
4 (27)
4 (27)
4 (27)
–
–
–
–
–
MG PO 6 months
3 (15)
3 (15)
3 (15)
3 (15)
5 (26)
1 (5)
1 (5)
–
1 (5)
1 (5)
MG Pre vs. MG PO
6 months
(Fisher test)
P = 0.161
P = 0.616
P = 0.360
P = 0.360
P = 0.640
P = 0.558
P = 0.558
P = 1.000
P = 0.695
P = 0.041*
CG vs. HG vs.MG
(PO 6 months)
(Chi-square test)
P = 0.035*
P = 0.121
P = 0.000*
P = 0.002*
P = 0.074
P = 0.351
P = 0.579
P = 1.000
P = 0.351
P = 0.351
MG Pre
CG, control group; HG, hypertrophy group; MG, mammaplasty group; P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point;
P5, nipple; Pre, preoperative; PO, postoperative. *Statistically significant.
Table 7. Frequency of Patients with Abnormal Sensitivity to Temperature hot and Cold Variables That Presented Sexual Dysfunction and Statistical
Comparisons Intra-group (Fisher Test) and Inter-groups (Chi-square Test)
Groups
Hot Temperature n (%)
Cold Temperature n (%)
P1
P2
P3
P4
P5
P1
P2
P3
P4
P5
CG
2 (10)
–
–
–
1 (5)
–
–
–
–
–
HG
4 (20)
1 (5)
1 (5)
2 (10)
–
1 (5)
–
1 (5)
–
–
MG Pre
1 (6)
1 (6)
1 (6)
–
1 (6)
1 (6)
–
1 (6)
1 (6)
–
MG PO 6 months
3 (15)
5 (26)
3 (15)
6 (31)
6 (31)
1 (5)
4 (21)
4 (21)
5 (26)
5 (26)
MG Pre vs. MG PO
6 months
(Fisher test)
P = 0.397
P = 0.149
P = 0.397
P = 0.020*
P = 0.085
P = 0.590
P = 0.083
P = 0.250
P = 0.149
P = 0.041*
CG vs. HG vs. MG
(PO 6 months)
(Chi-square test)
P = 0.715
P = 0.018*
P = 0.145
P = 0.015*
P = 0.005*
P = 0.603
P = 0.012*
P = 0.053
P = 0.003*
P = 0.003*
CG, control group; HG, hypertrophy group; MG, mammaplasty group P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point;
P5, nipple; Pre, preoperative; PO, postoperative. *Statistically significant.
regarding innervation of the NAC based on anatomical
studies, in terms of the identity of participating nerve
branches and whether they are symmetrical between
breasts.2,24-26
In the present study, the Semmes-Weinstein method
was used to evaluate cutaneous pressure sensitivity.23,27-30
This method has been criticized as not offering a thorough
assessment of pressure sensitivity because the range of
tested values is large.31 Areas of bias with this method
include variations between examiners and in the quality
and maintenance of the product, as well as the need to
convert the logarithmic results to measures of strength
and pressure.1,30 To minimize bias, we took care of the
equipment, replaced damaged monofilaments, and used
proper application techniques. We converted measurements
into grams using the manufacturer’s protocol. Finally, a
single examiner performed all of the tests. This technique
has the advantages of being reproducible, affordable,
accessible, easy to learn, and of not requiring specific
technology.23
Ducic et al, in a systematic review about nerve injuries
and sensitivity alteration in augmentation mammaplasty,
found a risk of any nerve injury in 13.6% of the patients.
The intercostal cutaneous nerves to the breast were the
most likely to be injured, followed by the T3-T5 intercostal
cutaneous nerves to NAC.32
Only two previous studies have assessed the sensitivity
to pressure before and after mammaplasty with a
Garcia et al
NP199
Table 8. Frequency of Patients with Abnormal Sensitivity to Pressure Variable That Presented Sexual Dysfunction and Statistical Comparisons Intra-group
(Fisher Test) and Inter-groups (Chi-square Test)
Groups
n (%)
P1
P2
P3
P4
P5
CG
4 (21)
8 (42)
6 (31)
6 (31)
9 (47)
HG
2 (10)
1 (5)
–
11 (55)
8 (40)
MG Pre
6 (40)
4 (26)
7 (46)
7 (46)
4 (26)
11 (57)
6 (31)
5 (26)
7 (36)
4 (21)
MG Pre vs. PO 6 months
(Fisher test)
P = 0.489
P = 0.946
P = 0.383
P = 0.820
P = 0.980
CG vs. HG vs. MG (PO 6 months)
(Chi-square test)
P = 0.002*
P = 0.023*
P = 0.025*
P = 0.043*
P = 0.218
MG PO 6 months
P1, areola superolateral point; P2, areola superomedial point; P3, areola inferomedial point; P4, areola inferolateral point; P5, nipple; PO, postoperative; CG, control group; HG, hypertrophy group;
MG, mammaplasty group. *Statistically significant.
superomedial pedicle.4,23 Ferreira et al,4 observed decreased sensitivity at all points in the areola and nipple 6
months postoperatively. In contrast, we found that the sensitivity of the lateral quadrants did not differ pre- and postoperatively. Similarly, Chiari Junior et al23 observed that in
all subjects, sensation in the NAC returned to preoperative
levels by 12 months postoperatively. Studies examining
the outcomes of mammaplasty using the inferior pedicle
technique reported improved areolar pressure sensitivity
postoperatively.3,33 Wechselberger et al34 reported no significant improvement in pressure sensitivity across the
NAC compared to preoperative levels. Nevertheless, all of
these studies were limited by small sample sizes.33,34
In studies comparing the pressure sensitivity of the upper
and lower pedicles, the inferior pedicle generally showed
better NAC sensitivity postoperatively.28,30 Preserving the
fourth lateral intercostal nerve would likely benefit postoperative sensitivity. Only Chiari Junior et al23 clearly indicate
that they had preserved this nerve. This possibility is supported by the observation that sensitivity close to preoperative levels was recovered when the lateral or superolateral
pedicle technique was used to preserve the fourth lateral intercostal nerve.1,35
In terms of temperature sensitivity, our findings corroborate those of other authors. Wechselberger et al34 and
Hamdi et al35 observed reduced sensitivity to hot and
cold temperatures in the NAC. Comparing the sensitivity
between groups, the areola was significantly more sensitive
to pressure in the CG than the HG, similar to results reported by Harbo, Jorum, and Roald33 and Delvecchyo, Caloca,
and Gómez-Jauregui.36 For other sensory modalities there
were no comparable studies in the literature.
Previous studies reveal a tendency toward reduced NAC
sensitivity postoperatively in all sensory modalities when comparing upper with lower base pedicles. However, the
published studies are limited by a small number of prospective
studies, discrepancies between the results, methodological
challenges, poor design, and challenges inherent to long-term
follow-up (dropouts and postoperative morbidities).26,27
Therefore, more studies are required to clarify the relationship between breast surgery and skin sensitivity.
Sexuality surveys highlight growing evidence for the
existence of mechanoreceptors that link the limbic system
to affective touch in non-glabrous skin, creating pleasurable sensations.6,37,38 Depending on the anatomic location
where the body is touched and the context (intensity and
intent) of touching, the perception of the stimulus can be
discriminative or interoceptive, generating psychological
comfort or discomfort. However, objectively evaluating the
cutaneous sensitivity of the breasts can be a challenging
task.23,39
Female sexual dysfunctions are characterized by alterations to the sexual response cycle, which is the process of
desire, arousal, orgasm, and resolution. Dysfunction can be
the lack of a stage, excessive response, or discomfort and/
or pain during the sexual response cycle. Various triggers
can cause occasional or prolonged sexual dysfunction, including problems with internal stimuli (thoughts and fantasies) and inadequate stimulation of erogenous zones.40,41
This complexity makes the study of mammary cutaneous
sensitivity extremely relevant.
To capture the patient perspective of their health status,
numerous instruments to assess patient quality of life have
been produced and validated.42,43 In this context, there is
a need for instruments that assess female sexual function and its connections to emotional and psychosocial
aspects.8,40,44 The FSFI is the first instrument for assessing
female sexual function that has been validated in a
Brazilian context and meets all of the requirements of the
proposed international validation protocol.8,13,45-47
Aesthetic Surgery Journal 35(7)
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The MG group did not have a significant difference in
sexual function pre- and postoperatively. This finding is in
contrast to that of Beraldo et al,13 who observed differences
in the total sexual function score and in the domains of
desire, arousal, and lubrication. Our results also differ from
those found by Resende et al,14 who used a different tool to
measure sexual function and reported improvement in sexual
function overall, and specifically in the domains of desire/
interest, foreplay, arousal/tune, and orgasm/satisfation.
Romeo et al12 reported significantly lower excitation in
patients undergoing breast reduction compared to the
control group. However, Cerovac et al11 documented a significant association between patients’ subjective impressions and FSFI scores, demonstrating an improvement in
the MG compared to the CG.
Consistent with Cerovac et al,11 we also observed an
improvement in the total sexual function score and in the
arousal, lubrication, orgasm, and satisfaction domains at
six months postoperatively in the MG compared to the
CG. These same authors reported that patients with good
sexual function were more satisfied with the aesthetic/
functional outcome of surgery, which could explain why
the MG had better sexual function than the other groups.
Given that the CG and HG in our study had worse
sexual function scores, including the total score, compared to the MG six months postoperatively, the results
demonstrate that female sexual function is multifactorial
and determined by more than breast sensitivity alone.41,44
Therefore, we must consider other parameters that influence sexual function, such as cultural, social, educational,
and interpersonal issues. The improvement in some
domains of sexual function index observed in the MG
postoperatively could also potentially be due to other
breast reduction effects, completely unrelated to nipple
sensation, such as less back pain or better self-esteem,
which have already been demonstrated in previous
studies.48-50 However, we were not able to find studies in
the published literature correlating these aspects and
women’s sexual function.
Our study has some weak points. Two of these are that
we did not record the women’s hormonal cycles and
pain sensitivities, which could influence not only NAC sensitivity, but also sexual function. Another weakness is our
follow-up period of 6 months. Our findings undoubtedly
would be stronger if we had a longer follow-up. However,
many times is very difficult to follow up with patients from
a public health service for a longer time.
When it comes to interpersonal relationships, it is extremely difficult to standardize the study sample because
relationships are so labile. We considered the absence of
sexual activity, and not relationship instability, as an exclusion criterion. According to Jaspars et al,25 the sensitivity of
the mammary skin, especially the NAC, is highly significant
in sexuality.
In the evaluation of cutaneous sensitivity and sexual dysfunction, the MG was significantly worse 6 months postoperatively at sensing vibration (P = 0.041), heat (P = 0.020),
and cold (P = 0.041). These relationships could suggest an
association between sensory deficit and worse sexual function. However, there were no differences on the FSFI total
score pre- and postoperatively, indicating that the operation,
despite leading to a decrease in NAC sensitivity, did not influence patients’ sexual function. On the other hand, the
arousal and lubrication domains may be related to reduced
skin sensitivity, which suggests that this aspect could contribute to the lack of postoperative improvement in sexual
function in dysfunctional patients. Overall, our findings contribute to the study of postoperative cutaneous sensitivity
and its psychological effects in the context of sexuality, a
topic that has not been extensively studied in a quantitative
manner. However, our study has several limitations: the
non-randomized design, the unique assessment of patients
in the CG and HG, and the small sample size, besides the
fact that the influence of hormonal cycles on NAC sensitivity
and on sexual function was not considered.
CONCLUSION
In the present study, reduction mammaplasty with superomedial pedicle led to a postoperatively cutaneous NAC
sensitivity decrease, without impact on patients’ sexual
function. However, further randomized controlled studies
with larger samples and addressing a larger number of variables are necessary to clarify the complex role of reduction
mammaplasty on women’s sexual function.
Disclosures
The authors declare no potential conflicts of interest with respect
to the research, authorship, and publication of this article.
Funding
Dr Leme received a research scholarship through Fundação de
Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG)
specifially to participate in this study. The other authors received no other financial support for the research, authorship,
and publication of this article.
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