Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies

Abstract

Background: Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex. Methods: The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses–compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist. Results: Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast skin is innervated by anterior cutaneous branches and lateral cutaneous branches of the second through sixth and the nipple/nipple-areola complex primarily by anterior cutaneous branches and lateral cutaneous branches of the third through fifth intercostal nerves. The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve supply the largest surface area of the breast skin and nipple/nipple-areola complex. The lateral cutaneous branch of the fourth intercostal nerve is the most consistent contributory nerve to the nipple/nipple-areola complex (pooled prevalence, 89.0 percent; 95 percent CI, 0.80 to 0.94). Conclusions: The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.

An Evolving Landscape

“…Although multiple cadaveric studies have demonstrated contributions of the cutaneous branches of the supraclavicular nerve at the superior breast, systematic reviews do not come to a consensus on the consistency or significance of this nerve on breast sensation. 27,28 Within each reconstructive cohort, the NAC showed both higher preoperative sensation and more improvement over time than other breast regions. The NAC receives innervation from the anterior and lateral cutaneous branches of the third through fifth intercostal nerves, and Jaspars et al 29 found that the anterior and lateral cutaneous branches of the fourth intercostal nerves innervate 35.5% and 29.8% of the NAC surface, respectively.…”

“…The supraclavicular neve, arising from the dorsal rami of C3–C4, provides sensation to the skin of the neck and shoulder. Although multiple cadaveric studies have demonstrated contributions of the cutaneous branches of the supraclavicular nerve at the superior breast, systematic reviews do not come to a consensus on the consistency or significance of this nerve on breast sensation 27,28 …”

Analgesic Efficacy of an Ultrasound-Guided Transversus Thoracis Plane Block Combined with an Intermediate Cervical Plexus Block on Postoperative Pain Relief After Trans-Areolar Endoscopic Thyroidectomy: A Single Center Prospective Randomized Controlled Study

“…The breast skin is innervated by anterior and lateral cutaneous branches of the T2-6 and the nipple/nipple-areola complex primarily by anterior and lateral cutaneous branches of the T3-5 intercostal nerves; The study did not use block such as serratus anterior block to block the lateral rami of the mammary gland. Moreover, the supraclavicular nerves are also important for the upper part of the breast 28 and probably for the endoscopic trocar part. However, the remifentanil dose, postoperative opioid demand rate and demand in the block group were significantly lower than those in the control group, which indicate good frugal opioid effects.…”

A Relative Value Unit–Based Model for Targeted Nipple–Areola Complex Neurotization in Gender-Affirming Mastectomy

“…7 The dominant sensory innervation to the anterior chest wall and nipple areolar complex (NAC) is from the lateral cutaneous branches of the third through fifth intercostal nerves. 8,9 These nerves are traditionally transected during gender-affirming mastectomy, resulting in nearly all patients reporting decreased anterior chest wall and nipple sensation at more than 1 year postoperatively. Although most patients report improvements in dysphoria and regret is low after surgery, approximately two-thirds of patients report loss of nipple sensation altogether, and one in five are completely dissatisfied with their lack of nipple sensation.…”