Modified technique for nipple-areolar reconstruction: a case series

SUMMARY: Thousands of women undergo postmastectomy breast reconstruction each year. Part of the reconstruction of an aesthetically pleasing breast is a high-quality nipple-areolar reconstruction. The goals for this reconstruction include appropriate nipple projection, areolar color, and areolar texture. Presented in this article is a novel technique that achieves these goals without the need for harvesting a distant skin graft. The nipple-areolar reconstruction is performed under local anesthesia. A skate flap is designed to achieve the nipple reconstruction. The skate flap donor sites are closed primarily, and the outline of the areola is then defined with a round template. The skin is then incised at the border of the areola, and a full-thickness graft is elevated to the base of the reconstructed nipple. After hemostasis is achieved, the skin graft is placed back down in its original position and a bolster dressing is applied. Tattooing is performed 4 months postoperatively to achieve a color match. Twenty-four consecutive patients underwent 31 nipple-areolar reconstructions using this novel technique. All patients achieved excellent results without complications. One patient did experience a partial skate flap loss; however, the wound healed secondarily without the need for revision. The technique described herein can achieve the goals of nipple-areolar reconstruction, including appropriate nipple projection, areolar color, and areolar texture, without the need for a distant skin graft.     

Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast

If a patient's nipple-areola complex is available for grafting after mastectomy, it is the best material to use for nipple-areola reconstruction. The authors performed delayed autologous nipple-areola complex transfer to reconstructed breasts in 10 patients (mean age, 47 years; range, 40 to 53 years). The nipple-areola complex was cryopreserved with a programmed freezer after mastectomy. Histological examination of the tissue surrounding the nipple and areola eliminated the possibility of cancer invasion. At the time of transfer, the cryopreserved nipple-areola complex was thawed in 37 degrees C water and grafted on a projection made by a denuded dermal flap on the reconstructed breast. Each patient underwent immediate breast reconstruction using an innervated pedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The patients' postoperative courses were uneventful. The timing of transfer ranged from 3 months to 1 year (mean, 5.8 months) after breast reconstruction. Nipple projection was made by the "four" dermal flap in five cases, a round dermal flap in three cases, a double dermal flap in one case, and a denuded skate flap in one case. The follow-up period ranged from 5 to 36 months (mean, 21.8 months). All grafts were adapted. The final evaluation of nipple-areola complex adaptation was good in four cases, fair in four cases, and poor in two cases. Histological examination of the hematoxylin and eosin stains showed no remarkable destruction of the skin of the nipple and areola, and electron microscopic examination of the areola skin revealed no significant change. However, electron microscopic examination of the nipple skin showed serious damage to skin components, including elongation of the desmosome, widening of the intercellular space at the prickle cell and basal layers, and shrinking of prickle and basal cells. Although further development of the freezing process and cryopreservation technique is needed to prevent depigmentation of the nipple and areola, cryopreserved nipple-areola complex transfer to a reconstructed breast could be an alternative method of nipple-areola reconstruction.     

Nipple-areola reconstruction: satisfaction and clinical determinants

After performing a chart review, the authors identified 120 patients who underwent breast cancer-related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple-areola reconstruction type, the interval between breast mound and nipple-areola reconstruction, the number of procedures needed to achieve nipple-areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple-areola reconstruction; what the patient disliked most about the nipple-areola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction.A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nipple-areola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S-flap (8 percent), a full-thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple-areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis.Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nipple-areola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple-areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple-areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple-areola reconstruction (p = 0.0001).     

Long-term predictable nipple projection following reconstruction.

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Integrated breast mound reduction and nipple reconstruction with the wraparound flap.

A new method for nipple reconstruction is described that combines revision of an autologous tissue breast mound with creation of a projecting nipple. The method is applicable only to reconstructed breast mounds that must be reduced or lifted to achieve symmetry with the opposite breast. In this technique, the mound is reduced as if it were a normal breast, using an inverted-T or vertical mammaplasty pattern. In this way, breast projection can be increased and, if necessary, the inframammary fold can be elevated. A rectangular flap is created from skin and subcutaneous tissue that would normally be discarded during the breast reduction, and this flap is wrapped around on itself to form a projecting nipple. This new technique avoids the flattening of the breast mound usually seen after nipple reconstruction because it does not take tissue away from the completed breast mound to make the nipple. In appropriate patients who require reduction in size of their reconstructed breast mound, the wraparound flap nipple reconstruction is worth considering.     

The S nipple-areola reconstruction

Nipple reconstruction is performed as a last stage in breast reconstruction following mastectomy. Various methods of nipple reconstruction have been described, most of them utilizing either free composite grafts or local flaps. The main problem encountered using either method is the gradual absorption and flattening of the nipple. The technique we used in reconstructing 22 nipples, in preference over the various methods accepted in breast reconstruction, achieves a long-standing, protruding nipple constructed from two large local flaps raised from an S-shape design. The technique is simple and permits freedom in choosing the height of the nipple, even in the presence of a mastectomy scar. The size of the nipple thereby constructed is in excess of what was expected. Shrinkage occurs during the first 2 months, and the resulting size is more than adequate. The areola is reconstructed by a full-thickness skin graft harvested from a nonhairy area of the upper inner thigh. The local flaps lack the necessary color, which is achieved by tattooing.     

Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.     

Construction of the nipple with a mushroom-shaped pedicle

Construction of the nipple-areolar complex has been the subject of much interest and many papers. We believe that the best way to ensure nipple protrusion is by the entrapment of tissue above the skin surface so that it cannot retract. This, in principle, is similar to creating an irreducible hernia. This technique for nipple construction employs a circular split-thickness island of skin which has its central circulation preserved through its attachment at the new nipple site. This central stalk represents about one-quarter of the total surface area of the constructed areola. The total diameter of the areolar disk is usually determined by the size of the opposite nipple-areolar complex. The new areola is developed from a full-thickness skin graft taken from the area below the inguinal crease. Once removed, it is sutured over the elevated nipple segment with its central island. The full-thickness graft is sutured into place before a small cruciate incision is made in the center. It should be just large enough to permit the delivery of the dermal-epidermal flap on its stalk up through the opening. Nothing more need be done to the raw undersurface of the split-thickness skin. Its raw surface has no place to reattach because its bed is now covered with the full-thickness graft.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nipple reconstruction with the double-opposing-tab flap

The double-opposing-tab flap, a new method of nipple reconstruction used in 50 patients to date, is described. This technique uses two dermal-fat flaps, each similar to those described by Hartrampf, but with tab extensions inspired by the skate flap of Little. The donor sites of the two flaps are closed like Burrough's triangles, bringing the flaps into opposition so that they support each other's projection. The tabs cover all the exposed fat on the nipple so that no skin graft is required on the nipple proper. The result is a nicely shaped nipple that can be designed directly over a scar, maintains a projection averaging 3.8 mm at 10 months, and is technically easy to construct.     

Single-stage, autologous breast restoration

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.     

Reconstruction of the burned nipple-areola complex

Reconstructive results of 115 burned nipple-areola complexes in 84 female patients were reviewed. Results of nipple reconstruction using local quadrapod flaps (33 percent good, 45 percent fair, 22 percent poor) and composition grafts from the earlobe (20 percent good, 60 percent fair, 20 percent poor) were comparable, and both were superior to results obtained with the "double-bubble" technique (24 percent good, 35 percent fair, 41 percent poor). Differences in nipple reconstruction techniques were not appreciated until 1 year postoperatively. The early appearance of areola reconstruction with tattooing and split-thickness grafts was excellent. However, significant late hypopigmentation changes were observed with both techniques. Areola reconstruction with full-thickness skin grafts from the superomedial thigh (47 percent good, 33 percent fair, 20 percent poor) were superior to those obtained with tattooing (14 percent good, 35 percent fair, 51 percent poor) and split-thickness skin grafts from the contralateral unburned areola (21 percent good, 21 percent fair, 58 percent poor). We recommend employing local quadrapod flaps (for nipple), provided there is adequate surrounding dermis, and full-thickness skin grafts (for areola) in the reconstruction of the burned breast.     

The pinwheel flap nipple and barrier areola graft reconstruction

The pinwheel flap with a snug barrier areola graft appears to be an efficacious modification of Little's quadripod flap for nipple reconstruction. Further, long-term evaluation is needed to test the validity of these observations over several years.     

Modified autogenous latissimus breast reconstruction and the box top nipple

During the past 3 years, the authors have been using the modified autogenous latissimus myocutaneous flap (MALF) for breast reconstruction in increasing numbers because of occasional patient and surgeon dissatisfaction with other methods of breast reconstruction. They have found this method to have unprecedented reliability, making it preferable to other forms of reconstruction in many patients. Considering the very low morbidity, the high patient satisfaction, and current economic factors, the authors are strong advocates of this form of reconstruction. A procedural outline proposed by McCraw and coworkers is followed, with some useful modifications. An elliptical transverse skin paddle is centered over the back fat roll. The area of the skin ellipse measures approximately 8 +/- 2 cm vertically and 30 +/- 5 cm transversely. After making the skin incision, a feathering technique is used in all directions through the fatty layer overlying the latissimus and in the tissue beyond the anteroposterior borders of the latissimus (not beyond 5 cm from the skin incision). By means of feathering, the shape of a breast mound can be created in the allowable tissue supported by the latissimus. A 180-degree rotation of the flap allows dependentvenous drainage and more bulk in the inferior outer quadrant, where it is needed. In the current series of 47 modified autogenous latissimus breast reconstructions, seromas were common. Other complications included one wound infection, one ulnar neuropraxia, and one fat necrosis. There were no flap necroses (partial or complete) or hematomas. The rarity of complications supports the use of this technique in selected patients. An innovative new technique for nipple reconstruction is also described. The "box top technique" of nipple reconstruction consists of four deepithelialized local flaps covered with a skin graft from the groin.     

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.     

即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后的运用分析

目的：探讨分析即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后的运用。方法：回顾性分析我院2008年2月-2012年4月收治的乳腺癌术后患者106例,采用乳癌术即时扩展型背阔肌肌皮瓣乳房再造保留乳头乳晕复合体,观察手术效果以及满意度。结果：术后患者乳房美容优良率为88．68％明显大于对照组的47．17％,并且术后6个月治疗组生活质量评价总分明显大于对照组总分术后6个月患者生活质量评价总分明显大于术前评价总分,差异具有条件下意义（P〈0．05）,差异均具有统计学意义（P〈0．05）。结论：即时扩展型背阔肌肌皮瓣乳房再造在保留乳头乳晕复合体乳癌术后患者乳房美容效果较好,提高患者生活质量高,值得在临床上推广,但在手术后需积极处理可能存在的并发症情况。     

Reconstruction of the breast areola by intradermal tattooing and transfer. Case report.

A method of reconstructing a missing areola with a pre-tattooed full-thickness skin graft from the contralateral breast is presented.     

Reconstruction of the breast after mastectomy for cancer.

Seventeen women who had had a mastectomy for cancer of the breast underwent reconstructions. Alloplastic implants were used in all. Preservation of the nipple and areola was possible in some of these patients. The normal (or uninvolved) breast sometimes required reduction in size or reshaping, to match as nearly as possible the reconstructed breast. The conditions suitable and unsuitable for mammary reconstruction, after mastectomy for cancer, are discussed.     

Complete one-stage,immediate breast reconstruction with prosthetic material in patients with large or ptotic breasts

Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one-stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted-T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple-areola complex, the original areola (n = 3) or nipple-areola complex (n = 7) was retained as a full-thickness skin graft.The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple-areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de-epithelialized portion, which still allows two-layer closure).In the subgroup of patients with large breasts or marked ptosis, a single-stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple-areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple-areola complex may be retained as a full-thickness graft.     

Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results.

A review was performed on 170 patients who underwent 173 consecutive latissimus dorsi myocutaneous flap breast reconstructions between 1978 and 1989. The majority of the patients had modified radical mastectomies, and reconstruction was usually delayed for 3 to 18 months after mastectomy. Acceptable symmetry was obtained in the majority of patients without the need for surgery on the opposite breast. Perioperative and long-term complications are reviewed. Patients were followed for an average of 4.7 years after reconstruction. Ninety-four percent of patients demonstrated little or no change in the reconstructed breast after the first year. This method of reconstruction has met patient expectations with a minimum number of procedures and low morbidity.