Nipple-areola reconstruction by tattooing and nipple sharing

Micro-pigmentation: implications for patients and professionals

In the UK, reconstructive breast surgery is routinely offered to patients undergoing surgery for breast cancer. The results can be excellent, but without a nipple-areola complex the patient can feel incomplete. In response to patient need, an innovative nurse-led micro-pigmentation service has been developed in the authors' NHS trust, which provides women (and men) an opportunity to complete their reconstruction process. With the use of coloured pigments, micro-pigmentation creates a permanent image of a nipple-areola complex, which improves the aesthetic appearance of the surgically-created breast. As with the development of any new nurse-led innovation, the micro-pigmentation service has professional and client implications. Breast cancer can be devastating and may induce many psychological concerns, not least about body image and sexuality. This article addresses these issues, along with professional matters, such as autonomous practice, role expansion and the blurring of clinical boundaries. These factors are considered in relation to the nursing management of the micro-pigmentation service, where patient autonomy is encouraged to promote acceptance of self-image and closure on the breast cancer experience.

Nipple-areolar pigmentation: histology and potential for reconstitution in breast reconstruction

The makeup of nipple-areolar skin, in terms of its melanin and melanocyte content has not previously been established. This histological information is required if pigmentation of the reconstructed nipple-areola is to be successful in post-mastectomy breast reconstruction. We describe examination of 200 parallel sections of nipple-areolar skin of 20 women using histochemical (Masson-Fontana) and immunohistochemical (Mel-5) techniques, evaluated using quantitative image analysis. The amount of melanin present per length of basement membrane was 2.14 times higher in areolar skin than breast skin. The ratio of melanocytes to keratinocytes was 1:9.7 in areolar skin vs. 1:14.7 in breast skin. We also describe a cell culture and skin construct method using autologous human serum without toxic growth promoting additives, which could be used in the clinical setting of nipple-areolar reconstruction.

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.

Fading of nipple-areolar reconstructions: the last hurdle in breast reconstruction?

Fading of nipple-areolar reconstructions is commonly reported, but there are few formal studies of this phenomenon. The purpose of this study was to determine whether deficiencies in nipple-areolar reconstruction and pigmentation were perceived by patients, their partners and independent observers, and whether a technique could be developed to measure nipple-areolar colour reliably. A total of 57 patients, 32 partners and four independent observers completed questionnaires about the appearance of the patients' breast reconstructions in general and specifically about their nipple-areolar reconstructions. Scores for the general attributes of the breast reconstruction were used as internal controls for the scores of the nipple-areolar reconstruction. A computer software package was developed to analyse colour in photographs of the reconstructions. Independent observers thought that nipple-areolar reconstruction improved the appearance of a breast reconstruction 81% of the time. Considerably fewer patients were happy with their nipple-areolar colour than were happy with the more general attributes of the breast reconstruction (P < 0.005). Colour analysis objectively demonstrated measurable mismatch between normal and reconstructed nipple-areolar skin, which was positively correlated with time since surgery due to fading of the nipple-areolar reconstruction. In our patients, the quality of nipple-areolar reconstruction, in particular its pigmentation, is seen as inferior to that of the rest of the breast reconstruction in the eyes of patients, their partners and independent observers. The poor colour match and fading of reconstructed nipple-areolar skin are phenomena that can be measured using colour analysis.

Assessment of long-term nipple projection: a comparison of three techniques

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.

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).

The use of Munsell colour charts in nipple–areola tattooing

Tattooing is an excellent, simple and quick option in nipple-areola reconstruction. Colour mismatch is one of the commonest problems with this procedure. Use of Munsell colour charts allows the premixing of common colours for different patient populations using pigments from various manufacturers. There are significant correlations between nipple colour and Fitzpatrick skin type and between nipple colour and parity. Three nipple-areola colours were more common than others and were found in 50% of patients; these can be premixed ready for use. Adjustment of premixed colours for individual patients can be performed prior to tattooing, speeding up the procedure. Accurate recording of colours also facilitates audit.

Correction of the post-burn malpositioned nipple-areola complex by transposition of two subcutaneous pedicled flaps

Symmetrical anatomy of the chest wall is the aesthetic goal in any technique for nipple-areola complex positioning in post-burn patients. In 15 patients, a new surgical technique was applied by transposition of two subcutaneously pedicled flaps, one of which carries the malpositioned nipple-areola complex. The long-term results of this procedure were found to be satisfactory in all patients.

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.

Tissue-engineered nipple reconstruction

We describe a simple, effective approach to the creation of autologous tissue-engineered cartilage in the shape of a human nipple by injecting a reverse thermosensitive polymer seeded with autologous chondrocytes in an immunocompetent porcine animal model. A biodegradable, biocompatible copolymer of polyethylene oxide and polypropylene oxide (Pluronic F-127), which exists as a liquid below 4 degrees C and polymerizes to a thick gel when it is exposed to physiologic temperatures (body temperatures), was used as a vehicle for chondrocyte delivery and as a scaffold to guide growth. Autologous chondrocytes isolated from porcine auricular elastic cartilage and suspended in 30% (weight/volume) Pluronic F-127 were injected on the ventral surface of the pigs from which the cells had been isolated. A circumferential subdermal suture was used to support the contour of the implant and assist in its projection in the form of a human nipple. After 3 weeks, the skin over and surrounding the implant was tattooed to create the appearance of a human nipple-areolar complex. As controls, an equal number of injections were made using either cells alone (not suspended in hydrogel), or hydrogel alone. After 10 weeks, all specimens were excised and examined both grossly and histologically. Before harvesting, visual inspection of the tattooed chondrocyte-Pluronic F-127 hydrogel implant sites revealed that they closely resembled a human female nipple-areolar complex. Nodules were similar in size, shape, and texture to a human nipple at each injection site. Glistening opalescent tissue was surgically isolated from each implant site. Hematoxylin and eosin, safranine o, trichrome blue, and Verhoeff's stains of the experimental implants showed nodules with the characteristic histologic signs of elastic cartilage. Control injections of copolymer hydrogel alone exhibited no evidence of cartilage formation. Control injections of chondrocytes alone showed evidence of dissociated microscopic nodules of elastic cartilage.