A method for correcting an inverted nipple with an artificial dermis

A New Technique in Correction of Nipple Inversion Using Dermal C Flaps

BACKGROUND

Nipple inversion, which is defined as a nipple located on a plane deeper than the areola, presents both functional and cosmetic problems. Surgical repair of severe cases involves suture or flap techniques. In the present study, an alternative repair technique using two cross dermal areolar flaps to correct challenging inverted nipples is presented. Releasing the inverted nipple is performed by severing the underlying tight fibrous tissue bands and canaliculi.

METHODS

This is a retrospective case series. Fifteen patients who had been operated between January 2010 and January 2016 were included in the study. Seven of these had bilateral inverted nipples. Patient age at operation ranged from 26 to 47 years (mean age, 32.5 years). All nipples were congenital, with no previous operations. The follow-up period ranged between 8 and 16 months (mean of 13 months).

RESULTS

There were no complications associated with surgery, including infection, hematoma, permanent sensory disturbance, or nipple necrosis. Unilateral recurrence occurred in one patient on the 26th postoperative day. This patient was reoperated on successfully using the same method. Adequate projection was achieved in all patients. All patients were satisfied with their results.

CONCLUSIONS

The authors conclude that their procedure is a reliable, simple, safe, and effective method for correction of inverted nipples. The alignment of the scar with the junction of the nipple and the areola leads to a more aesthetic appearance with no apparent scarring. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Central Tunnel Technique and Fat Grafting for Surgical Correction of Inverted Nipples and Introduction of a Treatment Algorithm

BACKGROUND

Inverted nipples are prevalent in 3% to 10% of women and can often cause functional, psychological, and aesthetic problems.

OBJECTIVES

The authors sought to treat inverted nipples and restore the aesthetic appearance of the nipple while minimizing ductal disruption, preserving the ability to breast-feed, and reducing recurrence rates.

METHODS

A retrospective review was performed on a total of 161 inverted nipples in 86 consecutive patients who underwent correction of inverted nipples at Oslo Plastic Surgery Clinic. Mean age at operation was 28.7 years and mean follow-up period was 14 months. A novel technique with central tunnelization of the retracted fibers/ducts was employed in 39 patients (45%); partial incision of the center of the inversion through a tunnel in 31 patients (36%); and total cut of the lactiferous ducts in 16 patients (19%). Fat grafting was utilized as support in 14 patients (26 nipples). Postoperatively, nipples were suspended for 4 weeks with a manually constructed device.

RESULTS

Most patients had moderate (grade 2, 40 patients) or severe (grade 3, 52 patients) nipple inversion. Infection occurred in 4 patients and 2 patients had local irritation. Recurrence was seen in 32 patients (55 nipples) after the first operation, in 6 patients (6 nipples) after the second operation, and in 1 patient (1 nipple) after the third operation.

CONCLUSIONS

The authors propose a treatment algorithm that addresses important therapeutic goals when treating inverted nipples. Clinical examination is crucial to determine the method to be employed. The new central tunnel method and fat grafting to support the nipple are promising, although additional follow-up is necessary.

LEVEL OF EVIDENCE: 4

How to Improve Projection in Nipple Reconstruction: A Modified Method Using Acellular Dermal Matrix Disk and Fragments

BACKGROUND

Nipple reconstruction is an essential, final stage in breast reconstruction. However, postoperative reduction in nipple projection often results in low patient satisfaction. The authors studied the causes of the projection decline and developed a new method using acellular dermal matrix. This research studies the effectiveness of the new method.

METHODS

The nipple flap was elevated using a modified C-V flap, and acellular dermal matrix disk was fixed onto the floor. A column was made, into which acellular dermal matrix fragments were put in to retain the projection. The footprint diameter and projection at 1 year were compared with those of the control group, in which acellular dermal matrix was not used. The authors studied the correlation between diameter and projection and whether reconstruction method caused any impact.

RESULTS

At 1-year follow-up, the nipple diameter and projection in the acellular dermal matrix group were measured to be 102.90 percent and 64.19 percent, respectively, of the baseline. Compared with the control group, the diameter was significantly smaller (p = 0.00) and the projection was higher (p = 0.00). A significant correlation was identified between nipple diameters and projections, at 1-year follow-up, across the total 90 reconstructed nipples (p = 0.00). Different reconstruction methods did not show significant differences in terms of nipple diameter and projection, but the projections at 1 year were highest in the latissimus dorsi flap plus implant group, followed by the expander group and the transverse rectus abdominis musculocutaneous flap group.

CONCLUSION

Nipple reconstruction using acellular dermal matrix disk and fragments prevents downward shifting of the nipple tissue and broadening of the footprint diameter and thus is favorable for long-term maintenance of nipple projection.

A Revision Restoring Projection after Nipple Reconstruction by Burying Four Triangular Dermal Flaps

Background

Numerous techniques have been used to achieve long-term projection of the nipple following nipple-areola reconstruction. However, the reconstructed nipple loses projection over time. We describe a technique that uses local flaps to improve the lost projection of reconstructed nipples.

Methods

Between November 2013 and March 2015, nine patients (11 nipples) underwent revisional nipple reconstruction for lost projection. Only C–H nipple reconstructions were included in this study. The medical history of each patient was reviewed and photographs were taken in front and lateral views. All patients attended routine follow-up visits. Deepithelialized triangular flaps were made on all four sides of the nipple and buried in the opposite corners in order to augment the volume of the nipple. Anchoring sutures were used to attach each triangular flap on the side opposite their point of origin, and the resulting defects were closed directly.

Results

This procedure was used successfully in nine patients (11 nipples). Adequate projection was achieved in all patients and no complications occurred. The average nipple height was 3 mm before operation, 7 mm one day after operation, 5 mm at the six-month follow-up, and 5 mm at the 12-month follow-up. The average nipple-areolar angle was 164° before the operation, 111° one day after the operation, 130° at the six-month follow-up, and 133° at the 12-month follow-up.

Conclusions

The method described provides a solution to the loss of projection in reconstructed nipples. We recommend this technique because it leads to better projection, greater volume, and a more natural shape.

Inverted Nipple With Nipple-Sparing Mastectomy

BACKGROUND

The inverted nipple is a relatively common aesthetic problem seen by plastic surgeons. The etiologies of an inverted nipple include insufficiency of supporting tissues, hypoplasia of the lactiferous ducts, and retraction caused by fibrous bands at the base of the nipple. Many different surgical techniques have been described, either individually or in combination, but none represents a landmark strategy. In our present study, we report our experience of spontaneous improvement immediately after nipple-sparing mastectomy with simple buried interrupted sutures to maintain nipple base in inverted nipple patients.

METHODS

We describe our 10 years' experience in using a simple approach to correct inverted nipples after nipple-sparing mastectomy with pedicled transverse rectus abdominis myocutaneous flap reconstruction. Between January 2001 and August 2010, we observed 23 inverted nipples after nipple-sparing mastectomy by using only a buried baseline suture to tighten the base of the nipple. The follow-up period ranged from 3 to 13 years.

RESULTS

After nipple-sparing mastectomy with tightening of the base of the nipple, improvements were seen in 18 of the 23 patients. No complications associated with surgery occurred, such as infection, depigmentation, sensory disturbance, or nipple necrosis.

CONCLUSIONS

The simple method of baseline suturing that only tightens the nipple base with nipple-sparing mastectomy has been used in our center over a 10-year period in patients with breast cancer and an inverted nipple. The retractile duct or fibrous cord was completely cut with nipple-sparing mastectomy, and over 70% of inverted nipples in the patients were improved and maintained with only the tightening of the base of the nipple. Our results show that inverted nipple is caused by tight fibrous band or short duct rather than a lack of subareolar tissue.

Inverted nipple repair revisited: a 7-year experience

BACKGROUND

Nipple inversion in females can be congenital or acquired. Women who desire treatment for this condition often report difficulty with breastfeeding and interference with their sexuality. However, data are limited on the demographics of patients who undergo surgery to repair inverted nipples and the associated recurrence rates and complications.

OBJECTIVES

The authors assessed outcomes of a 7-year experience with an integrated approach to the correction of nipple inversion that minimizes ductal disruption.

METHODS

A retrospective chart review was performed for 103 consecutive patients who underwent correction of nipple inversion. (The correction technique was initially reported in 2004 and entailed an integrated approach.) Complication rates, breastfeeding status, and patient demographics were documented.

RESULTS

Among the 103 patients, 191 nipple corrections were performed. Nine patients had undergone previous nipple-correction surgery. Recurrence was experienced by 12.6% of patients, 3 of whom had bilateral recurrence. Other complications were partial nipple necrosis (1.05%), breast cellulitis (1.57%), and delayed healing (0.5%). The overall complication rate was 15.74%. Fifty-seven percent of the patients had a B-cup breast size, and 59% were 21 to 30 years of age.

CONCLUSIONS

Results of the authors' 7-year experience demonstrate the safety and effectiveness of their technique to correct inverted nipples. LEVEL OF EVIDENCE 4: Therapeutic.

Inverted nipple correction with dermal flaps and traction

BACKGROUND

Inverted nipple occurs when part of or the entire nipple is abnormally located below the areola. Surgical repair of severe cases involves suture or flap techniques. Complications include recurrence, lactation problems, hypopigmented scar formation in the areola, and loss of sensation. We describe an alternative repair technique using a dermal flap and traction, which leads to less apparent scarring and preserves lactation function and sensation.

METHODS

Between January 2010 and January 2013, we treated 28 inverted nipples in 16 patients using two areola-based triangular dermal flaps and traction. The scar was aligned with the junction of the nipple and the areola. Postoperatively, traction was applied through an apparatus prepared from a 50-cc syringe. Patients were followed up for 8-24 months (mean = 16.5 months).

RESULTS

Adequate projection was achieved in all patients and no wound dehiscence or complications such as infection occurred. Unilateral recurrence occurred in one patient on the 10th postoperative day. This patient was reoperated on successfully using the same method. No loss of sensation was observed in any of the patients during the postoperative period.

CONCLUSIONS

This dermal flap technique for treating inverted nipple was effective and preserved lactation function. The alignment of the scar with the junction of the nipple and the areola led to a more aesthetic appearance with no apparent scarring. The traction method helped maintain traction for a longer period, which in our opinion increased the success rate of the surgery.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Correction of inverted nipple with "arabesque"-shape sutures

BACKGROUND

Inverted nipples are a common self-concern for many women and also a relatively aesthetic problem for the plastic surgeon.

METHODS

Many techniques for correcting inverted nipples have been reported, but none is totally successful. To avoid recurrence and to attain perfect shape of the nipple, the authors present a minimal-incision technique supported by "arabesque"-shape percutaneous sutures. First, four micro-incisions about 0.5 cm in size, each the circumference of the nipple, are designed horizontally. Second, after sufficient releasing of the loose connective tissue beneath the nipple, two 4/0 PDS sutures are made in perpendicular directions to increase the support and sustain the tissue under the nipple and to close the way the nipple inverts.

RESULTS

This method was used to correct 22 inverted nipples of 18 patients classified as grade 3 or 4. The entire nipple remained everted and symmetric during a follow-up period of 3 months to 1 year except in two cases of recurrence during the early postoperative period due to a loose knot.

CONCLUSION

The described technique is simple, safe, and reliable, providing sustained results over the long-term follow-up period with a high rate of stable eversion and patient satisfaction.

Correction of recurrent grade III inverted nipple with antenna dermoadipose flap: case report

BACKGROUND

Numerous techniques have been reported for the correction of the inverted nipple. It was also reported that no single technique was appropriate for correcting all types of nipple deformities because different grades of inverted nipple have different levels of fibrosis, soft tissue bulk, and lactiferous ductus structure. In this article a novel technique for the repair of recurrent grade III inverted nipple is described in detail.

METHODS

In this technique, dermoadipose flaps were generated within the area of de-epithelialization of mastopexy.The flap is called "antenna flap" because of its designing.

RESULTS

No major vital complications such as necrosis of the major flap or nipple were seen. There was no recurrence of nipple inversion after 15 months. The shape and projection of the patient's nipple was deemed satisfactory.

CONCLUSION

This technique yielded a satisfactory result without recurrence of inversion. It should be considered for use on any patient contemplating correction of inverted nipple and mastopexy. It should be emphasized that this technique also permits the performance of mastopexy in conjunction with the correction of inverted nipple.