La reconstruction de la plaque aréolomamelonnaire: résultats à long terme

Long-Term Maintenance of Projection of Nipples Reconstructed Using Three-Dimensionally Printed Poly-4-Hydroxybutyrate Bioabsorbable Scaffolds

BACKGROUND

For patients who are unable to undergo nipple-sparing mastectomy, reconstruction of the nipple-areola complex has been shown to promote greater satisfaction in cosmetic outcome, body image, and sexual relationships. Although a variety of techniques have been developed to optimize the shape, size, and mechanical properties of the reconstructed nipple-areola complex, maintenance of sustained nipple projection over time remains a challenge for plastic surgeons.

METHODS

Three-dimensionally printed poly-4-hydroxybutyrate (P4HB) scaffolds were designed and fabricated filled with either mechanically minced or zested patient-derived costal cartilage, designed with an internal P4HB lattice (rebar) to provide interior structure to foster tissue ingrowth, or left unfilled. All scaffolds were wrapped within a C-V flap on the dorsa of a nude rat.

RESULTS

One year after implantation, neonipple projection and diameter were well preserved in all scaffolded groups compared with nonscaffolded neonipples ( P < 0.05). Histologic analysis showed significant vascularized connective tissue ingrowth at 12 months in both empty and rebar-scaffolded neonipples and fibrovascular cartilaginous tissue formation in mechanically processed costal cartilage-filled neonipples. The internal lattice promoted more rapid tissue infiltration and scaffold degradation and best mimicked the elastic modulus of the native human nipple after 1 year in vivo. No scaffolds extruded or caused any mechanical complications.

CONCLUSIONS

Three-dimensionally printed biodegradable P4HB scaffolds maintain diameter and projection while approximating the histologic appearance and mechanical properties of native human nipples after 1 year with a minimal complication profile. These long-term preclinical data suggest that P4HB scaffolds may be readily translated for clinical application.

CLINICAL RELEVANCE STATEMENT

The authors' unique, three-dimensionally printed P4HB scaffolds can be used to create custom nipple scaffolds that contour to any nipple shape and size, enabling the fabrication of tissue-engineered neonipples with significantly greater projection maintenance and closely approximating desired nipple biomechanical properties.

[Patients' satisfaction after immediate breast reconstruction: Comparison between five surgical techniques]

INTRODUCTION

The purpose of this study is to evaluate patients' satisfaction after immediate breast reconstruction (IBR) according to the surgical technique.

METHODS

Included patients had an IBR between 2012 and 2017 and finished their reconstruction since a year. Patients were contacted by phone and their satisfaction was evaluated with the Breast Q questionnaire. According to the surgical technique, patients were divided into 5 groups: DIEP, gracilis, Latissimus Dorsi flap, definitive implant and expander implant. Techniques were grouped into two categories: free flaps and prothesis. Nipple reconstruction techniques were also evaluated: toe pulp grafting, nipple sharing and local flap.

RESULTS

Nighty-five patients on the 103 who were eligible accepted to answer the questionnaire. Satisfaction with breasts was stastistically higher in the free flap group (72.6/100) than in the prothesis group (62.7/100) (P<0.01). Physical well-being (chest) was better for the free flap group than for the prothesis group (92.2/100 vs. 85.2/100, P=0.02). Nipple reconstructions with nipple sharing and free flap give a better satisfaction for patients than toe pulp grafting (75.3/100 and 73.5/100 vs. 47.8/100, P<0.01).

CONCLUSION

IBR with free flap give, in a short time, a statistically higher satisfaction for breast than prothesis. Nipple reconstructions with free flap and nipple sharing give a better satisfaction too.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.]

INTRODUCTION

Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique.

OBJECTIVE

To assess patients' esthetic satisfaction with the results of tattooing performed by nurses.

METHOD

Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury.

RESULTS

97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%.

DISCUSSION

On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration.

CONCLUSION

Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.

[The reconstruction of the nipple-areolar]

The reconstruction of the nipple-areolar complex is the final stage of breast reconstruction that restores the visual identity of the breast. The most common options for reshaping the areola are tattooing, total skin grafting of the inner thigh and the total skin graft taken from the contralateral areola. Nipple reconstruction solutions include duplication of contralateral nipple, local flap, total skin graft and tattoo in three-dimension. Duplication of the nipple is the technique of choice because it immediately offers optimal color, texture and projection. The areolar tattoo is the most common procedure for its simplicity and reproducibility.

Management of the Nipple-Areola Complex in Selected Patients Undergoing Primary Breast Reconstruction: A Comparison of Immediate Replantation and Delayed Reconstruction

BACKGROUND

Management of the nipple-areola complex is an important issue in primary breast reconstruction. When nipple-sparing mastectomy is not suitable, alternatives are immediate nipple-areola complex replantation and delayed reconstruction. The aim of this study was to examine whether patients benefit more from nipple-areola complex preservation by immediate replantation or delayed nipple-areola complex reconstruction.

METHODS

Postoperative results and patient satisfaction after 54 primary breast reconstructions with immediate nipple-areola complex replantation or delayed nipple-areola complex reconstruction were retrospectively evaluated.

RESULTS

The nipple-areola complex was replanted immediately in 37 cases and reconstructed later with nipple sharing and full-thickness skin grafting in 17 cases. Compared with immediate replantation, delayed reconstruction resulted in significantly better postoperative nipple projection (P = 0.01*, Mann-Whitney U test), greater similarity of color and projection with the contralateral side and greater patient satisfaction (Breast-Q). Complete loss of projection occurred in 4 of the 37 replanted nipple-areola complexes. No complete nipple-areola complex necrosis or tumor recurrence was observed in any patient.

CONCLUSIONS

Immediate nipple-areola complex replantation is a safe and reliable procedure for selected patients with contraindications for nipple-sparing mastectomy who have a strong desire to maintain their own nipple-areola complexes, or in bilateral cases. However, drawbacks of this procedure include loss of projection and depigmentation. Delayed reconstruction with nipple sharing and full-thickness skin grafting is a good alternative, especially in unilateral cases; it leads to better postoperative results and greater patient satisfaction, but it involves a nipple-areola complex-free period.

[Nipple projection augmentation in breast reconstruction by artificial derm injection]

INTRODUCTION

The reconstruction of the Nipple-Areola Complex (NAC) is the last step and a key part in breast reconstruction. The technique to be used should be chosen as to avoid any complications on previous reconstruction steps. The use of local flaps for NAC reconstruction could be associated with implant exposure especially in the presence of a history of radiation therapy. The pure dermal flap could be indicated for the nipple reconstruction after breast reconstruction by implant after radiotherapy. The limit stay in the nipple hypoprojection. We suggest to assess the increase of the nipple projection, reconstructed by pure dermal flap, by injection of Integra^® Flowable Wound Matrix (Integra LifeSciences^®, Plainsboro, New jersey).

PATIENTS AND METHOD

Nipple projection has been measured among patients enclosed from february to March 2016 reconstructed by pure dermal flap: before, after and also at a 6months term from the injection of Integra^® Flowable Wound Matrix. Patient satisfaction and complications have been measured retrospectively.

RESULTS

Ten patients with an average of 55years have been enclosed, with an average limit of time of 19months (7 to 33months) between the breast nipple reconstruction by dermal flap and the injection. A volume of 1 to 1.6cc has been injected. A significative increase projection of 2mm at a 6months term has been measured (1.5 to 2.5mm, P<0.01), without complication and a satisfaction rate of 4.5/5.

CONCLUSION

The injection of an artificial derm-like Integra^® Flowable Wound Matrix seems to be efficient to increase the nipple projection reconstructed by pure dermal flap after a breast reconstruction and moreover, without complications.

Modified S-Flap for Nipple Reconstruction

BACKGROUND

Nipple reconstruction is an important last step in the process of autologous or implant-based breast reconstruction. A multitude of techniques have been described, among others the S-flap. To prevent nipple retraction after surgery, we modified the originally described method by Cronin.

METHODS

By adding an S-shaped incision line, the flap can be transposed with less tension and sutured on top of the new nipple along a curved line. Furthermore, two small triangular flaps were inserted at the base for reinforcement and reduced linear contraction. Assessment was completed by measuring nipple diameter and projection with a caliper.

RESULTS

A total of 16 patients underwent the technique, of whom 11 could be followed after 3 and 6 months. Overall patient satisfaction with the aesthetic result was high, and we observed no infection or necrosis. Nipples were stable in size and shape at 6 months. Although reduction of 68% in projection and 31% in diameter was observed, the nipples remained pleasantly similar to the contralateral non-operated side.

CONCLUSIONS

The modified S-flap is a simple and reliable technique for moderate-sized nipple reconstruction. By providing more tissue at the base, size and projection remain stable and durable. Moreover, by a modified linear incision line at the base, tension and subsequent scar contraction is minimal.

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 .

A systematic review of risks and benefits with nipple-areola-reconstruction

BACKGROUND

Most women who have their breast reconstructed are offered NAC reconstruction. Nonetheless, it is unclear what scientific evidence there is for the procedure. The aims of the present systematic review were to evaluate the quality of evidence for benefits and risks with NAC reconstruction, and to examine the evidence for different techniques.

METHODS

Relevant databases were searched. Inclusion criteria were controlled studies comprising ≥20 patients and a case series of ≥50 patients. Included articles had to meet criteria defined in a PICO (Patient, Intervention, Comparison, and Outcome). Data extraction and collection were performed according to the QUADAS tool. The level of evidence of the selected articles was assessed according to the Oxford Centre for Evidence-Based Medicine 2009 guidelines, and total evidence for the different research questions was graded according to the GRADE-system.

RESULTS

A total of 362 abstracts were retrieved following the search. Of these 325 did not meet the inclusion criteria and were excluded, leaving 37 studies to be included in the review. Among these, 36 were case series and one a small randomised non-blinded study Conclusions: The existing quality of evidence for risks and benefits of the operation is very low. It is unclear what the complication frequencies are after the reconstruction, and what effect on quality-of-life the operation has. Prospective studies of high quality are needed to evaluate the health effects and risks with NAC reconstruction.

The optimal reconstruction size of nipple-areola complex following breast implant in breast cancer patients

Background

Changes in the areola size after reconstruction of the nipple-areola complex (NAC) following mastectomy and breast reconstruction with a silicon implant in primary breast cancer patients have not been well examined. This study aimed to investigate time-dependent changes in the size of the donor and graft NACs and to assess clinical factors influencing these changes.

Methods

Fifty-eight consecutive patients who underwent nipple-areola reconstruction were retrospectively evaluated. Nipple-areola diameter was measured immediately after the NAC reconstruction and at each follow-up visit for at least 36 months.

Results

The donor NAC constituted 81 % of the graft NAC at the time of operation. The size of the donor NAC gradually increased by up to 36.8 % after the operation. The size of the graft NAC showed a decrease by 4.5 % at 7 months, followed by recovery to the initial value. The ratio of the donor site size to the graft site size was increased at month 1 and then showed a gradual decrease to 1.08 at 36 months. A history of mastopexy or reduction for the donor site was independent factors associated with changes in the NAC size.

Conclusions

To achieve symmetry, the diameter of the donor NAC immediately after the reconstruction should be at least 20 % smaller than that of the graft NAC, especially for patients without a history of additional operations.

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

BACKGROUND

Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction.

METHODS

MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars.

CONCLUSIONS

The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap

INTRODUCTION

After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate.

PATIENTS AND METHODS

All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications.

RESULTS

Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27-78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5 mm) after 6 months, but remained stable.

CONCLUSION

Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.

Nipple reconstruction using a star flap enhanced by scar tissue: the Regina Elena Cancer Institute experience

BACKGROUND

We propose a new, simple, and reliable method of nipple reconstruction using a star flap and a free graft of a linear fragment of scar tissue. The harvested fragment is deepithelialized and fixed under the flap to give the reconstruction consistency and make it steady.

METHODS

The study included 218 nipple reconstructions performed between 2002 and 2008. In an attempt to estimate their satisfaction, patients were then asked to complete a 1-year postoperative questionnaire. Patients were directed to use a numerical scale of 1-10, with 1 as the worst outcome and 10 as the best possible outcome.

RESULTS

The average projection of the nipple in the immediate postoperative period was 7.08 ± 0.5 mm (mean ± standard deviation). After 1 year, the average projection of the reconstructed nipple was 6.08 ± 0.5 mm. The average diameter of the reconstructed nipple in the immediate postoperative period was 14.9 ± 3 mm. After 1 year, the average diameter of the reconstructed nipple was 14.2 ± 4 mm. The average patient satisfaction with nipple projection was 7.28, sensation of the nipple, 4.11; color of the nipple, 6.36; position of the reconstructed nipple, 7.34; and symmetry compared with the opposite nipple-areola complex, 7.97. Overall patient satisfaction was 6.61.

CONCLUSION

We maintain that the technique presented here is safe, easy to perform, and reproducible and improves the long-term projection of the reconstructed nipple.

[The inferior gluteal musculocutaneous flap: Short and long-term results for 69 patients]

The inferior gluteal musculocutaneous flap described by Shaw then Le-Quang offers the possibility of harvesting a large amount of tissue with a well-concealed scar in the inferior fold. Since 1996, we used this flap for breast reconstruction without implant. The purpose of this study was to assess short and for long-term results in our patients. Between 1996 and 2005, 64 patients underwent 69 musculocutaneous flaps by two seniors surgeons, for secondary unilateral reconstruction (57 cases, 51 total mastectomy, three partial mastectomy, three constitutional breast asymmetry), five bilateral reconstruction or one thoracic skin ulceration after radiotherapy. The average flap weight and size was respectively 360g and 18 × 7cm. For short results, the assessment was based on flap success and surgical morbidity. For long-term results, the assessment was based on breast result (shape, volume, symmetry, skin and scar) and donor-site morbidity (scar, contour deformity, muscle function and sensation). Patients and surgeons global satisfaction were compared. Minimal follow-up was three years for 60 patients. Two patients died with metastasis. Sixty-three flaps succeeded. We had five flap necrosis, one after general complication (pulmonary embolism), four after venous thrombosis during the first period of our experience. Forty patients underwent a second procedure on the flap or on the other breast (25 cases). For the patients, the global result was excellent in 20 cases, good in 32 cases, fair in nine cases. For surgeons the global result was excellent in 13 cases, good in 32 cases, fair in 13 cases and poor in three cases. Concerning the donor-site, only one patient had an asymmetry of the buttock. Mostly, the scar of the donor site was good. Five cases needed a new surgery for poor scar. Five patients had functional complaints (for bicycle and squatting). Twenty-three patients noticed the hypoesthesia in the territory of the posterior femoral cutaneous nerve. For breast reconstruction, the gluteal region is an acceptable donor site with low morbidity and stable results. This technique needed a relative long learning curve, especially for the venous pedicle. We recommend to use a large vein dissected from the arm and axillary vessels. We also reduce the harvesting volume of the muscle to preserve the function. The reconstructive breast had a good shape, sufficient volume and acceptable symmetry.

[Nipple-areola complex reconstruction with full-thickness skin graft and subcutaneous pedicled island flap]

We are reporting on an easy, reliable and reproducible nipple-areola complex reconstruction. The main feature is to perform a full-thickness skin graft to rebuild the areola and a subcutaneous pedicled island flap for the reconstruction of the nipple in the middle of the graft. Each step is described. This technique remains easily practical and allows to keep an appropriate nipple projection. Moreover, it fits to all kind of breast reconstruction.