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Cazzato V, Stocco C, Scian A, Bonat Guarini L, Sidoti GB, Renzi N, Ramella V, Papa G. Nipple Reconstruction Using the "Arrow Flap" Technique: Outcomes and Patients Satisfaction. Clin Breast Cancer 2024; 24:e226-e231. [PMID: 38503614 DOI: 10.1016/j.clbc.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Skin-sparing mastectomy (SSM) entails complete removal of the breast tissue and the nipple and areola complex (NAC) with preservation of as much of the overlying skin as possible. The preservation of the natural skin envelope during SSM improves the aesthetic outcome of immediate breast reconstruction, but the lack of NAC determines that the reconstructed breast remains anatomically incomplete with not always satisfactory final results. For this purpose, the aim of the present study was to investigate and evaluate the impact of nipple reconstruction after skin sparing and skin reducing mastectomy on the patients' perception and intimate life. MATERIALS AND METHOD This was a comparative single-center prospective study that involved 42 patients underwent NAC reconstruction after SSM. A pre- and postoperative quality-of-life and psychological questionnaires Breast-Q questionnaire (Breast Conserving therapy module) were given to all the patients before the surgery and 6 months after. The statistical analysis with chi-square test was performed. RESULTS After 6 months a prevalence of patients reported to be very satisfied in regard to shape, appearance, naturalness, projection, position and symmetry. The study shows an overall improvement in all the psychological items analyzed with statistically significant difference regarding: "patient's satisfaction," "self-confidence," "appearance of the breast." CONCLUSION The authors believe that the NAC reconstruction has useful functional and aesthetic results particularly appreciated by patients who feel demoralized after breast demolition surgery.
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Affiliation(s)
- Vito Cazzato
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy; Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy.
| | - Chiara Stocco
- Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
| | - Alessandro Scian
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Luigi Bonat Guarini
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Nadia Renzi
- Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
| | - Vittorio Ramella
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy; Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
| | - Giovanni Papa
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy; Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
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Matsumine H, Niimi Y, Jibiki N, Sakurai H. Minimal Scar Autologous Breast Reconstruction with Skin-sparing Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5176. [PMID: 37554143 PMCID: PMC10406034 DOI: 10.1097/gox.0000000000005176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/22/2023] [Indexed: 08/10/2023]
Abstract
UNLABELLED A skin paddle severely impairs the appearance of the reconstructed breast. We have established a new technique called "minimal scar autologous breast reconstruction" involving delayed nipple reconstruction using a local flap designed on the skin paddle and simultaneous resection of the residual skin paddle. METHODS We analyzed 20 patients with unilateral breast cancer who underwent skin-sparing mastectomy followed by immediate breast reconstruction using a free flap (deep inferior epigastric perforator flap in 13 patients and profunda artery perforator flap in seven). Approximately 1 year after primary reconstruction, nipple reconstruction using an arrow flap designed on the skin paddle and resection of the residual skin paddle were performed. Several months later, medical areola tattooing was performed. Bilateral breast symmetry scores, obtained from the distances between anatomic landmarks, were compared before and after breast reconstruction. RESULTS Postoperative complications such as necrosis of the reconstructed nipple were not observed after two-stage reconstruction, and all procedures including total resection of the skin paddle, nipple reconstruction, and medical tattooing were performed successfully in all cases. Aesthetic outcomes were excellent: comparison of symmetry scores showed no significant differences in any parameters between before surgery and after reconstruction of the nipple-areola complex. CONCLUSIONS We have established step-by-step strategies for mastectomy, autologous breast reconstruction, and then nipple reconstruction, keeping in mind that the skin paddle would later be totally resected in nipple reconstruction, and thereby achieved breast reconstruction with markedly reduced postoperative scarring compared with conventional autologous breast reconstruction.
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Affiliation(s)
- Hajime Matsumine
- From the Department of Plastic and Reconstructive Surgery, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yosuke Niimi
- From the Department of Plastic and Reconstructive Surgery, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Norie Jibiki
- Department of Surgery, Yachiyo Medical Center, Tokyo Women’s Medical University, Chiba, Japan
| | - Hiroyuki Sakurai
- From the Department of Plastic and Reconstructive Surgery, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Heo JW, Park SO, Jin US. A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft. Aesthetic Plast Surg 2018; 42:1478-1484. [PMID: 29948101 DOI: 10.1007/s00266-018-1162-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/19/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Nipple-areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola. PATIENTS AND METHODS From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple-areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12 months postoperatively. At the final visit, the patient's subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale. RESULTS Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12 months postoperatively, respectively. Patients' overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a 'good' satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be 'poor' and 'disappointing' each accounted for 1 and 3 patients. CONCLUSION The combination of nipple-areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only. 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 .
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Affiliation(s)
- Jae-Woo Heo
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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Cuomo R, Sisti A, Grimaldi L, D'Aniello C. Modified Arrow Flap Technique for Nipple Reconstruction. Breast J 2016; 22:710-711. [DOI: 10.1111/tbj.12659] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Roberto Cuomo
- General and Specialist Surgery Department; Plastic Surgery Division; University of Siena; Siena Italy
| | - Andrea Sisti
- General and Specialist Surgery Department; Plastic Surgery Division; University of Siena; Siena Italy
| | - Luca Grimaldi
- General and Specialist Surgery Department; Plastic Surgery Division; University of Siena; Siena Italy
| | - Carlo D'Aniello
- General and Specialist Surgery Department; Plastic Surgery Division; University of Siena; Siena Italy
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Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D'Aniello C, Nisi G. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol 2016; 42:441-65. [PMID: 26868167 DOI: 10.1016/j.ejso.2016.01.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/07/2015] [Accepted: 01/06/2016] [Indexed: 11/30/2022] Open
Abstract
Many techniques for nipple-areola complex (NAC) reconstruction are described. Clarity is required on the currently available options. Since a complete list of all the techniques described until now is not available, a possibly comprehensive literature overview was carried out from 75 papers (years 1946-2015). The local flap was the most frequently described technique for the nipple reconstruction with no significant difference in complications' rate among the various types of techniques. Complications in nipple reconstruction were 46.9% after graft, 7.9% after local flap, and 5.3% in case of flaps with autologous graft/alloplastic/allograft augmentation, while complications in areola reconstruction were 10.1% after graft, and 1.6% after areola tattoo. Flaps appear to be more reliable than grafts in nipple reconstruction, while tattoo is thought to be safer than graft in areola reconstruction. The loss of projection, although considerable (45%-75%), had not significant impact on patients' satisfaction. Due to contraction, overcorrection of 25-50% of the desired result is advisory when adopting local flaps, in order to prevent loss of projection. The use of flaps with autologous graft/alloplastic/allograft augmentation (cartilage, fat, calcium hydroxylapatite, acellular dermal matrix, polymethylmethacrylate, biologic collagen) showed a minor loss of nipple projection but may expose to a relative increased number of postoperative flap necrosis.
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Affiliation(s)
- A Sisti
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy.
| | - L Grimaldi
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - J Tassinari
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - R Cuomo
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - L Fortezza
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - M A Bocchiotti
- Department of Plastic Surgery, University of Turin, San Giovanni Battista Hospital, Turin, Italy
| | - F Roviello
- Oncologic Surgery, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - C D'Aniello
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - G Nisi
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
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Rem K, Al Hindi A, Sorin T, Ozil C, Revol M, Mazouz Dorval S. Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap. J Plast Reconstr Aesthet Surg 2016; 69:617-22. [PMID: 26810406 DOI: 10.1016/j.bjps.2015.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- K Rem
- Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France.
| | - A Al Hindi
- Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - T Sorin
- Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - C Ozil
- Paris Diderot University, Sorbonne Paris Cité, 75010 Paris, France; Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - M Revol
- Paris Diderot University, Sorbonne Paris Cité, 75010 Paris, France; Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - S Mazouz Dorval
- Paris Diderot University, Sorbonne Paris Cité, 75010 Paris, France; Plastic, Reconstructive and Aesthetic Surgery Department, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
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Abstract
BACKGROUND Acellular dermal matrix (ADM) has been well described for use in breast reconstruction. The purpose of this study was to describe a novel use for ADM in areolar reconstruction. METHODS A total of 19 patients and 24 nipple-areolar complexes of breast cancer or BRCA-positive patients status postmastectomy were treated. After nipple flap reconstruction was completed, the areolar complex was marked at 40-45 mm and de-epithelialized. ADM was reconstituted and cut to size. This was sewn into place as an areolar onlay graft using 5-0 chromic running sutures and a vaseline gauze bolster. RESULTS All 24 areola re-epithelialized in an average of 8.1 weeks. Graft take was 100% in 23 areolas, while 1 areola had only 75% graft take. Two patients underwent subsequent nipple projection procedures. Sixteen areolas were tattooed for color, with plans to tattoo the others. All patients had satisfactory transition from native skin to nipple-areolar complex. All surveyed patients stated they would undergo the procedure again. Average follow-up was 15.7 months. CONCLUSION The ADM onlay graft for areolar reconstruction is a feasible addition to the plastic surgeon's armamentarium. The primary benefits of this technique are grafting the donor bed of nipple reconstruction, avoidance of a skin graft donor site wound, and prevention of flattening of the breast dome, as seen with primary closure after nipple flap reconstruction. The cost of ADM must be taken into account ($31 per square centimeter), which could be offset by banking excess ADM at the time of breast reconstruction.
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Objective and subjective evaluation of donor-site morbidity after nipple sharing for nipple areola reconstruction. J Plast Reconstr Aesthet Surg 2014; 68:168-74. [PMID: 25465146 DOI: 10.1016/j.bjps.2014.10.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/25/2014] [Accepted: 10/19/2014] [Indexed: 11/22/2022]
Abstract
Nipple reconstruction is of importance in achieving the best possible aesthetic outcome after breast reconstruction. Nipple sharing is a common technique; this study focused on the potential morbidity at the donor nipple. Between 2008 and 2012, 26 patients underwent nipple sharing at our institution. The donor nipple was examined before and after the procedure (mean follow-up of 21 months). Sensitivity, projection, diameter, and patient satisfaction were evaluated. The sensitivity in the donor nipple decreased, albeit insignificantly, from 1.2 g/mm2 (0.8-1.6) to 1.8 g/mm2 (0.8-4.8) (p=0.054, n=26). The projection due to graft removal decreased from 8.0 mm (6.8-10.0) to 4.5 mm (4.0-5.0) (p=0.001). Of the patients, 88% were "very satisfied" or "somewhat satisfied" with the sensitivity and 89% with the symmetry between the donor and reconstructed nipple. At least 60% of the patients were "very satisfied" with all aesthetic outcome parameters (projection, appearance, naturalness, color, and shape). All patients would agree to undergo this procedure again, if necessary. Nipple sharing was associated with minimal morbidity at the donor nipple. The postoperative projection was adequate. Regardless of whether simultaneous mastopexy was performed, the loss of sensitivity was minimal and presumably imperceptible to the patient. By using no sutures after graft removal and letting the donor nipple heal spontaneously, scarring was minimized and the natural appearance and good sensitivity of the donor nipple were preserved.
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Carvalho R, Vaz M, Saraiva L, Coelho R, Pinheiro S, Costa HZ, Freire dos Santos MJ. Nipple projection evolution using the modified arrow flap: prospective study on 25 consecutive nipple reconstructions. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0987-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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