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Dong X, Shih S, Premaratne ID, Sariibrahimoglu K, Ginter P, Scott J, Limem S, Spector JA. Long-Term Maintenance of Projection of Nipples Reconstructed Using Three-Dimensionally Printed Poly-4-Hydroxybutyrate Bioabsorbable Scaffolds. Plast Reconstr Surg 2023; 152:646e-654e. [PMID: 36877752 DOI: 10.1097/prs.0000000000010384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
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.
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Affiliation(s)
- Xue Dong
- From the Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College
| | - Sabrina Shih
- From the Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College
| | - Ishani D Premaratne
- From the Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College
| | | | - Paula Ginter
- Pathology and Laboratory Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Jeffrey Scott
- Tepha, Inc
- Department of Medical Science, Brown University
| | | | - Jason A Spector
- From the Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University
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Oganesyan RV, Lellouch AG, Acun A, Lupon E, Taveau CB, Burlage LC, Lantieri LA, Randolph MA, Cetrulo CL, Uygun BE. Acellular Nipple Scaffold Development, Characterization, and Preliminary Biocompatibility Assessment in a Swine Model. Plast Reconstr Surg 2023; 151:618e-629e. [PMID: 36472499 PMCID: PMC10859846 DOI: 10.1097/prs.0000000000009998] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The standard in nipple reconstruction remains the autologous skin flap. Unfortunately, the results are not satisfying, with up to 75% loss of nipple projection over time. Existing studies investigated the use of primates as a source of implants. The authors hypothesized that the porcine nipple can serve as a perfect shape-supporting implant because of functional similarities to the human nipple. A decellularization protocol was developed to obtain an acellular nipple scaffold (ANS) for nipple reconstruction. METHODS Tissue samples were collected from eight disease-free female Yorkshire pigs (60 to 70 kg) and then decellularized. The decellularization efficiency and extracellular matrix characterization was performed histologically and quantitatively (DNA, total collagen, elastin, and glycosaminoglycan content). In vitro and in vivo biocompatibility was determined by human dermal fibroblast culture and subcutaneous implantation of six ANSs in a single Yorkshire pig (60 to 70 kg), respectively. Inflammation and adverse events were monitored daily based on local clinical signs. RESULTS The authors showed that all cellular structures and 96% of DNA [321.7 ± 57.6 ng DNA/mg wet tissue versus 11.7 ± 10.9 ng DNA/mg wet tissue, in native and ANS, respectively ( P < 0.001)] can be successfully removed. However, this was associated with a decrease in collagen [89.0 ± 11.4 and 58.8 ± 9.6 μg collagen/mg ( P < 0.001)] and elastin [14.2 ± 1.6 and 7.9 ± 2.4 μg elastin/mg ( P < 0.05)] and an increase in glycosaminoglycan content [5.0 ± 0.7 and 6.0 ± 0.8 ng/mg ( P < 0.05)]. ANS can support continuous cell growth in vitro and during preliminary biocompatibility tests in vivo. CONCLUSION This is a preliminary report of a novel promising ANS for nipple reconstruction, but more research is needed to validate results. CLINICAL RELEVANCE STATEMENT Breast cancer is very common among women. Treatment involves mastectomy, but its consequences affect patient mental well-being, and can lead to depression. Nipple-areola complex reconstruction is critical, and existing methods lead to unsatisfactory outcomes.
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Affiliation(s)
- Ruben V. Oganesyan
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
| | - Alexandre G. Lellouch
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris
- Shriners Children’s Boston
| | - Aylin Acun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
- Department of Biomedical Engineering, Widener University
| | - Elise Lupon
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
- University Institute of Locomotor and Sport (IULS), Pasteur Hospital
- Shriners Children’s Boston
| | - Corentin B. Taveau
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris
| | - Laura C. Burlage
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
- Department of Plastic Surgery, Amsterdam University Medical Center
| | - Laurent A. Lantieri
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris
| | - Mark A. Randolph
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
| | - Curtis L. Cetrulo
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
| | - Basak E. Uygun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
- Shriners Children’s Boston
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Dong X, Premaratne ID, Sariibrahimoglu K, Limem S, Scott J, Gadjiko M, Berri N, Ginter P, Spector JA. 3D-printed poly-4-hydroxybutyrate bioabsorbable scaffolds for nipple reconstruction. Acta Biomater 2022; 143:333-343. [PMID: 35240316 DOI: 10.1016/j.actbio.2022.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 02/03/2023]
Abstract
Nearly all autologous tissue techniques and engineered tissue substitutes utilized for nipple reconstruction are hindered by scar contracture and loss of projection of the reconstructed nipple. The use of unprocessed costal cartilage (CC) as an internal support for the reconstructed nipple has not been widely adopted because of the excessively firm resultant construct. Herein we use a 3D-printed Poly-4-Hydroxybutyrate (P4HB) bioabsorbable scaffold filled with mechanically processed patient-derived CC to foster ingrowth of tissue in vivo to protect the regenerated tissue from contractile forces as it matures. After 6 months in vivo, newly formed spongy fibrovascular cartilaginous tissue was noted in processed CC filled 3D-printed scaffolds, which maintained significantly greater projection than reconstructions without scaffolds. Interestingly, 3D-printed P4HB scaffolds designed with an internal 3D lattice of P4HB filaments (without CC) displayed the fastest material absorption and vascularized adipose-fibrous tissue as demonstrated by SEM and histological analysis, respectively. Using 3D-printed P4HB scaffolds filled with either processed CC, a 3D P4HB lattice or no fills, we have engineered neo-nipples that maintain projection over time, while approximating the biomechanical properties of the native human nipple. We believe that this innovative 3D-printed P4HB nipple reconstruction scaffold will be readily translatable to the clinic. STATEMENT OF SIGNIFICANCE: Nearly all autologous tissue techniques and engineered tissue substitutes utilized for nipple reconstruction are hindered by scar contracture and substantial loss of projection of the reconstructed nipple, leading to significant patient dissatisfaction. Using 3D-printed P4HB scaffolds filled with either processed costal cartilage or 3D P4HB lattices, we have engineered neo-nipples that resist the forces induced by scar contracture, resulting in maintenance of neo-nipple projection over time and biomechanically approximating human nipples after 6 months in vivo implantation. This novel 3D-printed bioabsorbable P4HB scaffold will be readily translatable to the clinic to reconstruct nipples with patient-specific dimensions and long-lasting projection.
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Affiliation(s)
- Xue Dong
- Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College, 525 East 68th Street, Payson 709-A, New York, NY 10065, United States
| | - Ishani D Premaratne
- Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College, 525 East 68th Street, Payson 709-A, New York, NY 10065, United States
| | | | | | - Jeffrey Scott
- Tepha, Inc., Lexington, MA, United States; Department of Medical Science, Brown University, Providence, RI, United States
| | - Mariam Gadjiko
- Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College, 525 East 68th Street, Payson 709-A, New York, NY 10065, United States
| | - Nabih Berri
- Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College, 525 East 68th Street, Payson 709-A, New York, NY 10065, United States
| | - Paula Ginter
- Pathology and Laboratory Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, United States
| | - Jason A Spector
- Laboratory of Bioregenerative Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Weill Cornell Medical College, 525 East 68th Street, Payson 709-A, New York, NY 10065, United States; Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, United States.
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Van Belleghem S, Mahadik B, Snodderly K, Mote Z, Jiang B, Yu JR, McLoughlin S, He X, Nam AJ, Fisher JP. Dual Extrusion Patterning Drives Tissue Development Aesthetics and Shape Retention in 3D Printed Nipple-Areola Constructs. Adv Healthc Mater 2021; 10:e2101249. [PMID: 34617414 PMCID: PMC8665136 DOI: 10.1002/adhm.202101249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/16/2021] [Indexed: 12/11/2022]
Abstract
Breast cancer and its most radical treatment, the mastectomy, significantly impose both physical transformations and emotional pain in thousands of women across the globe. Restoring the natural appearance of a nipple-areola complex directly on the reconstructed breast represents an important psychological healing experience for these women and remains an unresolved clinical challenge, as current restorative techniques render a flattened disfigured skin tab within a single year. To provide a long-term solution for nipple reconstruction, this work presents 3D printed hybrid scaffolds composed of complementary biodegradable gelatin methacrylate and synthetic non-degradable poly(ethylene) glycol hydrogels to foster the regeneration of a viable nipple-areola complex. In vitro results showcased the robust structural capacity and long-term shape retention of the nipple projection amidst internal fibroblastic contraction, while in vivo subcutaneous implantation of the 3D printed nipple-areola demonstrated minimal fibrotic encapsulation, neovascularization, and the formation of healthy granulation tissue. Envisioned as subdermal implants, these nipple-areola bioprinted regenerative grafts have the potential to transform the appearance of the newly reconstructed breast, reduce subsequent surgical intervention, and revolutionize breast reconstruction practices.
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Affiliation(s)
- Sarah Van Belleghem
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Bhushan Mahadik
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Kirstie Snodderly
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Zoe Mote
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Bin Jiang
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Justine R Yu
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Shannon McLoughlin
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Xiaoming He
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Arthur J Nam
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, 21201, USA
| | - John P Fisher
- Fischell Department of Bioengineering, Center for Engineering Complex Tissues, University of Maryland, College Park, 20742, USA
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Paolini G, Firmani G, Briganti F, Sorotos M, Santanelli di Pompeo F. Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm. Aesthetic Plast Surg 2021; 45:933-945. [PMID: 33216178 PMCID: PMC8144123 DOI: 10.1007/s00266-020-02047-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/05/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Nipple-areola complex reconstruction (NAR) most commonly represents the finishing touch to breast reconstruction (BR). Nipple presence is particularly relevant to the patient's psyche, beyond any shadow of doubt. Many reconstructive options have been described in time. Surgery is easy, but final result is often disappointing on the long run. METHODS The goal of this manuscript is to analyze and classify knowledge concerning NAR techniques and the factors that influence success, and then to elaborate a practical evidence-based algorithm. Out of the 3136 available articles as of August 8th, 2020, we selected 172 manuscripts that met inclusion criteria, which we subdivided into 5 main topics of discussion, being the various NAR techniques; patient factors (including patient selection, timing and ideal position); dressings; potential complications and finally, outcomes/patient satisfaction. RESULTS We found 92 articles describing NAR techniques, 41 addressing patient factors (out of which 17 discussed patient selection, 14 described ideal NAC location, 10 described appropriate timing), 10 comparing dressings, 7 studying NAR complications, and 22 addressing outcomes and patient satisfaction. We elaborated a comprehensive decision-making algorithm to help narrow down the choice among NAR techniques, and choose the correct strategy according to the various scenarios, and particularly the BR technique and skin envelope. CONCLUSIONS No single NAR technique provides definitive results, which is why we believe there is no "end-all be-all solution". NAR must be approached as a case-by-case situation. Furthermore, despite NAR being such a widely discussed topic in scientific literature, we still found a lack of clinical trials to allow for more thorough recommendations to be elaborated. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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)
- Guido Paolini
- Faculty of Medicine and Psychology, Plastic Surgery Department, Sapienza University of Rome-Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Guido Firmani
- Faculty of Medicine and Psychology, Plastic Surgery Department, Sapienza University of Rome-Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy.
| | - Francesca Briganti
- Faculty of Medicine and Psychology, Plastic Surgery Department, Sapienza University of Rome-Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Michail Sorotos
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Ageing, Università degli Studi di Salerno, Salerno, Italy
| | - Fabio Santanelli di Pompeo
- Chair of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
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Sisti A. Nipple-Areola Complex Reconstruction. ACTA ACUST UNITED AC 2020; 56:medicina56060296. [PMID: 32560062 PMCID: PMC7353867 DOI: 10.3390/medicina56060296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 12/04/2022]
Abstract
The reconstruction of the nipple–areola complex is the last step in the breast reconstruction process. Several techniques have been described over the years. The aim of this review is to provide clarity on the currently available reconstructive options.
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Affiliation(s)
- Andrea Sisti
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
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Khoo D, Ung O, Blomberger D, Hutmacher DW. Nipple Reconstruction: A Regenerative Medicine Approach Using 3D-Printed Tissue Scaffolds. TISSUE ENGINEERING PART B-REVIEWS 2019; 25:126-134. [PMID: 30379123 DOI: 10.1089/ten.teb.2018.0253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IMPACT STATEMENT This work provides a comprehensive overview and critique of nipple reconstruction techniques to date. It then explores different tissue engineering concepts and how these may improve clinical outcomes for patients undergoing nipple reconstruction. A novel technique is proposed, whereby a three-dimensional-printed tissue-engineered construct is used as an autologous graft to assist nipple reconstruction.
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Affiliation(s)
- Denver Khoo
- 1 Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Owen Ung
- 1 Faculty of Medicine, University of Queensland, Brisbane, Australia.,2 Centre for Breast Health, Unit 1 Surgery-Breast Endocrine Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Daniela Blomberger
- 3 Centre in Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Dietmar W Hutmacher
- 3 Centre in Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,4 ARC Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, Australia
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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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Tremp M, di Summa PG, Schaakxs D, Oranges CM, Wettstein R, Kalbermatten DF. Nipple Reconstruction After Autologous or Expander Breast Reconstruction: A Multimodal and 3-Dimensional Analysis. Aesthet Surg J 2017; 37:179-187. [PMID: 27986753 DOI: 10.1093/asj/sjw181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume. OBJECTIVES The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses. METHODS Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10). RESULTS A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5). CONCLUSIONS Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Mathias Tremp
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Pietro G di Summa
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Dominique Schaakxs
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Carlo M Oranges
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Reto Wettstein
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Daniel F Kalbermatten
- Dr Tremp is a Plastic Surgeon and Attending, Dr Oranges is a Plastic Surgeon and PhD candidate, Dr Wettstein is a Plastic Surgeon and Consultant, and Prof Kalbermatten is a Plastic Surgeon and Medical Director at the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Dr di Summa is a Plastic Surgeon and Attending, and Dr Schaakxs is a Resident, Division of Plastic, Reconstructive, and Aesthetic Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland.
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10
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A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction. Plast Reconstr Surg 2016; 137:14e-23e. [PMID: 26710046 DOI: 10.1097/prs.0000000000001861] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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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: 72] [Impact Index Per Article: 9.0] [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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Biologic collagen cylinder with skate flap technique for nipple reconstruction. PLASTIC SURGERY INTERNATIONAL 2014; 2014:194087. [PMID: 25114802 PMCID: PMC4120924 DOI: 10.1155/2014/194087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 06/20/2014] [Accepted: 06/28/2014] [Indexed: 11/17/2022]
Abstract
A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3-5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging.
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