Twin flap technique for nipple reconstruction

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.

Alternative technique for nipple-areola complex reconstruction with poor skin condition

BACKGROUND

Reconstruction of the nipple-areola complex (NAC) is generally the final step in breast reconstruction. NAC reconstructions are frequently complicated by scars, which are a common complication of radical surgery. Sometimes, radiotherapy further complicates these cases.

METHODS

Under these conditions, we present an alternative technique with a better chance of ensuring the vitality of the reconstructed NAC. We evaluated in a 35-patient group (G1) the average healing time, the subjective perception (aesthetics satisfaction), projection and diameter of the NAC as measures of the aesthetic and safety of the results compared with those of a control group 2 who underwent traditional techniques reconstruction.

RESULTS

We present the following results: an average post-op projection of 5 ± 2 mm in group 1 and 8 ± 2 mm in group 2; good stability over a 12-month period: lower reduction of the NAC projection (cumulative values within 2 mm) has been 80% in group 1 and 68.57% in the control group G2. A faster full recovery has been observed without post-operative complications in group 1 (11 ± 2 days) versus group 2 (14 ± 2 days) with minor complications. Other parameters were good in measures and comparable in both groups.

CONCLUSION

According to our data, this technique appears to ensure a good aesthetic result with acceptable stability over time. Moreover, healing process appears to be faster and less complicated in the experimental group.

Aesthetic quality of the nipple-areola complex in breast reconstruction with a new local graft technique

BACKGROUND

Reconstruction of the nipple-areola complex (NAC) is the last stage of breast reconstruction and represents the search for symmetry in regard to the contralateral breast. The objective of this study was to present an areola reconstruction technique with local skin graft to improve the texture and aspect of the reconstructed areola, searching for a natural look.

METHODS

This technique was performed on 122 patients who in the period from January 2000 to December 2005 were submitted to nipple and areola reconstruction. Once the position of the new nipple was determined, markings were made for the reconstruction of the areola. Then the external limit of the new areola was incised and the skin was centripetally deepidermized up to 85% of its diameter. After this procedure the detached skin was repositioned in its bed as a graft and sutured with 4.0 mononylon thread. Incisions with an 11-blade scalpel were then made in V and C forms associated with the detachment of this skin of the receptor area along the local graft so that at the end of the healing process they would determine alterations in the areolar texture mimicking the texture of a normal areola. All patients underwent tattooing 3 months after reconstruction of the NAC taking into account the different shades of the contralateral areola and nipple colors.

RESULTS

The use of a local skin graft associated with C and V incisions allowed alteration in the texture of the reconstructed areola. The use of different ink shades for tattooing helped to give a tridimensional aspect to this areola. These factors determined a good aesthetic result in these patients.

CONCLUSION

This areola reconstruction using a local skin graft allows change in the areola texture and a tridimensional aspect similar to that of a normal areola without the inconvenience of grafting from a distance.

Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions

Numerous techniques have been used in an attempt to achieve long-term nipple projection following nipple-areolar reconstruction (NAR). A common setback, however, is the diminution of projection over time; this phenomenon is particularly evident following implant based breast reconstruction. The purpose of this report was thus to evaluate surgical outcomes and long-term nipple projection with the use of "modified skate flap" technique in exclusively implant based postmastectomy reconstructions. A retrospective review was performed for the period between 1993 and 2007. All consecutive patients with 2-staged tissue expander/implant reconstructions followed by NAR using the modified skate flap technique performed by the senior author (P.C.) were identified in a prospectively maintained breast reconstruction database. Only patients with a minimum of 1-year follow-up were included in the study. Patients with a history of irradiation to the breast were excluded from nipple projection assessment. Clinical outcome measurements included long-term nipple projection as well as incidence of complications from the NAR procedure using the modified skate flap technique. Over the 15-year study period, 475 patients underwent 2-staged tissue expander/implant reconstruction followed by NAR using the modified skate flap technique. Of these, there was a total of 292 patients with the minimum requirement of 1-year follow-up post NAR (61% follow-up rate). The total number of reconstructed nipple areolar complexes evaluated in this series was 422 (130 bilateral and 162 unilateral NAR). Forty patients (28 unilateral and 12 bilateral NAR) who received radiation to their breasts were excluded from nipple projection assessment. At a median follow-up of 44 months (range: 12-84 months), mean nipple projection was 2.5 mm (range: 1-4 mm). Minor complications occurred in 7.2% of the patients (n = 292). Skin graft donor site dehiscence was the most common complication (3.1%) followed by partial skin graft nontake of the areola (2.1%). This report documents the largest series of NAR using a single technique in the setting of postmastectomy reconstructions. This technique can be safely performed over breast implants with acceptably low rates of complications and predictable results. Long-term nipple projection over implant reconstructions using this technique is modest and this must be forewarned to patients completing the final stage of their implant reconstruction.

Reconstruction of the nipple-areola complex: an update

Along with continuing progress in reconstructive surgery of the breast numerous techniques of nipple-areola reconstruction have been developed. With time and experience some methods have been discredited to historical significance only while others have evolved to widely accepted concepts used by surgeons all over the world, which in turn contributed new ideas and modifications. In addition to those favourite techniques others are reserved as second-line alternatives in specific situations. The principle criterion for a pleasing nipple-areola complex is symmetry regarding several parameters: colour, texture, size, and projection. The purpose of this manuscript is to review and discuss the concepts and techniques of nipple-areola reconstruction that have evolved over the past decades. Furthermore, those principles and techniques are pointed out that fulfil best the criteria of an ideal nipple-areola complex with emphasis on different techniques of breast reconstruction and individual conditions of the patient.

Improving Long-Term Projection in Nipple Reconstruction Using Human Acellular Dermal Matrix

Reconstructed nipples rapidly lose projection. We describe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction.

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

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