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Sapino G, Tay SK, Maruccia M, Nanhekhan L, Watfa W, Mantovani GP, Guillier D, Tedeschi P, Bramhall R, Di Summa PG. Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review. J Clin Med 2023; 12:6135. [PMID: 37834779 PMCID: PMC10573810 DOI: 10.3390/jcm12196135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 10/15/2023] Open
Abstract
Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.
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Affiliation(s)
- Gianluca Sapino
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
| | - Sherilyn K. Tay
- Canniesburn Plastic Surgery Department, Glasgow Royal Infirmary, Glasgow G4 0SF, UK; (S.K.T.); (R.B.)
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, University Hospital of Bari, 70124 Bari, Italy; (M.M.)
| | - Lloyd Nanhekhan
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
| | - William Watfa
- Department of Plastic and Reconstructive Surgery, Saint George University Hospital, Beirut 1100, Lebanon;
| | - Gian Piero Mantovani
- Department of Plastic and Reconstructive Surgery, University Hospital of Modena, 41121 Modena, Italy;
| | - David Guillier
- Department of Plastic Reconstructive and Hand Surgery, Department of Oral and Maxillofacial Surgery—University Hospital, 21000 Dijon, France;
| | - Pasquale Tedeschi
- Department of Plastic and Reconstructive Surgery, University Hospital of Bari, 70124 Bari, Italy; (M.M.)
| | - Russell Bramhall
- Canniesburn Plastic Surgery Department, Glasgow Royal Infirmary, Glasgow G4 0SF, UK; (S.K.T.); (R.B.)
| | - Pietro Giovanni Di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland (L.N.)
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Wolf O, Liu J, Legarda C, Kronowitz SJ. The spare-parts technique: A safe and efficient single-stage nipple and areola reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:1871-1878. [PMID: 32601013 DOI: 10.1016/j.bjps.2020.05.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 03/15/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The authors hypothesized that optimization of nipple-areolar reconstruction using full-thickness skin graft and cartilage graft can be completed safely in a single-stage procedure. METHODS A retrospective analysis of abdominal-based flap breast reconstruction patients who underwent nipple-areolar reconstruction (NAR) using the modified double-opposing tab (mDOT)1 flap technique was conducted. Complication rates were compared between patients who underwent NAR in a traditional staged procedure versus a single stage. The single-stage group of patients had NAR performed at the time of revision surgery. Reconstruction was performed with full-thickness skin graft from the abdominal standing-cone deformity and costal cartilage that was removed at the time of breast reconstruction and banked subcutaneously until the revision surgery. RESULTS In this study, 1,233 nipple reconstructions were reviewed, of which 113 procedures using themDOT technique were analyzed. No significant differences in complication rates were found between the single-stage and the traditional staged NAR, including the risk of total loss of reconstruction or delayed skin graft take. However, the risk of delayed wound healing of the nipple reconstruction was higher in the single-stage group. CONCLUSIONS Our study shows that optimizing NAR results by adding cartilage to the nipple construct and enhancing the areolar component by full-thickness skin grafting can be achieved safely in a single stage at the time of flap revision. This represents potential for better long-term nipple projection and better areolar texture mimicry of NAR for breast reconstruction patients.
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Affiliation(s)
- Omer Wolf
- Department of Plastic Surgery, Yitzhak Shamir Medical Center, formerly known as Assaf Harofeh Medical Center, Zerifin, Israel.
| | - Jun Liu
- Department of Plastic Surgery, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Carolina Legarda
- Department of Plastic Surgery, Souraksy Medical Center, Tel Aviv, Israel
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One-stage nipple and breast reconstruction using a deep inferior epigastric perforator flap after a skin-sparing mastectomy. Arch Plast Surg 2020; 47:26-32. [PMID: 31964120 PMCID: PMC6976742 DOI: 10.5999/aps.2019.00598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/24/2019] [Indexed: 11/12/2022] Open
Abstract
Background Nipple reconstruction is usually performed as a delayed procedure in patients with breast cancer who undergo skin-sparing mastectomy and breast reconstruction surgery using a deep inferior epigastric perforator (DIEP) flap. The authors designed this study to evaluate the utility of breast reconstruction based on a DIEP flap and immediate nipple reconstruction. Methods A retrospective review was conducted of all patients who underwent breast reconstruction performed by a single plastic surgeon from October 2016 to June 2018. Through a questionnaire and chart review, we compared surgical results and complications in cases of single-stage nipple reconstruction after skin-sparing mastectomy (n=17) with patients who underwent delayed nipple reconstruction after skin-sparing mastectomy, modified radical mastectomy, or simple mastectomy (n=7). Results In a subjective analysis using clinical photos, the immediate nipple reconstruction group had higher scores than their counterparts in an evaluation of the nipple-areolar complex (NAC) (NAC placement, 3.34 vs. 3.04; nipple projection, 3.05 vs. 3.03; nipple size, 3.30 vs. 3.29). No significant differences between the groups were found in terms of complications. Conclusions Simultaneous nipple reconstruction is a reliable surgical method with economic advantages. No differences were found in terms of outcomes and complications in comparison to delayed reconstruction. Therefore, surgeons can consider simultaneous nipple reconstruction without particular concerns about asymmetry or necrosis.
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Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi breast reconstruction: A review of patient satisfaction. Arch Plast Surg 2018; 45:534-541. [PMID: 30466233 PMCID: PMC6258984 DOI: 10.5999/aps.2017.01725] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 10/02/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Nipple-areolar complex (NAC) reconstruction following curative mastectomy is traditionally performed as a second-stage procedure several months after initial breast reconstruction. The recent literature has documented the increasing popularity of immediate nipple reconstruction carried out simultaneously during autologous reconstruction. The aim of this study was to evaluate the surgical outcomes and patient satisfaction with immediate breast and nipple reconstruction performed in a single stage after skin-sparing mastectomy. METHODS All patients who underwent a skin-sparing mastectomy with immediate latissimus dorsi flap breast and NAC reconstruction as a single-stage procedure from 2007 to 2015 were included. Patient demographics, oncologic details, and surgical outcomes were recorded. The BREAST-Q questionnaire was administered to patients to assess the impact and effectiveness of this reconstructive strategy. RESULTS During the study period, 34 breast and NAC reconstructions in 29 patients were performed at Cork University Hospital. The majority of our patient cohort were non-smokers (93.1%) and did not receive adjuvant radiotherapy. Postoperative complications were infrequent, with no cases of partial necrosis or complete loss of the nipple. The response rate to the BREAST-Q was 62% (n=18). Patients reported high levels of satisfaction with the reconstructed breast (62±4), nipple reconstruction (61±4.8), overall outcome (74.3±5), and psychosocial well-being (77.7±3.2). CONCLUSIONS Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi reconstruction was demonstrated to be a safe and aesthetically reliable procedure in our cohort, yielding high levels of psychological and physical well-being. A single-stage procedure promotes psychosocial well-being involving issues that are intrinsically linked with breast cancer surgery.
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Yoon JS, Chang JW, Ahn HC, Chung MS. Modified C-H flap for simultaneous nipple reconstruction during autologous breast reconstruction: Surgical tips for safety and cosmesis. Medicine (Baltimore) 2018; 97:e12460. [PMID: 30235735 PMCID: PMC6160055 DOI: 10.1097/md.0000000000012460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Reconstruction of the nipple-areolar complex is the final stage of breast reconstruction. Nipple reconstruction is usually performed several months after breast reconstruction, because simultaneous reconstruction is thought to be risky. Here, we introduce our experiences of 1-stage procedures with immediate reconstruction of the nipple-areolar complex during autologous breast reconstruction. METHODS Between 2008 and 2015, 51 mastectomy patients underwent 1-stage breast and nipple reconstruction. All cases were reconstructed immediately with autologous tissue for the breast mound. The patients were divided into 2 groups according to the method of nipple-areolar complex reconstruction. In group A, 23 cases were reconstructed with a classical C-H flap, also known as the Hammond flap. In group B, 28 cases were reconstructed with a modified C-H flap, which is the evolved form of the classical Hammond flap. The nipple-areolar complex was evaluated preoperatively, immediately postoperatively, and 1 year postoperatively. Postoperative complications were also evaluated. RESULTS The mean projection of the reconstructed nipple decreased by approximately 50% in group A and 38% in group B during the postoperative 1 year. However, the reconstructed nipple width and areolar diameter did not show a significant change in either group. Group A showed 26% of complication rate and 17% of revision rate, whereas group B showed 11% of complication rate and 4% of revision rate. However, no major complications such as complete necrosis of the reconstructed nipple, were observed in any patients. CONCLUSION The modified technique group showed superior results in terms of safety and cosmesis. With our modified C-H flap method, simultaneous breast and nipple reconstruction is safe and has satisfactory results.
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Affiliation(s)
- Jung Soo Yoon
- Department of Plastic and Reconstructive Surgery, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul
| | - Jung Woo Chang
- Department of Plastic and Reconstructive Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri
| | - Hee Chang Ahn
- Department of Plastic and Reconstructive Surgery, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul
| | - Min Sung Chung
- Department of Surgery, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea
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Hong KY, Kim YE, Minn KW, Jin US. Immediate Nipple Reconstruction During Implant-Based Breast Reconstruction. Aesthetic Plast Surg 2017; 41:793-799. [PMID: 28204930 DOI: 10.1007/s00266-017-0804-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/19/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nipple reconstruction is usually performed as a separate procedure, several months after the primary breast reconstruction. This study compared the outcomes of immediate and delayed nipple reconstructions during implant-based breast reconstructions. METHODS A retrospective review was conducted of patients who underwent nipple reconstruction, after implant-based breast reconstruction, between September 2014 and August 2015. The nipple was simultaneously reconstructed following tissue expander removal and implant placement. The reconstructed nipple was evaluated immediately after surgery and 1 year later using objective measurements of nipple dimension and position, and a subjective assessment. RESULTS Sixty-one patients were included in the study, undergoing either immediate (n = 37) or delayed (n = 24) nipple reconstructions. Patients undergoing immediate nipple reconstructions had a significantly lower chance of radiotherapy (p = 0.018) and demonstrated a shorter period of tissue expansion (p = 0.011) than those undergoing delayed reconstructions. In the objective evaluations, nipple projections and symmetries between the groups were similar at the 1-year postoperative assessment. In the subjective reviews, esthetic breast mound outcomes were higher among those undergoing immediate reconstructions than among those undergoing delayed reconstructions; similar nipple symmetry and shape outcomes were obtained for both groups. CONCLUSION In cases of implant-based breast reconstruction, immediate nipple reconstruction concurrent with breast reconstruction provides satisfactory esthetic results compared with conventional delayed nipple reconstruction, in properly selected patients. 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)
- Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Young-Eun Kim
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Kyung Won Minn
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
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New technique of immediate nipple reconstruction during immediate autologous DIEP or MS-TRAM breast reconstruction. Ann Plast Surg 2016; 74:645-51. [PMID: 25136923 DOI: 10.1097/sap.0000000000000006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local flaps or composite graft from the opposite nipple. METHODS Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local flaps is used. The dermal-fat flaps are lifted and sutured together to form the new nipple. RESULTS Seventeen patients (average age, 47 years; range, 33-58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2-25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity. CONCLUSIONS One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local flaps on skin envelope flap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous flap. Our technique is suitable for patients with ptotic or hypertrophic breasts.
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He J, Wang T, Xu H, Zhang Y, Dong J. Immediate two-stage nipple reconstruction with a local mastectomy flap following secondary autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:206-10. [DOI: 10.1016/j.bjps.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 10/03/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022]
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He J, Xu H, Wang T, Qiao Y, Zhang Y, Dong J. Immediate nipple reconstruction with thoracodorsal artery perforator flap in breast reconstruction by latissimus dorsi myocutaneous flap in patients with Poland's syndrome. Microsurgery 2015; 36:49-53. [PMID: 25752505 DOI: 10.1002/micr.22395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/21/2014] [Accepted: 02/16/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Jinguang He
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
| | - Hua Xu
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
| | - Tao Wang
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
| | - Yufei Qiao
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
| | - Yi Zhang
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
| | - Jiasheng Dong
- Department of Plastic and Reconstructive Surgery; Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai People's Republic of China
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