Nipple Reconstruction With C-V Flap Using Dermofat Graft

Free Dermal Fat Grafting: A Novel Technique for the Correction of Nasolabial Folds During Facelift Surgery

BACKGROUND

Traditional facelift surgery does not behave well in the correction of nasolabial folds, which is a common clinical problem and needed to be improved.

OBJECTIVES

To investigate the effect of free dermal fat grafting during facelift surgery for the treatment of nasolabial folds.

METHODS

This prospective cohort study involved 80 patients with moderate to severe nasolabial folds and facial skin dermatolysis. Fifty of them underwent facelift surgery combined with free dermal fat grafting, and 30 of them underwent traditional facelift surgery. These patients were followed up 2 months, 6 months, and 1 year after the surgery to evaluate the effect.

RESULTS

The difference in Wrinkle Severity Rating Scale (WSRS) scores, assessed at each follow-up, between the patients who underwent and did not undergo free dermal fat grafting during facelift surgery, was statistically significant. For patients who underwent free dermal fat grafting during facelift surgery, the WSRS scores assessed at 2 months, 6 months, and 1 year after the surgery were significantly different from those before the surgery. The analytic results of FACE-Q indicated a high level of overall satisfaction rate. No major complications were recorded.

CONCLUSIONS

Free dermal fat as a filler for nasolabial folds can achieve excellent therapeutic effect. The combination of facelift surgery with free dermal fat grafting for the treatment of nasolabial folds can provide very good long-term results and a high patient satisfaction rate for patients with symptoms of facial aging such as facial dermatolysis, obvious wrinkles, and deep nasolabial folds.

LEVEL OF EVIDENCE: 4

Dual Extrusion Patterning Drives Tissue Development Aesthetics and Shape Retention in 3D Printed Nipple-Areola Constructs

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.

Update on oncoplastic techniques in breast conserving surgery: algorithms for predictable results and custom-made reconstructions

Breast cancer surgery is going to be a relevant specialty involved in the multidisciplinary disease management, finalized to guarantee high performances on mortality reduction together with a quality of life improvement. The intellectual architecture of this field is characterized by its inclination to respect, sharing, empathy and scientific knowledge that can make it a high model of medical culture. In this context, oncoplastic breast conserving surgery is identified by special aesthetic sensitivities, as well as creativity and innovation. Knowing how to reshape the gland and fill the gaps, planning the targeted exeresis design, while anticipating the final outcome, respecting symmetries and ensuring first of all oncological safety, are the new skills that are required to the breast surgeon. Several tecniques could provide a refined surgical treatment but always challenging according to anatomical findings and patient expectations, as a systematic process of self-critical reflection, with the purpose to optimize criteria for improving therapeutic results.

The Modified Skate Flap: A New Technique for Nipple-Areola Complex Reconstruction in Implant-Based Breast Reconstruction

Nipple-areola complex (NAC) reconstruction is an important part of breast reconstruction. Although several techniques for NAC reconstruction have been described in the literature, the long-term outcomes after NAC reconstruction remain less satisfactory, especially following implant-based breast reconstruction. The authors reported their newly developed technique for NAC reconstruction in implant-based breast reconstruction. The authors describe their modified skate flap, by preserving more dermal tissues from the skate flap, for NAC reconstruction, following implant-based breast reconstruction. Additional derma-fat grafts, harvested from the full-thickness skin graft site, are also added to the reconstructed nipple to ensure long-term shape, size, and projection of the reconstructed nipple. A total of 30 patients underwent such a NAC reconstruction after successful implant-based breast reconstruction by the senior author. The minimum follow-up time was 1 year. No significant surgical complications have been observed in their series of 30 patients, and only a minor office procedure was performed subsequently in 6 patients (4 unilateral and 2 bilateral) to improve the shape of the reconstructed nipple. During a minimum of a 1-year follow-up period, outcomes with the authors’ technique in 30 patients are satisfactory; good size, shape, and projection of the reconstructed nipple are maintained. The long-term outcome of NAC reconstruction after implant-based breast reconstruction can be optimized with their modified skate flap by using all available flap tissue and with the addition of derma-fat grafts. The authors’ technique can be used safely for NAC reconstruction after implant-based breast reconstruction with good outcome and high patient satisfaction.

Nipple Reconstruction: A Regenerative Medicine Approach Using 3D-Printed Tissue Scaffolds

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.

Dimensional changes in reconstructed nipples: autologous versus prosthetic breast reconstruction

Purpose

The creation of the nipple-areola complex is the final stage in breast reconstruction and highly affects patient satisfaction. The neo-nipple is well known to shrink over time, particularly in the nipple projection. Currently, no reconstruction technique is clearly superior in terms of nipple size maintenance. We evaluated nipple size changes among several methods of breast mound reconstruction.

Methods

Seventy-eight patients received nipple-areola complex reconstruction secondarily after breast reconstruction. C-V flap nipple reconstructions were performed using a free transverse rectus abdominis myocutaneous (TRAM) flap in 25 cases (TRAM group), a latissimus dorsi (LD) myocutaneous flap in 27 cases (LD group), and an implant in 26 cases (implant group). The circumference and projection of the neo-nipple were measured using a flexible ruler, immediately after reconstruction and average 10 months after surgery.

Results

The overall circumference and projection at the final measurement were 91.43% ± 7.11% and 62.16% ± 21.55%, respectively, of immediate postoperative values. The change in circumference did not significantly differ among the 3 groups. In contrast, the change in projection was significantly worse in implant group compared to that in TRAM and LD groups. In addition, among the patients in implant group, greater inflation was significantly associated with greater decrease in the nipple projection.

Conclusion

Breast mound reconstruction with autologous musculocutaneous flap techniques achieves better long-term maintenance of the neo-nipple projection compared to that achieved with expanded tissue and implantation. Considering the prospective loss of long-term nipple dimension, the preoperative design should be oversized in accordance with its origin in mound reconstruction.

A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft

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 .

Nipple-Areola Complex Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions.

SUMMARY

Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices.

Use of acellular dermal matrix (ADM) in nipple reconstruction: the 'central-pillar technique'

Nipple reconstructions are prone to a variable and unpredictable degree of flattening, which in some cases lead to secondary reconstruction. The use of an acellular dermal matrix (ADM) augmentation may be appropriate in cases with very thin dermis that are particularly prone to flattening or in revision cases where the first procedure has already failed. The authors present a series of 13 nipple reconstructions in ten cases. Average projection at 12 months was 51% in primary cases and 46% in secondary revision cases. This represents a better than expected long term result in a difficult cohort of patients.

A New Local Flap Nipple Reconstruction Technique Using Dermal Bridge and Preoperatively Designed Tattoo

Supplemental Digital Content is available in the text.

Background:

Nipple–areolar reconstruction is the final step in breast reconstruction. Reconstruction using local flaps and tattooing is useful in cases of bilateral reconstruction, a small nipple–areolar complex (NAC) as the donor site, and avoiding disturbance of the normal side and other body parts. However, this method can cause projection loss and color fading of the nipple. Moreover, the breast mound is reconstructed with an implant.

Methods:

We performed nipple–areolar reconstruction of 90 nipples using clover-designed flaps oriented at 120 degrees and tattooing after breast silicone implantation in 64 women. The tattoo was designed before flap operation and stained darker. Following donor site closure, a dermal flap was made as a bridge for nipple support. The nipple space was separated by the dermal flap from the breast mound and was filled with subcutaneous tissue. The size of the reconstructed nipple projection was measured postoperatively and 1 year later. The projection maintenance rate was calculated.

Results:

The heights of the nipple projection were 11.3 ± 1.8 mm (95% confidence interval [CI]: 10.9–11.7) just after the operation and 6.09 ± 2.4 mm (95% CI: 5.6–6.6) 1 year later. The actual range of nipple projection between these 2 heights was 5.2 ± 2.4 mm (95% CI: 4.7–5.7). The maintenance rate of the reconstructed nipple projection after 12 months was 54.1 ± 20.9 (95% CI: 49.7–58.5). The nipple color was maintained for over a year.

Conclusions:

Our nipple–areolar reconstruction technique could maintain the projection and color of the reconstructed nipple for a long period. Good outcomes were obtained in this implant-based breast reconstruction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Immediate Nipple Reconstruction as Oncoplastic Breast Surgery: the Cigar Roll Flap with Inner Dermal Core Technique

BACKGROUND

Postoperative loss of projection is the most common problem following nipple reconstruction. Despite the various available nipple reconstruction techniques, a simple and reliable method that maintains nipple projection has not yet been developed. Here, we introduce a simple and feasible method for immediate nipple reconstruction-the cigar roll flap with inner dermal core technique-which is expected to maintain long-term nipple projection.

METHODS

Between January 2013 and August 2014, 23 breast cancer patients underwent unilateral nipple reconstruction using the cigar roll flap with inner dermal core technique during immediate breast reconstruction. The projection of the reconstructed nipple was measured at the time of surgery and after radiation therapy (average postoperative duration, 8 months).

RESULTS

The mean nipple projection at the time of surgery was 1.1 ± 0.2 cm. After radiation therapy, the mean projection was 1.0 ± 0.2 cm. The mean maintenance of nipple projection was 84.5 ± 5.3 %. No immediate or delayed major postoperative complications were noted in our series. Most of the patients were satisfied with the three-dimensional projection of the nipple.

CONCLUSIONS

The cigar roll flap with inner dermal core technique is a simple and reliable method for oncoplastic breast surgery during immediate nipple reconstruction and maintains constant projection without any major complications or donor-site morbidity.

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 .

Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study

BACKGROUND

Nipple-areola complex (NAC) reconstruction occurs toward the final stage of breast reconstruction; however, not all women follow through with these procedures. The goal of this study was to determine the impact of the health state burden of living with a reconstructed breast before NAC reconstruction.

METHODS

A sample of the population and medical students at McGill University were recruited to establish the utility scores [visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG)] of living with an NAC deformity. Utility scores for monocular and binocular blindness were determined for validation and comparison. Linear regression and Student's t test were used for statistical analysis, and significance was set at P < 0.05.

RESULTS

There were 103 prospective volunteers included. Utility scores (VAS, TTO, and SG) for NAC deformity were 0.84 ± 0.18, 0.92 ± 0.11, and 0.92 ± 0.11, respectively. Age, gender, and ethnicity were not statistically significant independent predictors of utility scores. Income thresholds of <$10,000 and >$10,000 revealed a statistically significant difference for VAS (P = 0.049) and SG (P = 0.015). Linear regression analysis showed that medical education was directly proportional to the SG and TTO scores (P < 0.05).

CONCLUSIONS

The absence of NAC in a reconstructed breast can be objectively assessed using utility scores (VAS, 0.84 ± 0.18; TTO, 0.92 ± 0.11; SG, 0.92 ± 0.11). In comparison to prior reported conditions, the quality of life in patients choosing to undergo NAC reconstruction is similar to that of persons living with a nasal deformity or an aging neck requiring rejuvenation.

Nipple reconstruction with rolled dermal graft support

Background

Loss of nipple projection is a common problem following nipple reconstruction. The aim of this study was to demonstrate that the use of a tightly rolled dermal graft is effective in the long-term maintenance of nipple projection.

Methods

Nipple reconstruction was performed using the C-V flap technique. A dermal graft was harvested from the dog-ear portion of previous scars. The graft was rolled tightly into a compact cylinder and used to augment the nipple reconstruction. Postoperatively, stacked Allevyn dressing was used for protecting the nipple from compression for a minimum of two months. Nipple projection was measured at the time of surgery and at 12 months postoperatively.

Results

Forty nipple reconstructions were performed using this technique. There were 19 transverse rectus abdominis musculocutaneous (TRAM) flaps, 10 latissimus dorsi (LD) flaps, and 11 tissue-expanded breast mounds. At one year, the mean projection was 0.80 cm (range, 0.62-1.22 cm). The twelve-month average maintenance of nipple projection was 70.2% for the TRAM flap group, 76.3% for the LD flap group, and 61.8% for the tissue-expanded group. In two patients with previous irradiation of the reconstructed breasts, relatively poor maintenance of nipple projection was noted (45.7%). No complications were noted, and all of the donor sites healed well primarily.

Conclusions

Our results demonstrated that the use of a C-V flap with a tightly rolled dermal graft for nipple reconstruction improves the long-term maintenance of nipple projection. Its advantages include reproducibility, technical simplicity, cost-effectiveness, and minimal donor site morbidity.

Nipple reconstruction after implant-based breast reconstruction: a "matched-pair" outcome analysis focusing on the effects of radiotherapy

BACKGROUND

The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed.

METHODS

A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study.

RESULTS

A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03).

CONCLUSION

While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

Nipple Reconstruction: Risk Factors and Complications after 189 Procedures

BACKGROUND

A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction.

METHODS

Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy.

RESULTS

A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001).

CONCLUSION

While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead.

LEVEL OF EVIDENCE

IV.

The angel flap for nipple reconstruction

Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.

The impact of nipple reconstruction on patient satisfaction in breast reconstruction

BACKGROUND

Nipple reconstruction is an integral part of the breast reconstruction process, as patients associate this stage with closure while providing a sense of completeness. This study evaluates the effect of nipple reconstruction on patient satisfaction with breast reconstruction.

METHODS

All patients at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected retrospectively while aesthetic and general satisfaction was evaluated by an administered survey. Patients with nipple reconstruction at the time of survey were compared to patients without nipple reconstruction.

RESULTS

Nine hundred two breast reconstructions were performed in 696 patients; 490 patients underwent nipple reconstruction and 206 did not. Autologous reconstruction predominated in patients with and without nipple reconstruction (61.8% and 54.8%, respectively). There were no significant differences in individual and overall total complications between groups. Patients with nipple reconstruction had significantly higher general (72.2% vs 52.8%, P<0.0001) and aesthetic (70.5% vs 46.5%, P<0.0001) satisfaction scores compared to patients without nipple reconstruction. These results were seen in unilateral and bilateral breast reconstruction. Across reconstructive techniques, patients with nipple reconstruction had higher aesthetic satisfaction. Patient satisfaction scores in all individual survey questions were statistically higher in patients with nipple reconstruction.

CONCLUSIONS

Patients with breast reconstruction who undergo nipple reconstruction have higher general and aesthetic satisfaction compared to breast reconstruction alone. These differences were observed in both unilateral and bilateral reconstruction. Patients should be fully counseled about potential benefits nipple reconstruction can provide to all forms of breast reconstruction.

Patient satisfaction following nipple reconstruction incorporating autologous costal cartilage

BACKGROUND

Nipple-areolar reconstruction completes post-mastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time.

OBJECTIVES

To determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction.

METHODS

Sixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction.

RESULTS

Of 26 respondents (mean +/- SEM follow-up period 3.7+/-3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstructions. While both groups would opt for nipple reconstruction again, patients with cartilage grafts incorporated into their reconstructions had overall satisfaction ratings 1.92 grades higher on average (not significant, P=0.12) than those without. This difference increased to 3.2 grades when the satisfaction of the patient's partner was taken into account (P<0.05). Improved satisfaction corresponded to higher scores for volume, consistency, texture, and particularly for projection and contour of the nipple (P<0.05). Although nipple morphology changed over time, there was a trend toward improved stability in the cartilage group.

CONCLUSIONS

Patient satisfaction with nipple reconstruction can be improved by incorporating costal cartilage beneath the skin flaps. Superior contour and projection are sustained over time.

Staged wise-pattern skin excision for reconstruction of the large and ptotic breast

BACKGROUND

The postmastectomy reconstruction of large and/or ptotic breasts poses a more difficult aesthetic challenge than the reconstruction of small or moderately sized breasts because of an excessively large skin envelope in both horizontal and vertical dimensions. The Wise-pattern skin excision best addresses this excess skin but is associated with a high incidence of tissue necrosis with subsequent wound breakdown, primarily at the T point. To optimize the aesthetic potential and minimize complications in the setting of these large skin envelopes, the authors have deconstructed the single-stage Wise-pattern skin excision into a two-stage procedure, eliminating the need for a primary simultaneous T-point closure.

METHODS

In the first stage, the mastectomy and reconstruction are performed using a vertical excision, which tightens the breast skin envelope horizontally. In the second stage, the redundant skin at the inframammary fold is excised horizontally, tightening the breast skin envelope vertically. The summation of the two staged excisions recreates the Wise pattern, breaking up the T point into two straightforward primary closures.

RESULTS

Twelve patients (21 breasts) underwent successful reconstruction using the staged Wise-pattern skin excision. The breast size, shape, and projection of the patients were greatly improved without any wound complications.

CONCLUSIONS

The staged Wise-pattern skin excision for breast reconstruction is a simple technique that delivers superior results for the challenging reconstruction of large and/or ptotic breasts. This method offers an aesthetically pleasing breast shape, allows for the correction of ptosis, eliminates wound complications, and results in a standard Wise-pattern scar.

Effectiveness of the Asteame Nipple Guard™ in maintaining projection following nipple reconstruction: a prospective randomised controlled trial

As the final step in breast reconstruction, nipple reconstruction is considered a minor surgical procedure. However, despite the multitude of techniques and postoperative dressings proposed, none have proven to resist the tendency of the reconstructed nipple to gradually flatten over time. A prospective randomized controlled trial was conducted assessing the value of using the Asteame Nipple Guard™ compared to standard gauze dressing in maintaining nipple projection postoperatively. A total of 30 nipple reconstructions in 22 patients were included in the study with randomisation of 15 nipples to each study arm. Nipple projection was measured at various time points postoperatively with calculation of the percent changes in nipple projection. The mean decrease in long-term nipple projection at 6 months in the experimental group was 46.6% vs. 71.8% in the control group (p<0.05). In conclusion, the Nipple Guard™ helps in maintaining nipple projection postoperatively.

Nipple reconstruction: evidence-based trials in the plastic surgical literature

Although many technical descriptions of nipple reconstruction exist in the medical literature, insufficient evidence-based data are present about the outcome. This study aimed to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) in the plastic surgical literature addressing nipple reconstruction, and to elucidate whether a hand search was superior to an extensive database search in retrieving all pertinent studies. The hand search included analysis of all "original articles" published in four of the leading plastic surgery journals from January 1990 to December 2005, with subsequent identification of RCTs and CCTs. Additionally, a computerized search was conducted including the following databases: PubMed, Web of Science, and Evidence-Based Medicine Reviews. From a total of 10,476 published original articles in four plastic surgery journals over a 16-year period, only one RCT was identified that addressed nipple reconstruction. The database search, however, retrieved two trials: the RCT identified by hand search and one CCT. The impact of nipple reconstruction is well described in the literature. However, it is astonishing that the plastic surgical literature lacks evidence-based trials addressing this issue. Clearly, more evidence-based trials are necessary to ensure that recommendations for a particular technique are based on solid scientific data.