Nipple-areola complex reconstruction

Nipple Areola Complex Reconstruction: An 8-Year Experience With Modified Technique and Systematic Review

Background

Nipple areola complex reconstruction is often the last procedure offered to patients undergoing breast reconstruction. Although comparatively minor, this final step creates the focal point of the breast while signifying the end of an often long and difficult journey for patient and surgeon. The literature demonstrates that nipple areolar complex (NAC) reconstruction conveys a positive impact on overall body image while defining the final aesthetic outcome. This paper presents a novel technique for NAC reconstruction developed at a UK tertiary referral center. It is supported by a systematic review of the current literature.

Methods

Between 2014 and 2022, a new technique was used to reconstruct the NAC using a modification of the C-V flap with a full-thickness skin graft (FTSG) and later nipple tattoo, if required. Patients were followed up in clinic noting complications, satisfaction, and need for revision surgery. The study was completed by conducting a systematic review of the literature assessing areolar reconstruction with skin grafts, according to PRISMA guidelines.

Discussion

This technique provides excellent results in terms of patient satisfaction and objective outcomes (complication rate, need for revision procedures, and loss of projection requiring further surgery). This literature review reflects alternative techniques and highlights the advantages of using a modified C-V flap with FTSG, in terms of morbidity and patient satisfaction.

Conclusions

NAC reconstruction is the "cherry on top" at the end of the breast reconstructive journey. This paper advocates a technique that is reproducible, with minimal complications, excellent outcomes, and long-standing results.

3D printing of Ceffe-infused scaffolds for tailored nipple-like cartilage development

The reconstruction of a stable, nipple-shaped cartilage graft that precisely matches the natural nipple in shape and size on the contralateral side is a clinical challenge. While 3D printing technology can efficiently and accurately manufacture customized complex structures, it faces limitations due to inadequate blood supply, which hampers the stability of nipple-shaped cartilage grafts produced using this technology. To address this issue, we employed a biodegradable biomaterial, Poly(lactic-co-glycolic acid) (PLGA), loaded with Cell-Free Fat Extract (Ceffe). Ceffe has demonstrated the ability to promote angiogenesis and cell proliferation, making it an ideal bio-ink for bioprinting precise nipple-shaped cartilage grafts. We utilized the Ceffe/PLGA scaffold to create a porous structure with a precise nipple shape. This scaffold exhibited favorable porosity and pore size, ensuring stable shape maintenance and satisfactory biomechanical properties. Importantly, it could release Ceffe in a sustained manner. Our in vitro results confirmed the scaffold's good biocompatibility and its ability to promote angiogenesis, as evidenced by supporting chondrocyte proliferation and endothelial cell migration and tube formation. Furthermore, after 8 weeks of in vivo culture, the Ceffe/PLGA scaffold seeded with chondrocytes regenerated into a cartilage support structure with a precise nipple shape. Compared to the pure PLGA group, the Ceffe/PLGA scaffold showed remarkable vascular formation, highlighting the beneficial effects of Ceffe. These findings suggest that our designed Ceffe/PLGA scaffold with a nipple shape represents a promising strategy for precise nipple-shaped cartilage regeneration, laying a foundation for subsequent nipple reconstruction.

Reconstruction of the human nipple-areolar complex: a tissue engineering approach

Introduction: Nipple-areolar complex (NAC) reconstruction after breast cancer surgery is challenging and does not always provide optimal long-term esthetic results. Therefore, generating a NAC using tissue engineering techniques, such as a decellularization-recellularization process, is an alternative option to recreate a specific 3D NAC morphological unit, which is then covered with an in vitro regenerated epidermis and, thereafter, skin-grafted on the reconstructed breast. Materials and methods: Human NACs were harvested from cadaveric donors and decellularized using sequential detergent baths. Cellular clearance and extracellular matrix (ECM) preservation were analyzed by histology, as well as by DNA, ECM proteins, growth factors, and residual sodium dodecyl sulfate (SDS) quantification. In vivo biocompatibility was evaluated 30 days after the subcutaneous implantation of native and decellularized human NACs in rats. In vitro scaffold cytocompatibility was assessed by static seeding of human fibroblasts on their hypodermal side for 7 days, while human keratinocytes were seeded on the scaffold epidermal side for 10 days by using the reconstructed human epidermis (RHE) technique to investigate the regeneration of a new epidermis. Results: The decellularized NAC showed a preserved 3D morphology and appeared white. After decellularization, a DNA reduction of 98.3% and the absence of nuclear and HLA staining in histological sections confirmed complete cellular clearance. The ECM architecture and main ECM proteins were preserved, associated with the detection and decrease in growth factors, while a very low amount of residual SDS was detected after decellularization. The decellularized scaffolds were in vivo biocompatible, fully revascularized, and did not induce the production of rat anti-human antibodies after 30 days of subcutaneous implantation. Scaffold in vitro cytocompatibility was confirmed by the increasing proliferation of seeded human fibroblasts during 7 days of culture, associated with a high number of living cells and a similar viability compared to the control cells after 7 days of static culture. Moreover, the RHE technique allowed us to recreate a keratinized pluristratified epithelium after 10 days of culture. Conclusion: Tissue engineering allowed us to create an acellular and biocompatible NAC with a preserved morphology, microarchitecture, and matrix proteins while maintaining their cell growth potential and ability to regenerate the skin epidermis. Thus, tissue engineering could provide a novel alternative to personalized and natural NAC reconstruction.

Tattooing to reconstruct Nipple-Areola Complex after oncological breast surgery: a scoping review

PURPOSE

The dermopigmentation of the Nipple-Areola Complex (NAC) is a safe non-surgical reconstruction technique that can restore psychophysical integrity, representing the final step after oncological surgery. This scoping review aims to identify and synthesize the literature focused on medical tattooing for NAC reconstruction in women who underwent breast reconstruction after cancer surgery. Competence and training, outcomes and organizational aspects were assessed as specific outcomes.

METHODS

The Joanna Briggs Institute (JBI) methodology for scoping reviews was followed. MEDLINE, Embase, Cochrane Library, Clinical Key, Scopus and Cinahl databases were consulted. After title (N = 54) and abstract (N = 39) screening and full-text review (N = 18), articles that met eligibility criteria were analyzed, critically apprised and narratively synthesized.

RESULTS

13 articles were analysed, with full texts (N = 11) and only abstract (N = 2). The overall quality of the literature (N observational studies = 11; N pilot experimental studies = 2) is weak. Nurses were the professionals mostly involved (N = 6), then medical staff (N = 4) and tattoo artists (N = 2). The professional training is poorly described in 6 papers. The most frequently assessed outcome was the satisfaction rate (N = 8). One study explored aspects of quality of life with a validated questionnaire. The management of these services resulted variable. Nurse-led services were implemented in 2 studies.

CONCLUSION

Despite methodological weaknesses, NAC tattooing research is relevant because it helps women redefine their identity after demolitive cancer treatments. Further research on processes and outcomes is needed.

Factors influencing final rendering in areola tattoo reconstruction: a statistical analysis

BACKGROUND AND AIM

Reconstruction of the nipple-areola complex announces the end of breast reconstruction process, sometimes difficult to live for the patient, and significantly improves the perception of body image. In literature there are no studies addressing the possible influencing factors of the final rendering of areola reconstruction with tattoo. The aim of the present study was to evaluate all the factors which could influence the yield and the final result of the nipple areola complex pigmentation.

METHODS

97 patients who underwent areolar tattooing between January 2018 and February 2020 were retrospectively reviewed. Breast reconstruction timing and personal history, as well as surgical details were recorded.

RESULTS

Mean age was 52 years old (range 29-71), almost the totality of cases was women including even 2 men (one with Poland syndrome and one post mastectomy). 27 patients needed bilateral tattooing. 22 had history of adjuvant radiotherapy, 16 received neoadjuvant chemotherapy and 4 adjuvant chemotherapy. In the logistic regression analysis, radiotherapy resulted a risk factor for retattooing (p<0.05) while the autologous breast reconstruction resulted a protective factor for retattooing. Neo - and adjuvant chemotherapy were not statistically significant.

CONCLUSIONS

Tissue thickness, sex, reconstructive technique and history of radiotherapy could influence the final result in areola reconstruction with tattoo, and must be taken into account to obtain the best result, knowing when the pigmentation has to be repeated.

Optimizing aesthetic results in autologous breast reconstruction

Advances in breast cancer management have provided most patients with the hope for cure or avoidance of cancer altogether. Such advances have made quality of life much more important after treatment and have led to equally incredible advances in breast reconstruction, to the point where reconstructive goals have altered the way mastectomies are now performed. As experience and expertise in microsurgery has grown, the surgical feat of successfully transferring tissue to restore breast volume is no longer considered an adequate endpoint for aesthetic breast reconstruction. A shift towards patient-centered care has motivated plastic surgeons to adapt their approaches to reconstruction integrating aesthetic principles to the process of recreating a breast mound in order to provide patients with a long-term, natural, and optimal result. Vital to restoring a shapely breast is a thorough preoperative assessment and the understanding of the breast footprint, breast conus, skin envelope and nipple-areolar complex (NAC) position. These aesthetic goals should also extend to the donor site, where adequate contour improvement is sought to offset the price of the donor site scar and the morbidity is minimized. By utilizing strategies for optimizing the NAC position, incorporating novel techniques to ensure core projection, and paying attention to the donor site, the skilled microsurgeon can elevate breast reconstruction to the level of true aesthetic surgery where the reconstructed appearance is superior to the presurgical one.

The Double Donut: A Safe and Simple Option for Immediate Nipple Areolar Complex Reconstruction in Skin-Sparing Mastectomy Patients With Contraindications to Nipple-Sparing Mastectomy

Background

Restoration of the nipple areolar complex (NAC) has been shown to improve quality of life (QoL) in post-mastectomy patients. Despite expansion of nipplesparing mastectomy inclusion criteria, many patients remain ineligible and are relegated to bilateral skin-sparing mastectomy. In this study, we evaluated immediate NAC reconstruction with the double donut areolar graft and split nipple composite graft reconstruction (DDSNS).

Methods

A single-center prospective study was performed for patients undergoing immediate post-mastectomy reconstruction with the DDSNS technique. Demographics and post-reconstruction endpoints were collected, focusing on aesthetic and functional outcomes.

Results

A total of 31 patients and 62 breasts underwent immediate reconstruction with the DDSNS technique. Four of 62 (6.4%) nipple composite grafts and 1 of 62 (1.6%) areolar grafts experienced partial graft loss. All incidents of initial loss healed to a satisfactory result. All patients were able to proceed with adjuvant therapy, if indicated, without delay.

Conclusions

The DDSNS technique can be successfully applied to achieve cosmetically satisfactory results in the post-mastectomy patient. This technique has shown reliable outcomes with respect to graft success and patient satisfaction with their NAC reconstruction.

Simultaneous nipple reconstruction in autologous breast reconstruction

BACKGROUND

Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Nipple-areola reconstruction was previously done after an interval of several months using variable techniques, often resulting in low projection and flattened breast mound over time. We present algorithm of simultaneous nipple reconstruction (SNR) that leaves adequate residual projection and naturally shaped breast mound.

METHODS

Forty patients underwent a skin-sparing mastectomy and nipple excision between October 2016 and December 2020. In the control group, 21 patients underwent delayed nipple reconstruction for 6 months after breast reconstruction. The experimental group of 19 patients underwent nipple and breast reconstruction simultaneously. We collected relevant information and photographs of nipple profiles of both groups in the preoperative, postoperative 6-month, and postoperative 1-year time periods. We also examined the ratio between the reconstructed and contralateral nipples.

RESULTS

Scores regarding patient satisfaction questionnaire averaged higher in experimental groups to every category. The control group's scores gradually declined over time and the experimental group showed lesser decline. At the 1-year postoperative follow-up, the mean projection of the immediately reconstructed nipple was approximately the same as the contralateral nipple at 91%, whereas the delayed reconstructed nipple resulted in a 77% ratio.

CONCLUSIONS

Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction. The nipple appears to be essential component of breast reconstruction for patient. SNR with immediate breast reconstruction is a simple and reliable technique, giving stable aesthetic results over time.

Long-Term Outcome of Nipple Projection Maintenance After Reconstruction with Clover Flap Technique

BACKGROUND

Nipple reconstruction using local skin flap leaves no morbidity in the healthy nipple. However, one disadvantage of this procedure is that the projection is not often maintained. There are few reports on the rate of long-term maintenance of nipple projection. This study aimed to analyze the 5-year results of clover flap (C-F) nipple reconstruction to determine whether it can be used to maintain nipple projection for long periods and to investigate the factors involved in maintenance of nipple projection.

METHODS

Patients that underwent nipple-areola reconstruction using C-F after undergoing a two-stage implant-based breast reconstruction with skin-sparing mastectomy between January 2012 and December 2019 were included. The projection of the reconstructed nipple was measured annually for 5 years postoperatively, and the nipple projection maintenance rate (%) was calculated. The influence of eight factors, namely smoking, irradiation, scarred skin, flap pedicle relative to the mastectomy scar, location of the mastectomy scar, flap suturing, and flap necrosis, on nipple height were evaluated.

RESULTS

Overall, 275 patients were enrolled. The average maintenance rates (%) at 1-5 years after surgery were 47.1, 39.8, 36.4, 34.6, and 33.5. Creating a well-vascularized skin flap, designing the pedicle farther away from the mastectomy scar, choosing a surgical technique involving an oblique scar on the side of the nipple by wrapping the skin flaps, and including an appropriate amount of fat tissue inside the reconstructed nipple are important for nipple projection maintenance.

CONCLUSION

Nipples reconstructed using the C-F technique on the artificial mound achieve excellent long-term result.

LEVEL OF EVIDENCE IV

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 .

Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm

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.

Nipple-Areola Complex Reconstruction

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.

One-stage nipple and breast reconstruction using a deep inferior epigastric perforator flap after a skin-sparing mastectomy

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.

De-epithelialized dermal flap for nipple reconstruction: A modified star flap

Background

Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results.

Methods

We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method.

Results

From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was 56.28%±18.58% in the modified method group, and 44.23%±14.15% in the conventional method group. This difference was statistically significant (P<0.05).

Conclusions

The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.

Nipple Reconstruction: A Novel Triple Flap Design

Supplemental Digital Content is available in the text.

Background:

Restoring the nipple–areola complex completes the breast reconstructive process. Local flaps are often used for the nipple reconstruction; however, the number of techniques indicates the lack of a superior design. The aims of this study were to test the feasibility of a new triple flap design for nipple reconstruction and to evaluate complication rate and nipple projection.

Methods:

From November 2015 to November 2018, we performed the triple flap nipple reconstruction guided by a template for preoperative mark-up. Patients were followed up postoperatively to evaluate healing and signs of complications including wound dehiscence, infection, and flap necrosis, and nipple projection. The areola was tattooed 3 months postoperatively.

Results:

Twenty-six nipple reconstructions were successfully performed in 22 women. Four nipple reconstructions (15%) were performed in irradiated tissue. One reconstruction had a superficial infection, while there were no cases of wound dehiscence or flap necrosis. Three nipple reconstructions (12%) experienced prolonged healing that did not require intervention. None of these reconstructions had received radiation therapy. The nipple projection was 7.3 mm (range 6–9 mm) at the time of surgery and 3.1 mm (range 0–6 mm), 2.5 mm (range 2–3 mm), and 1.6 mm (range 0–3 mm) at follow-up of 3, 6, and 12 months, respectively.

Conclusions:

We present the new triple flap design for nipple reconstruction guided by a template for mark-up. The preliminary results indicate a low complication rate in both irradiated and nonirradiated patients while sustaining the projection over time remains to be a challenge.

Breast cancer involvement of the nipple-areola complex and implications for nipple-sparing mastectomies: a retrospective observational study in 137 patients

Introduction

Nipple-sparing mastectomy (NSM) has gained much attention by enhancing the aesthetic outcome in breast carcinoma patients. The aim of this study was to assess the prevalence of malignant affection of the nipple-areola complex (NAC) in breast carcinoma patients and its correlation with prognostic factors for breast cancer.

Patients and methods

This study included 137 female patients diagnosed with breast carcinoma at different disease stages who were admitted to our surgical oncology unit at Suez Canal University Hospital from June 15, 2014 to January 25, 2017. We excluded patients with evidence of nipple involvement as ulceration or patients with previous breast surgery with periareolar incisions. This study was designed to test the hypothesis that the NAC can be spared in certain selected patients. All studied participants provided a full history and underwent general and local clinical examinations, pre-operative laboratory tests, and radiological and pathological evaluations.

Results

The mean age of the study population was 47.39 ± 8.01 years. Among the patients, the NAC was affected in 12 (11.40%) patients. Patients with NAC involvement showed a significantly larger tumor size of more than 4 cm and a shorter tumor-nipple distance of less than 2 cm (p = 0.000). Lymph node metastasis was associated with NAC involvement (p = 0.001), with increased risk when more than 10 lymph nodes were involved (p = 0.007). Lymphovascular invasion was a significant predictor of NAC involvement (p = 0.014). Multifocal as well as multicentric tumors were significantly associated with NAC involvement (p = 0.016 and 0.003, respectively). NAC involvement was more likely in Estrogen receptor (ER) and Progesterone receptor (PR) patients than in ER+ and PR+ patients (p = 0.000), while Human epidermal receptor (HER+) patients were more likely to have NAC involvement than HER patients (p = 0.000). Additionally, stage ΙΙΙ cancer was significantly associated with NAC involvement (p = 0.041), and histological grade III disease carried a greater risk than grade I disease of NAC involvement (p = 0.008).

Conclusion

The incidence of NAC affection among breast carcinoma patients who underwent mastectomy and axillary clearance was associated with important parameters, such as tumor size, areola edge-tumor distance, lymph node affection, hormonal receptor status and lymphovascular invasion. Accordingly, NAC-preserving surgeries could be tailored to patients with favourable tumor characteristics.

Quadruped and Dermal Bridge Flap for Nipple Reconstruction

Background:

This report describes the authors' novel preferred method of nipple reconstruction over 10 years.

Methods:

The procedure was used in 39 patients (unilateral 38, bilateral 1). The circle is designed as the new nipple cap. Then, 4 fan-shapes (one-quarter of the circle) are drawn so that the base portion is in contact with the circumference. These fanshapes are deepithelialized, and their linear portions are cut with full thickness of skin and elevated as dermal flaps. Then, the cross-type flap is elevated with sufficient subcutaneous fat. The two pairs of dermal flaps are sutured to each other on a diagonal line. Double-layer dermal bridge flaps sustain the base of the pocket. As a result, the cross flap becomes a birdcage-like tower. The rolled auricular cartilage is placed into the pocket.

Results:

In one early case, the cartilage was exposed. Early postoperatively, the other three cases underwent reoperation during other procedures because the reconstructed nipple was too large or too small. The projection of the flap was designed to be 7–15 mm (average, 9.3 mm). The average follow-up period was 25.7 ± 22.0 months. The reconstructed nipple projection was maintained at 4.4 ± 2.4 mm (maintenance rate, 48.4% ± 27.0%).

Conclusions:

All scars were contained within the periareolar region and thus could be completely camouflaged by tattooing. The perfusion of the skin flap is stable because of sufficient circulation from quadruped pedicle. The cartilage supported by the double-layered dermal bridge flaps contributes to nipple projection. We recommend it for patients seeking nipple reconstruction.

Immediate Nipple-Areolar Complex Reconstruction for Patients Undergoing Implant-Based Reconstruction or Therapeutic Mammoplasty

Background:

We report a technique of immediate nipple-areolar complex (NAC) reconstruction for patients undergoing skin-sparing mastectomy and implant-based breast reconstruction or therapeutic mammoplasty with central excision.

Methods:

Immediate nipple reconstruction is performed using a modified C-V flap planned along the edge of the incision. The areola is reconstructed using a full-thickness skin graft taken from skin usually discarded during the procedure. Immediate NAC reconstruction using this technique was performed on 32 breasts in 21 patients. This included 19 risk-reducing mastectomies, 9 therapeutic mastectomies, and 2 major revisions to existing implant reconstruction. Reconstruction was direct to implant in 29 breasts and by expander in 1 breast. The device was placed in a pre- or post-pectoral plane utilizing dermal sling and/or acellular dermal matrix as determined on a case-by-case basis. Immediate NAC reconstruction was also performed on 2 patients undergoing therapeutic mammoplasty with central excision.

Results:

Mean follow-up is 12 months (5–27 months), and cosmetic results have been good. There have been no significant complications, and no revisional surgery has been required.

Conclusion:

The application of simple techniques for NAC reconstruction in the primary procedure allows reconstruction of the whole breast in a single stage. There is an immediate focal point to the reconstruction to improve cosmesis, patient satisfaction, and psychosocial function without delay.

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.

Oncoplastic central quadrantectomies

Tumors localized in the central quadrant (centrally located breast tumors) have always represented a challenge for the surgeon because of the critical aesthetical matters related to the nipple-areola complex (NAC). Many years of experience with breast cancer patients treated by using various oncoplastic techniques, has allowed us to develop the modified hemibatwing for the treatment of central breast tumors, where the NAC is involved. Modified hemibatwing-along with the removal of the NAC-is a useful oncoplastic technique and it represents an ideal option for the treatment of central tumors because it assures oncological safety, a reduced surgical timetable and greater aesthetical results.

The optimal reconstruction size of nipple-areola complex following breast implant in breast cancer patients

Background

Changes in the areola size after reconstruction of the nipple-areola complex (NAC) following mastectomy and breast reconstruction with a silicon implant in primary breast cancer patients have not been well examined. This study aimed to investigate time-dependent changes in the size of the donor and graft NACs and to assess clinical factors influencing these changes.

Methods

Fifty-eight consecutive patients who underwent nipple-areola reconstruction were retrospectively evaluated. Nipple-areola diameter was measured immediately after the NAC reconstruction and at each follow-up visit for at least 36 months.

Results

The donor NAC constituted 81 % of the graft NAC at the time of operation. The size of the donor NAC gradually increased by up to 36.8 % after the operation. The size of the graft NAC showed a decrease by 4.5 % at 7 months, followed by recovery to the initial value. The ratio of the donor site size to the graft site size was increased at month 1 and then showed a gradual decrease to 1.08 at 36 months. A history of mastopexy or reduction for the donor site was independent factors associated with changes in the NAC size.

Conclusions

To achieve symmetry, the diameter of the donor NAC immediately after the reconstruction should be at least 20 % smaller than that of the graft NAC, especially for patients without a history of additional operations.