Our Experiences in Nipple Reconstruction Using the Hammond flap

Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions

Background and Objective

Mastectomy is a primary treatment for breast cancer patients, and both autologous and implant-based reconstructive techniques have shown excellent results. In recent years, advancements in bioengineering have led to a proliferation of innovative approaches to breast reconstruction. This article comprehensively explores the promising perspectives offered by bioengineering and tissue engineering in the field of breast reconstruction.

Methods

A literature review was conducted between April and June 2023 on PubMed and Google Scholar Databases. All English and French articles related to bioengineering applied to the field of breast reconstruction were included. We used the Evidence-Based Veterinary Medicine Association (EBVM) Toolkit 14 checklist for narrative reviews as a quality assurance measure and the Scale for the Assessment of Narrative Review Articles (SANRA) tool to self-assess our methodology.

Key Content and Findings

Over 130 references related to breast bioengineering were included. The analysis revealed four key applications: enhancing the quality of the skin envelope, improving the viability of fat grafting, creating breast shape and volume via bio-printing, and optimizing nipple reconstruction through engineering techniques. The primary identified approaches revolved around establishing structural support and enhancing cellular viability. Structural techniques predominantly involved the implementation of 3D printed, decellularized, or biocompatible material scaffolds. Meanwhile, promoting cellular content trophicity primarily focused on harnessing the regenerative potential of adipose-derived stem cells (ADSCs) and increasing the tissue's survivability and cell trophicity.

Conclusions

Tissue and bioengineering hold immense promise in the field of breast reconstruction, offering a diverse array of approaches. By combining existing techniques with novel advancements, they have the potential to significantly enhance the therapeutic options available to plastic and reconstructive surgeons.

Acellular Nipple Scaffold Development, Characterization, and Preliminary Biocompatibility Assessment in a Swine Model

BACKGROUND

The standard in nipple reconstruction remains the autologous skin flap. Unfortunately, the results are not satisfying, with up to 75% loss of nipple projection over time. Existing studies investigated the use of primates as a source of implants. The authors hypothesized that the porcine nipple can serve as a perfect shape-supporting implant because of functional similarities to the human nipple. A decellularization protocol was developed to obtain an acellular nipple scaffold (ANS) for nipple reconstruction.

METHODS

Tissue samples were collected from eight disease-free female Yorkshire pigs (60 to 70 kg) and then decellularized. The decellularization efficiency and extracellular matrix characterization was performed histologically and quantitatively (DNA, total collagen, elastin, and glycosaminoglycan content). In vitro and in vivo biocompatibility was determined by human dermal fibroblast culture and subcutaneous implantation of six ANSs in a single Yorkshire pig (60 to 70 kg), respectively. Inflammation and adverse events were monitored daily based on local clinical signs.

RESULTS

The authors showed that all cellular structures and 96% of DNA [321.7 ± 57.6 ng DNA/mg wet tissue versus 11.7 ± 10.9 ng DNA/mg wet tissue, in native and ANS, respectively ( P < 0.001)] can be successfully removed. However, this was associated with a decrease in collagen [89.0 ± 11.4 and 58.8 ± 9.6 μg collagen/mg ( P < 0.001)] and elastin [14.2 ± 1.6 and 7.9 ± 2.4 μg elastin/mg ( P < 0.05)] and an increase in glycosaminoglycan content [5.0 ± 0.7 and 6.0 ± 0.8 ng/mg ( P < 0.05)]. ANS can support continuous cell growth in vitro and during preliminary biocompatibility tests in vivo.

CONCLUSION

This is a preliminary report of a novel promising ANS for nipple reconstruction, but more research is needed to validate results.

CLINICAL RELEVANCE STATEMENT

Breast cancer is very common among women. Treatment involves mastectomy, but its consequences affect patient mental well-being, and can lead to depression. Nipple-areola complex reconstruction is critical, and existing methods lead to unsatisfactory outcomes.

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.

Modified C-H flap for simultaneous nipple reconstruction during autologous breast reconstruction: Surgical tips for safety and cosmesis

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.

Usefulness of Rapiplug in nipple reconstruction to improve nipple projection

BACKGROUND

The final stage of breast reconstruction after mastectomy for breast cancer is nipple reconstruction. However, a consistent and reliable method resulting in the most ideal aesthetic results has yet to be clarified. This study analysed the long-term outcomes of nipple reconstruction using Rapiplug.

METHODS

Forty-one patients who underwent immediate breast reconstruction after mastectomy between January 2014 and February 2017 were enrolled. Nipple reconstruction was performed with C-V flap and Hammond flap, and hat-shaped Rapiplug was implanted at the flap core. Nipple projection and width were measured and nipple reduction rates were calculated immediately after and at 3, 6, and 12 months after surgery. Patient satisfaction was surveyed at the 12-month follow-up and compared with patient characteristics and other variables.

RESULTS

Forty-one nipple reconstructions were performed in 41 patients. Most post-operative adverse events were resolved with conservative management, and revision was performed in only one case. The mean nipple projections were 8.9 ± 1.8, 7 ± 1.8, 5.6 ± 1.6 and 4.9 ± 1.6 mm immediately, and 3, 6 and 12 months after surgery, respectively, and the mean reduction rate of nipple size with reference to the size immediately after surgery was 22.2%, 37.2% and 44.7% at 3, 6 and 12 months after surgery, respectively. Patient satisfaction was 82.9% in overall outcome, and 85.3% of projection was good or excellent.

CONCLUSION

Rapiplug can improve the long-term preservation of nipple projection after nipple reconstruction and is considered to be consistent and reliable with good aesthetic outcomes and no severe complications.

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.

Nipple-areola complex reconstruction techniques: A literature review

Many techniques for nipple-areola complex (NAC) reconstruction are described. Clarity is required on the currently available options. Since a complete list of all the techniques described until now is not available, a possibly comprehensive literature overview was carried out from 75 papers (years 1946-2015). The local flap was the most frequently described technique for the nipple reconstruction with no significant difference in complications' rate among the various types of techniques. Complications in nipple reconstruction were 46.9% after graft, 7.9% after local flap, and 5.3% in case of flaps with autologous graft/alloplastic/allograft augmentation, while complications in areola reconstruction were 10.1% after graft, and 1.6% after areola tattoo. Flaps appear to be more reliable than grafts in nipple reconstruction, while tattoo is thought to be safer than graft in areola reconstruction. The loss of projection, although considerable (45%-75%), had not significant impact on patients' satisfaction. Due to contraction, overcorrection of 25-50% of the desired result is advisory when adopting local flaps, in order to prevent loss of projection. The use of flaps with autologous graft/alloplastic/allograft augmentation (cartilage, fat, calcium hydroxylapatite, acellular dermal matrix, polymethylmethacrylate, biologic collagen) showed a minor loss of nipple projection but may expose to a relative increased number of postoperative flap necrosis.