Nipple Reconstruction

8/2/2019 Nipple Reconstruction

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NIPPLE RECONSTRUCTION

Max Pekarev, M.D.

UMass Division of Plastic andReconstructive Surgery

6/8/2011


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Nipple-Areolar Reconstruction

Nipple reconstruction is an essential

component of an attractive breast.

The goal of nippleareolar reconstruction is to

create nipples ofappropriate size, shape,

color, and texture.

More challenging to achieve these goals when

performing unilateral breast reconstructions

need to match the contralateral NAC.


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History of NAC Reconstruction

Adams (1949) - labial skin graft.

Broadbent, Woolf, and Metz (1977) - Upper innerthigh skin graft.

Klatsky (1981) - Toe pulp transfer. Little (1984) - Skate flap.

Hallock (1990) - Polyurethane nipple prosthesis.

Anton, Eskenazi, and Hartrampf (1991) - Star and

wrap flaps. Nohira, Shintomi, and Ohura (1991) - Skate flap

and tattoo.


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History

Eng (1996) Bell flap.

Tanabe et al (1997) - Dermal fat flap and rolledauricular cartilage.

Bhatty and Berry (1997) - Nipple sharing and tattoo. Losken, Mackay, and Bostwick (2001) - C-V flap.

Cheng et al (2003) - Banked cartilage graft andmodified top hat flap.

Nahabedian (2005) AlloDerm. Panettiere, Marchetti, and Accorsi (2005) - Filler

injection.


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Maintaining Projection

Smooth muscle and lactiferous ducts are

primarily responsible for the natural firmness

and projection of the nipple.

The loss of nipple projection is between 50-

70% regardless of the technique used.

Projection loss occurs during the first 3

months and stabilizes by 1 year after

reconstruction.


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Local Flaps

Local flaps are the most frequently performed methods ofreconstruction.

A central dermal fat pedicle is wrapped by full-thicknessskin flaps, creating a nipple.

Flaps raised from flaps. Skin grafts or primary closure to close the donor defects.

The breast mound must provide well-vascularized softtissue of sufficient thickness.

May not be suitable for reconstructions in patients with

thin skin or irradiated tissue. Initial overcorrection is warranted (by 50 to 100% as

compared to the opposite nipple)


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Bell Flap

Introduced by Eng in 1996.

Pull-out flap that is

elevated and folded onitself with primary closure

of the flap donor area

using a periareolar purse-

string suture.

Results in areola

projection.


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Modified Skate Flap

DC. Hammond, M.D., D. Khuthaila, M.D.,

J. Kim, M.D. The Skate Flap Purse-String

Technique for Nipple-Areola Complex

Reconstruction. Plast Reconstr Surg. 2007Aug;120(2):399-406.


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Modified Skate Flap

Allows for an adequate bulk and long-termprojection.

Allows for primary closure of the donor site withminimal distortion of the breast.

The oval periareolar flap design pattern used toreconstruct the areola with matching island skinflaps is closed with a simple purse-string suture.

Should be used when a skin island from either aLD or TRAM flap is present.

Can be considered when the native mastectomyflaps are thick.


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Modified Skate Flap

In most instances, C (cap

length) will equal P (nipple

projection) to allow for a

tension-free closure.

The measurement for the

radius of the lower skin

island is made from the

center of the skate-flappattern, and the same

measurement for the upper

skin island is made from the

center of the skate-flap cap.


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Modified Skate Flap

The margins of the areolarhemiflaps and the skate flap

nipple are incised.

The outer periareolar flaps are

undermined slightly to ease

subsequent closure.

The skate flap is elevated,

keeping a uniform thickness of fat

on the underside of the flap.

The inner corners of the two

hemiflaps are undermined slightly

to minimize tension once the twoflaps are brought together.


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Modified Skate Flap

A Gore-Tex suture on a straightneedle is used for the periareolar

purse-string suture.

The suture is placed within thedeep dermal margin of the

periareolar incision and cinched

down to the desired areolar

diameter.

Reconstructed nipple and areola

with excellent projection and a

mild pseudoherniation of the

reconstructed areola.


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Skate Flap

T. Zhong, A. Antony, P. Cordero. Surgical

outcomes and nipple projection using the

modified skate flap for nipple-areolar

reconstruction in a series of 422 implant

reconstructions.Ann Plast Surg. 2009

May;62(5):591-5.


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Skate Flap

The largest series.

All patients with 2-staged TE/implantreconstructions followed by NAR using themodified skate flap.

Only patients with a minimum of 1-year follow-upwere included.

Patients with a history of irradiation to the breastwere excluded.

Clinical outcome measurements included long-term nipple projection as well as incidence ofcomplications.


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Skate Flap

292 patients with 422 NAR by the modified skateflap

At a median follow-up of 44 months (range: 12-84 months), mean nipple projection was 2.5 mm(range: 1-4 mm).

Minor complications occurred in 7.2% of thepatients.

Skin graft donor site dehiscence was the mostcommon complication (3.1%)

Partial skin graft nontake of the areola (2.1%).


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Star Flap

The star flap design was first described by

Anton and Hartrampf in 1991.

Since then multiple modifications have been

used.

One of the most reliable and commonly used

designs used today in nipple reconstruction.


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Star Flap with Dermal Platform

A. Sierakowski, N. Niranjan. Star flap with a

dermal platform for nipple reconstruction.Journal of Plastic, Reconstructive & Aesthetic Surgery

(2011) 64, e55-56.


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Three triangular flaps.

Arch is drawn from the

mid-point of the leading

edges of the lateral flaps

which transects thevertical flap across its mid-

point.

This creates three smaller

zones which are

deepithelialised.

The two de-epithelialised

zones are brought

together to create a semi-

circular dermal platform.


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300 patients over 15 years.

The use of a dermal platform helps prevent

loss of projection in the reconstructed nipple,

with good long term results.


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Comparison of 3 techniques

KC. Shestak, A. Gabriel, A. Landecker, S. Peters, A.

Shestak, J. Kim. Assessment of Long-Term

Nipple Projection: A Comparison of Three

Techniques. Plast Reconstr Surg. 2002 Sep1;110(3):780-6.


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Comparative assessment of nipple and areola projection after

the reconstruction with either a bell flap, a modified star flap,

or a skate flap.

Patients with 5 mm or less of opposite nipple projection were

treated with either the bell flap or the modified star flap.

In patients with significantly projecting a bell flap was chosen

over the modified star flap.

In patients with greater than 5-mm nipple projection,

reconstruction a skate flap was used.

Maintenance of nipple projection was assessed over a 1-year

period of follow-up.


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The best long-term nipple projection wasobtained and maintained by the skate and startechniques.

The major decrease in projection of the

reconstructed nipple occurred during the first 3months.

After 6 months, the projection was stable.

The loss of both nipple and areola projectionwhen using the bell flap was so significant thatthe authors discourage the use of the bell flaptechnique in NAC reconstruction.


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C-V Flap

A. Losken, M.D., GJ. Mackay, M.D., J. Bostwick, III,

M.D. Nipple Reconstruction Using the C-V

Flap Technique: A Long-Term Evaluation.

Plast Reconstr Surg. 2001 Aug;108(2):361-9.


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C-V Flap


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C-V Flap


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C-V Flap

Six-year follow-up views of

a patient after left NAC

reconstruction.


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C-V Flap

Long-term follow-up data for nipplereconstruction using the C-V flap technique.

11 patients in the study.

Questionnaire focusing on patient satisfactionusing a visual analogue scale.

Nipple measurements were taken and comparedwith the opposite breast for symmetry.

14 nipple reconstructions were evaluated in 11patients with an average follow-up of 5.3 years.

All patients had TRAM flap reconstructions.


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C-V Flap

Patient satisfaction was 42% with nipple projection ,

62% with pigmentation, and 26 % with sensation.

Overall patient satisfaction with the procedure was

81%. Average nipple projection of the reconstructed

nipple was 3.77mm - not statistically different when

compared with the opposite nipple.

Conclusion - long-term subjective evaluation of the

C-V flap technique shows a loss in nipple projection;

however, overall patient satisfaction at 5.3 years is

good.


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Swiss Roll Flap

CR. Macdonald, M.D., A. Nakhdjevani, M.D., A. Shah.

The "Swiss-Roll" flap: A modified C-V flap

for nipple reconstruction. Breast. 2011 May 10.


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Swiss Roll Flap

Similar to the C-V flap.

The two major differences:

- Flaps are raised with extended rectangular

wings ending with the V to facilitate in

tension-free closure.

- Only dermal flaps are raised devoid of any

subcutaneous fat.


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Swiss Roll Flap

The rectangular portion formsthe mass and lateral covering

of the nipple.

The rounded area will become

the cap of the nipple.

The hatch shaded area will

be de-epithelialised.

The block shaded

triangular wings are raised to

aid in a direct closure and are

reexcised.


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Swiss Roll Flap

One of the wings is de-

epithelialised prior to

rolling.


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Swiss Roll Flap

The flap is

rolled.


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Swiss Roll Flap


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Swiss Roll Flap

3 patients in the study. All nipples were reconstructed to a standard height of 1 cm.

At 3 months post-op the mean nipple projection was 9 mm(90% reconstructed height).

At 6 months the mean nipple projection was 8.7mm(87%reconstructed height).

No cases of nipple necrosis.

Only one patient was contactable at 2 years post-reconstruction .

She rated her satisfaction as very pleased with overallresult, very pleased with projection, as pleased now asat six months and very pleased with the symmetry.


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Diamond Double-Opposing V-Y Flap

The diamond double-opposing V-Y flap: a

reliable, simple, and versatile technique for

nipple reconstruction. Malcolm Lesavoy, M.D.,

Tom S. Liu, M.D.PRS. 2010 Jun;125(6):1643-8.


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Skin incision of

diamond island

flap.


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Elevation of the corners of

the flap,with care taken to

preserve the central

underlying subcutaneous

pedicle.

Medial rotation of flap limbs

with central suture.

Subcutaneous donor site

left open to demonstrate

original size of flap.


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V-Y closure of donor-site

limbs with a Prolene suture.

Example of the diamond

island design on a previously

healed transversemastectomy scar .

The direction of the diamond

island design limbs is

opposite the previousmastectomy scars.


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Postoperative

result of nipple

reconstructionafter areola

tattooing

after 2 weeks.


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Postoperative

result of nipple

reconstruction

after 8 years.


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Bipedicled Dermal Flap

G. Turgut, B. Sacak, T. Gorgulu, A.K. Yesilada, L. Bas.

Nipple Reconstruction with Bipedicled

Dermal Flap: A New and Easy Technique.

Aesth Plast Surg.Aesth Plast Surg(2009) 33:770773.


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13 patients with 19 nipple reconstructions.

7 underwent breast reconstruction with a

DIEP flap following unilateral mastectomy.

6 were diagnosed with gigantomasty and

underwent BBR with a free nipple grafting.

Flap design relies on a vertically oriented

bipedicled flap with horizontally oriented

extensions from the mid-portion.


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11 months after

breast reduction,

areola grafting, andnipple reconstruction


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15 month foolow-up.

No necrosis.

The mean new nipple projection was

measured as 9 mm, while mean nipple width

was measured as 10 mm.

No significant projection loss.

Patients satisfaction was noted as high.


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Trapeze Flap

J. Lebeau, M.D., T. Rodrigues Lopes, M.D., A. Gallodoro, M.D.,

B. Raphael, M.D. Nipple reconstruction: technical

aspects and evolution in 14 patients. Plast

Reconstr Surg. 2006 Mar;117(3):751-6.


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Trapeze Flap

14 nipple reconstructions.

5 cases - LD, 6 cases - TRAM, 3 cases

implants.

The results were assessed at least 10 months

after surgery.

3 possible indices of satisfaction could be

chosen by each patient: bad, good, and

excellent.


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Trapeze Flap

D Diameter of thenipple

H Height

The height of the

neonipple is

double that of the

reference nipple toadjust for the

shrinkage.


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Trapeze Flap

The trapeze can be oriented in any direction.


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Trapeze Flap

Suturing the two banks, upper and lower

horizontal, by separate stitches with

resorbable thread.


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Trapeze Flap

A purse-string suturecloses the top.


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Trapeze Flap

To prevent invagination of the neonipple, a hemicircular

patch is deepithelialized. This is the base on which the

neonipple will rest.


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Trapeze Flap

To prevent invagination of the neonipple, a hemicircular patch

is deepithelialized. This is the base on which the neonipple will

rest.


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Trapeze Flap


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Trapeze Flap

Immediate result on the left side and the result at 1

month on the right side.


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Trapeze Flap

Ten months later


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Trapeze Flap

The assessment of results by the patients:

excellent 3 cases, good - 10 cases.

1 case of necrosis at day 8 that required excision

and repair with a new flap. The variation in projection from the normal

nipple was


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S-Flap

K. Narra, M.D. A new approach to nipple

reconstruction: the modified s-flap. PRS. 2008

Aug;122(2):89e-90e.


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S-Flap

The modified S-flap

design. A 4 by 2-cm

elliptical incision

is performed downto the subcutaneous

fat layer with

modified S-flap

extensions toprevent constriction

of the randomized

bare skin flaps


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S-FlapThe faces of the

randomized

skin flaps are

opposed by

matching A to A

and B to B.

These flaps are

then assimilated

to the

contralateralnonoperative

nipple during

suturing.

Nipple Reconstruction:


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Nipple Reconstruction:

The Hammond Flap

Dolmans GH, van de Kar AL, van Rappard JH,

Hoogbergen MM. PRS. 2008 Jan;121(1):353-4.


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The Hammond Flap

14 NAC reconstructions in 11 patients.

8 patients underwent breast implant

reconstruction.

2 patients with lat dorsi reconstruction and 1

with TRAM.

Nipple and areola dimensions were measured

3, 6, and 12 months postoperatively.


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The Hammond Flap

During the flap elevation only a little

subcutaneous fat is left in place to preserve

the subdermal blood supply.

The surrounding skin is deepithelialized in theshape of the neo-areola.

The flap is folded into the shape of a cylinder.

The flap donor site is covered by a full-

thickness skin graft taken from the inner thigh.


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The Hammond Flap

The base of the flapis 1 cm.

The height is 1 cm.

The width is 3 cm.

The base of the flapis positioned

halfway between

the center and the

lower border of thenipple.


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The Hammond Flap


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The Hammond Flap

14 NAC reconstructions were performed.

The average overall satisfaction rate was 82%.

The average satisfaction rate with the amount of

nipple projection was 52%.

After 12 months, mean nipple projection was 5

mm (50 percent residual projection).

3 patients developed partial necrosis of the FTSG. All Hammond flaps survived.


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Spiral Flap

Giovanni Di Benedetto, M.D., Ph.D., Vanessa Sperti, M.D.,Marina Pierangeli, M.D., and Aldo Bertani, M.D., Ph.D.

A Simple and Reliable Method of Nipple

Reconstruction Using a Spiral Flap Made ofResidual Scar Tissue. PRS. 2004 Jul;114(1):158-61.


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Spiral Flap

The portion of the residualscar located medial to the

circle is drawn approximately

5 to 6 cm in length and

approximately 1 cm in width.

The skin is incised from

medial to lateral, leaving a

base of approximately 2 cmin width at the center of the

previously drawn new

areola.


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Spiral Flap

The flap is elevated and

then twisted in a spiral way

on its main axis andsutured, to resemble a

snail, with nylon 5-0

interrupted stitches

l l


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Spiral Flap

Neonipple with 60% overprojection compared

to the opposite normal nipple to make up for

the shrinkage of tissue.

Application of antibiotic ointment and aprotective hydrocellular dressing with a nipple

stent for approximately 3 weeks.

Neonipple with 60%


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Neonipple with 60%

overprojection compared

to the opposite normalnipple to make up for the

shrinkage of tissue.

Application of antibiotic

ointment and a

protective hydrocellular

dressing with a nipplestent for approximately 3

weeks.

l


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Arrow Flap

C. Rubino, L.A. Dessy and A. Posadinu. Modified

technique for nipple reconstruction: The

arrow flap.Br. J. Plast. Surg. 56: 247, 2003.

A Fl


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Arrow Flap

Prospective study. 32 patients with unilateral breast reconstruction

(16 implants, 16 TRAM flaps)

32 nipple reconstructions.

Implant reconstructions were randomly assignedto subgroups A1 and B1, whereas TRAM flapreconstructions to subgroups A2 and B2.

The modified star flap was used for group Apatients.

The arrow flap was used in group B.

A Fl


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Arrow Flap

The rectangle height is 150% of the final

required nipple projection.

A Fl


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Arrow Flap

The flap pedicle is

centrally located, on

the opposite side of

the rectanglecircle

juncture.

The donor site is

covered by a FTSG

from the upper innerthigh or primarily

closed and tattooed

at a later time.

A Fl


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Arrow Flap

In group A, the meanresidual projection percentage

of each nipple was 34.3%

The mean nipple projection

was 3.25 mm.

In group B, the meanpercentage was 49.1%, and the

mean nipple projection was

4.75 mm (p , 0.001).

NAC B ki


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NAC Banking

A. Ahmed, D. Hahn, J. Hage, E. Bleiker, Le.

Woerdeman. Temporary banking of the

nipple-areola complex in 97 skin-sparing

mastectomies. Plast Reconstr Surg. 2011Feb;127(2):531-9.

NAC B ki


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NAC Banking

61 women underwent skin-sparingmastectomies (stage 1 Ca or prophylaxis)

Total of 97 NAC banking and replantations.

The groin or lower abdominal areas were

chosen as the site of temporary banking.

The areola was harvested as a FTSG in

combination with the nipple as a compositegraft.

NAC B ki


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NAC Banking

Frozen sections were obtained. If negative, the banking site was

deepithelialized to receive the graft.

The banked nipple-areola complexes werereplanted only after the size and shape of thereconstructed mammary mound had provenacceptable - at least 3 months after skin-

sparing mastectomy.

No recurrent, residual, or de novo tumor.

NAC B ki


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NAC Banking

The skin-sparing mastectomy is startedwith the areola as a full-thickness skin

graft in combination with the nipple as a

composite graft

10 days post-op

3 months post-op

NAC B ki


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NAC Banking

The temporary banking

site is closed primarily,

leaving a single linear scar

with a lengthapproximately twice the

diameter of the

transplanted nipple-

areola complexes.

NAC B ki


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NAC Banking


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Banked Cartilage Graft


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M. Cheng, M. Ho-Asjoe, F. Wei, D. Chuang. Nipple

reconstruction in Asian females using banked

cartilage graft and modified top hat flap. Br J

Plast Surg. 2003 Oct;56(7):692-4.



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25 patients underwent nipple reconstructions. All previous TRAM flap recons with the internal

mammary artery and vein as recipient vessels.

During the initial dissection, the third costalcartilage is removed to expose the underlyingvessels.

1 cm segment of costal cartilage is banked

between the flap and the mammary pocket. Nipple reconstruction at 3 months post-op.



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The length of the

two wings equals

the circumference of

the circular top.

The circular marker

at 11 oclock shows

the position of the

banked costalcartilage.



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Retreived banked

cartilage



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3 months post-op



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None of the patients complained abouthardness of the nipple.

The height of nipple projection was

maintained at above 1 cm in all cases.

No excessive decrease in nipple projection at 3

month to 1 year follow-up.

AlloDerm


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AlloDerm

C. Garramone, B. Lam. Use of AlloDerm inPrimary Nipple Reconstruction to Improve

Long-Term Nipple Projection. PRS. 2007

May;119(6):1663-8.

AlloDerm


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AlloDerm

Modified star dermal flap pattern measuring 5cm in length and 1.0 to 1.5 cm in width.

1.5 by 4.5-cm piece of AlloDerm was placed

into the core of the newly reconstructednipple and sutured closed.

Ocular eye bubble protector was used to

protect the reconstructed nipple for 6 weeks.

AlloDerm


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AlloDerm

A profile view of a nipplereconstructed with a skate flap

3mm projection.

The modified star flap is

marked with a length of 5 cmand a width of 1.0 to 1.5 cm.

Dermal flaps are elevated and

wrapped around each other,forming a barrel shape

A piece of AlloDerm is cut to

the dimensions of 1.5 4.5 cm.

AlloDerm


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AlloDerm

The AlloDerm is rolled lengthwise

with the dermal side out, into a

barrel shape and secured to itself

using Vicryl suture.

The AlloDerm is placed into thecore of the new nipple.

12 month postop photograph

of a TRAM flap patient with a nipple

reconstructed with AlloDermprojection of 0.8cm (original

intraoperative height measurement

of 1.5 cm).

AlloDerm


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AlloDerm

30 nipple reconstructions were performed.

14 TRAMS and 16 tissue-expanded breast mounds.

Measurements of nipple projection were recorded at

the time of surgery and at 3, 6, and 12 months post-op.

At 12 months, average maintenance of nipple

projection was 56 percent for the TRAM flap group

and 47 percent for the tissue-expanded group.

No infections or associated complications.

Filler Injection


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Filler Injection

P. Panettiere, L. Marchetti, and D. Accorsi. FillerInjection Enhances the Projection of the

Reconstructed Nipple: An Original Easy

Technique.Aesthetic Plast Surg. 2005 Jul-Aug;29(4):287-94.

Filler Injection


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Filler Injection

70 patients in total.

90 nipples reconstructed using either a small wedgefrom the labia minora (LMW) (n = 70) or nipple sharing(NS) (n = 20).

At 2 months each reconstructed nipple was injectedwith DermaLive (hydroxyethylmetacrylate andethylmetacrylate in a hyaluronic acid suspension).

Second and third injections were performed 2 and 5months later.

Nipple projection was measured at the moment ofreconstruction, before and after each injection, and 6and 12 months after the last injection.

Filler Injection


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Filler Injection

Injection

technique:

inside the

nipple (A)and at the base

(B).

Filler Injection


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Filler Injection

(A,B) Unilateral nipplereconstruction with a

small wedge from the

labia minora at 12

months.

(C,D) Bilateral nipple

reconstruction with

nipple sharing at 12

months.

Filler Injection


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Filler Injection

Nipple projection was satisfactory in all casesand comparable with that of the contralateral

nipple.

The average nipple projection at 6 monthswas 5.8 mm in the LMW group and 3.8 mm in

the NS group (p < 0.01) and, respectively, 5.6

mm and 3.5 mm at 12 months (p < 0.01). No complications occurred.

Nipple Sharing


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Nipple Sharing

M. A. Bhatty and R. B. Berry. Nipple-areolareconstruction by tattooing and nipple

sharing. British Journal of Plastic Surgery (1997), 50,

331-334.


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Nipple Sharing


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Nipple Sharing

First, the areola is tattoed. At a second stage l-3 months later, the nipple is

reconstructed.

A small disc of epidermis of an appropriate

diameter is excised from the centre of thetattooed areola.

A composite graft is taken from the distal half ofthe normal nipple and sutured to the de-

epithelialized area. The donor site defect is allowed to heal by

secondary intention.

Nipple Sharing


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Nipple Sharing

Left breastrecon

(implant),

right breast

reduction at 1and 3 years.

Nipple Sharing


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Nipple Sharing

17 patients had a nipple reconstruction by thenipple sharing technique.

At follow-up of 2 months to 4 years, 4 patients

have required further tattooing because offading of the pigment and 1 patient had agross areolar colour mismatch.

There have been no nipple graft failures.

Reconstructed nipples had adequateprojection.

Far From Evidence Based Approach


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Far From Evidence Based Approach

A combination of a single pedicle local flap withtattooing for complete NAC reconstruction iscurrently the most supported method.

However, the majority of the literature is

retrospective analyses with variation inoutcomes.

Data concerning which type of reconstruction is

best suited to immediate versus delayedreconstruction and type of breast mound stillremain to be examined.

Documents

Nipple Reconstruction