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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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Star Flap with Dermal Platform
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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Star Flap with Dermal Platform
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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Comparison of 3 techniques
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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Comparison of 3 techniques
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Comparison of 3 techniques
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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Diamond Double-Opposing V-Y Flap
Skin incision of
diamond island
flap.
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Diamond Double-Opposing V-Y Flap
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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Diamond Double-Opposing V-Y Flap
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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Diamond Double-Opposing V-Y Flap
Postoperative
result of nipple
reconstructionafter areola
tattooing
after 2 weeks.
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Diamond Double-Opposing V-Y Flap
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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Bipedicled Dermal Flap
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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Bipedicled Dermal Flap
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Bipedicled Dermal Flap
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Bipedicled Dermal Flap
11 months after
breast reduction,
areola grafting, andnipple reconstruction
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Bipedicled Dermal Flap
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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Banked Cartilage Graft
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.
Banked Cartilage Graft
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Banked Cartilage Graft
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.
Banked Cartilage Graft
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Banked Cartilage Graft
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.
Banked Cartilage Graft
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Banked Cartilage Graft
Retreived banked
cartilage
Banked Cartilage Graft
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Banked Cartilage Graft
3 months post-op
Banked Cartilage Graft
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Banked Cartilage Graft
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.
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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.
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Injection
technique:
inside the
nipple (A)and at the base
(B).
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(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.
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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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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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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.
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Nipple Sharing
Left breastrecon
(implant),
right breast
reduction at 1and 3 years.
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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.