Nipple-areolar reconstruction is undertaken to complete a breast reconstruction such that it looks more natural- looking breast. Retrospective analyses have shown that patient satisfaction with their breast reconstruction highly correlates with the presence of a nipple and areola.1 It is best to wait a few months following breast mound reconstruction before reconstructing the nipple, irrespective of the original breast mound reconstructive technique, as this allows the breast tissue to stabilize and develop a more natural ptosis. Performing the nipple reconstruction early increases the risk of incorrect placement. Unfortunately, there is no gold standard technique for consistently producing the ideal nipple and many different techniques are, therefore, in use. Such techniques include local flaps and nipple sharing, each of which is simple and can be undertaken with local anesthetic as an outpatient procedure.2 The downtime is very short, and most patients can return to normal activities the following day.
2. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg 2006;59(1):40–53 A key goal of nipple reconstruction is to achieve symmetry between the two breasts and for this reason the new nipple may need to be placed in a nonanatomic position. Ideally the nipple will be sited at the point of maximal projection (or convexity), but this is not always possible when considering symmetry. Nipple position is an important contributor to the final result of breast reconstruction and the patient should be involved in the decision-making process because this improves patient satisfaction. Patients should be marked standing straight with the shoulders relaxed, in the presence of a chaperone. The orientation of the C-V flap will depend on the orientation of scars on the breast mound rather than be limited to a set transverse design.1,2
There are a range of different local flap techniques used in nipple reconstruction. The skate flap remains a popular traditional flap that uses local flaps and a skin graft to provide predictable, versatile nipple reconstruction (Fig. 60.1). A central dermal fat pedicle is elevated from the breast mound with lateral wings that may be either partial or full thickness. The wings are wrapped around the central dermal fat pedicle and the donor site is closed with a skin graft. The modified skate flap avoids skin grafting by using local flaps to achieve direct closure. The Bell flap is useful for reconstructing a nipple that requires little projection and involves a local flap without skin grafting (Fig. 60.2). It involves a pull-out flap that is folded on itself and the donor site is closed primarily with a purse-string suture. Maximal projection of the flap is half the flap length because it is folded on itself. The star flap is a derivative of the skate flap that avoids the use of a skin graft. It is simple to create but tends not to provide much projection (Fig. 60.3). The fishtail flap is a modification of the C-V flap where the V flaps are angulated to be less than 180 degrees from one another. The S flap uses two adjacent flaps in conjunction with a full-thickness skin graft and is useful in areas where a scar crosses the proposed location for the nipple. For further reading, see also the review article by Farhadi et al.1 A B C D E Incision Purse-string suture Fig. 60.2 Bell flap. (Adapted from Spear SL, Little JW, Bogue DP. Nipple areola reconstruction. In: Spear SL, Willey SW, Robb GL, et al, eds. Surgery of the Breast: Principles and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.) E Distal tip of flap is past midline, permitting stacking B D A C 4 mm adipose tissue Fig. 60.3 Star flap. (Adapted from Hartrampf CR, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg 73:982, 1984.) B C E F Incision H H Graft A D Fig. 60.1 A–C, Skate flap with primary closure of donor site. D–F, With skin graft. (Adapted from Spear SL, Little JW, Bogue DP. Nipple areola reconstruction. In: Spear SL, Willey SW, Robb GL, et al, eds. Surgery of the Breast: Principles and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)
The main problem with local flap nipple reconstruction techniques is a lack of long-term projection. Areolar fading occurs after tattooing but can easily be touched up in clinic. In fact, patients may need to do so multiple times. Patient satisfaction is a very important goal of nipple reconstruction, and patients are generally very satisfied after this procedure. Some studies suggest that the principal determinant of patient dissatisfaction with nipple reconstruction is excessive flattening.1 However, this is not uniformly the case, and patients have been shown to have high levels of satisfaction even where nipple projection is not well maintained.2 Scar stretch can be a problem as scars do not reliably accept tattoo pigments, but hypertrophic scarring is uncommon and may be treated with conservative measures such as massage, silicone therapy, and steroid injection.
Loss of nipple projection will depend on several factors such as flap design and tissue quality. Reports of projection loss vary within the literature and range from 43 to 71% when C-V–type skin flaps are used.1 Banducci et al2 reported a decrease of 71% at 3 years using a modified star flap. Shestak et al3 observed a 50–70% reduction at 2 years with local flaps (including star, skate, and bell flaps). Attempts to improve projection include placing auricular cartilage or AlloDerm within the nipple construct and these have reported varied results. Jones and Erdmann4 found a 67% reduction at 2 years even when cartilage grafts were placed inside the construct. The dressings placed around the nipple reconstruction may affect the reconstruction, and compression should be avoided. This is usually achieved by placing a donut-shaped dressing around the nipple and avoiding direct pressure from garments.
The C-V flap has evolved from the skate flap and preoperative markings are shown in Fig. 60.4. It comprises a central C flap with bilateral V flaps. The V flaps wrap around to form a cylinder-shaped construct which creates the walls of the nipple papule and the C component then forms the construct lid. The main factor that will dictate the initial nipple projection will therefore be the width of the V flaps. The length and depth of the V flaps will dictate how wide or bulky the papule is. It is advisable to oversize the flaps to allow for subsequent shrinkage. A rule of thumb is to create a nipple that starts off twice the desired final height.1,2 V C Diameter of nipple Height of nipple Circumference of nipple Fig. 60.4 C-V flap. The width of the V flap determines nipple projection, and the diameter of the C flap determines nipple diameter. (From Bostwick J III. Nipple-areolar reconstruction. In: Bostwick J III, ed. Plastic and Reconstructive Breast Surgery, 2nd ed. St Louis: Quality Medical Publishing, 2000.)
Nipple inversion is relatively common and affects 1 in 10 women of child-bearing age. It is usually bilateral and many cases are as a result of chronic mastitis, but the most common cause is congenital. Other important causes include breast cancer and Paget’s disease of the nipple and these must be diagnosed and treated early. Inversion results from relative shortness of the lactiferous ducts that tether the nipple and prevent normal projection, and a paucity of normal dense collagenous tissue surrounding the ducts.1
Evaluation of patients with inverted nipples involves an assessment of whether the inversion can be manually corrected and whether it maintains correction following release of traction. This is important as it provides information on the severity and guides surgical management. The classification system by Han and Hong1 formally grades the severity of nipple inversion based on the findings of this assessment: Grade I: Nipple can be easily pulled out manually and maintains projection without traction. Grade II: Nipple can be pulled out manually but with less ease than grade I and tends to retract. Grade III: Nipple is inverted, difficult to pull out manually, and promptly retracts. Surgical management involves release of the pathologic bands with or without release of the lactiferous ducts and creation of tightness at the neck of the inverted nipple using a purse-string suture. Additional bulk may also be added beneath the nipple using cartilage or adjacent dermal fat flaps providing that full release has been undertaken.