CLINICAL PAPERS

Free Nipple Grafting An Alternative for Patients Ineligible for Nipple-Sparing Mastectomy? Erin Louise Doren, MD,* Lauren Van Eldik Kuykendall, MD,* Jonathan Jeremiah Lopez, MD,* Christine Laronga, MD, FACS,Þ and Paul David Smith, MD*Þ Abstract: Nipple-sparing mastectomy is an option for patients fitting oncologic criteria and may improve cosmetic outcomes of breast reconstruction. When anatomical limitations exist, we propose the use of free nipple grafting, akin to reduction mammaplasty. This study is a retrospective review of patients having a nipple-sparing mastectomy and immediate reconstruction using free nipple grafting (N = 36 breasts). Average graft take was 93.6% with no nipples having complete graft loss. Four nipples (11%) lost all projection and 4 nipples experienced significant hypopigmentation requiring tattooing (11%). For those ineligible for nipple-sparing mastectomy due to anatomical limitations, free nipple grafting is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties and, more importantly, saves women a subsequent operation for nipple reconstruction. Key Words: breast reconstruction, nipple-sparing mastectomy, free nipple grafting, nipple reconstruction, breast reduction (Ann Plast Surg 2014;72: S112YS115)

O

ver the past several decades, the surgical management of breast cancer has significantly evolved with guidance by principles of patient safety, oncologic safety, and more recently cosmetic outcome.1,2 The optimal cosmetic outcome following mastectomy and reconstruction involves preservation of the nipple-areolar complex.2 The nipple-areolar complex defines a breast as a breast and similarly defines a reconstructed breast mound.2 Nipple-sparing mastectomy is emerging as a safe alternative to skin-sparing mastectomy for both therapeutic and prophylactic indications in properly selected patients.3 Additionally, nipple-sparing mastectomy has been demonstrated repeatedly to have a positive impact on body image and patient statisfaction.3 Spear et al, among many others, have developed widely accepted patient selection criteria for nipple-sparing mastectomy based on oncologic and surgical factors.2,3 The oncologic criteria include a tumor size less than 3 cm, tumor greater than 2 cm from the nipple-areolar complex, clinically negative axillary nodes, and no skin involvement or inf lammatory cancer/Paget disease.2,3 Operative criteria include negative intraoperative frozen section and negative permanent nipple pathology.2,3 Certain anatomic criteria also exist that can preclude patients from undergoing nipple-sparing mastectomy, which include

Received October 21, 2013, and accepted for publication, after revision, October 29, 2013. From the *Division of Plastic Surgery, Department of Surgery, University of South Florida, Tampa, FL; and †Comprehensive Breast Program, H. Lee Moffitt Cancer Center, Department of Women’s Oncology, Tampa, FL. Conflicts of interest and source of funding: none declared. The contents of this paper were reported in poster format at the American Association of Plastic Surgeons (AAPS), New Orleans, Louisiana, April 2013 and at the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS), Bonita Springs, Florida, June 2013. Reprints: Erin Louise Doren, MD, Division of Plastic Surgery, Department of Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7202-S112 DOI: 10.1097/SAP.0000000000000077

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large breast size (greater than 500 g), breast ptosis (grade II-III), radiation, and prior periareolar incisions.2Y4 Additional patient factors, although not absolute contraindications, can cause an increased risk for postoperative complications. Factors including BMI greater than 25 kg/m2, breast mass greater than 750 g, and sternal notch to nipple distance greater than 26 cm are associated with increased risk of f lap necrosis, partial flap loss, and wound dehiscence.3,4 When these anatomical limitations exist, alternative strategies for preserving the nipple include reducing the skin envelope before mastectomy, grafting the nipple-areolar complex, or performing a mastopexy at the same time as the mastectomy.1,2,5 In 1987, Woods described his approach to nipple-sparing mastectomy with simultaneous mastopexy and suggested that the nipple could be spared and the skin envelope reduced at the time of mastectomy to create better cosmetic outcomes.5,6 However, that option has become less favorable because of the need to retain larger quantities of breast tissue to ensure nipple and f lap viability.5 More recently, Spear et al proposed a staged approach with a pre-mastectomy mastopexy or reduction in carefully selected patient with ptosis or macromastia.5 Although this staged approach has comparable complication rates to published ranges of nipple-sparing mastectomy and skin-sparing mastectomy with immediate reconstruction, the patients are subjected to multiple operations.5 We propose an alternative, single-stage reconstruction with the use of free nipple grafting, akin to reduction mammoplasty, with anticipated similar complication rates.

METHODS This study is a retrospective review of 21 prospectively gathered patients having a nipple-sparing mastectomy with immediate breast reconstruction using free nipple grafting. Moffitt Cancer Center has established our institutional eligibility and exclusion criteria for nipple-sparing mastectomy which encompasses oncologic and technical/ cosmetic considerations. Patients, thus, were excluded from standard nipple-sparing mastectomy at our facility based on the following institutional ineligibility criteria: prior periareolar incisions (n = 2), breast size greater than 700 g (n = 3), grade II-III ptosis (n = 1), previous radiation treatment (n = 5), and desire for autologous reconstruction (n = 10). Skin-sparing mastectomies were performed by a single breast surgeon in a standard fashion via a circumareolar incision. The nipple-areola complex was then harvested from the mastectomy specimen as a full-thickness graft with a 10-blade scalpel (Fig. 1). Frozen sections from the base of the nipple were sent to assure there was no malignancy or atypia in the specimen. The nipples were defatted in a standard fashion with minimal thinning of the dermis. Breast reconstruction, prosthetic or autologous, was then performed, on occasion requiring a vertical reduction pattern or change of nipple position. Free nipple grafts were then re-implanted to the deepithelialized recipient sites and secured with a Xeroform bolster. Bolsters were removed in the clinic on postoperative days 7Y10. Complications and outcome were recorded in the patient’s medical record and subsequently logged in the breast reconstruction database. Photos of all patients were reviewed at the last documented postoperative visit to assess overall graft take, nipple projection, and areola Annals of Plastic Surgery

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Free Nipple Grafting for Nipple-Sparing Mastectomy

hypopigmentation requiring subsequent nipple-areola tattooing. The type of reconstruction did not impact the rate of complications requiring intervention or return to the operating room (Table 1). No patient had recurrence of cancer on final follow-up visit. Examples of preoperative and postoperative patients can be found in Figures 2 and 3.

DISCUSSION

FIGURE 1. Free nipple grafts harvested.

pigmentation. A chi-square test using exact method with Monte Carlo estimation was used to determine if the type of breast reconstruction affected complication rates. Complications included anything that required surgical or procedural intervention.

RESULTS Of 21 patients, 8 women had bilateral prophylactic mastectomy, 6 women had unilateral mastectomies, and 7 women had bilateral mastectomies for unilateral cancer, totaling 36 nipple-areola grafts harvested. The mean patient age at the time of surgery was 48 years (range 21Y66 years) and none of the women had a current or recent (6 months) history of tobacco use. The mean BMI was 24.98 (range 20Y33.1). Most of the women had grade 2 ptosis and the mean breast weight at mastectomy was 481.76 g (range 110.4Y835.8 g). The mean follow-up was 17.28 months (range 0.7Y69 months). Reconstruction was performed as follows: implant sparing with latissimus dorsi muscle f lap (2/36), transverse rectus abdominus myocutaneous f lap (TRAM) (18/36), and latissimus dorsi f lap with tissue expanders (16/36). All nipple base pathology was found to be benign on frozen and permanent specimens. Upon removal of nipple Xeroform bolsters, many patients had a small amount of epidermolysis. The average graft take, with full-thickness necrosis being a value of zero and no necrosis 100, was 93.6% (range 60%Y100%). No patients had complete nipple necrosis (0%). Average nipple projection was 59% of original size (n = 34, as 1 patient did not have longterm follow-up photo) (range 0%Y100%). Four (of 36) nipples (11%), in 3 patients, lost all projection and required subsequent nipple reconstruction. Pigmentation of the nipple-areola was rated by the surgical team on a scale of 0%Y100%, zero with no pigmentation remaining, 100% normal pigmentation, the average was 86.5% (n = 34, as 1 patient did not have long-term follow-up photo) (range 20%Y100%). In addition, four (of 36) nipples (11%), in 2 patients, experienced significant

Nipple-sparing mastectomy is increasingly being performed in appropriately selected patients for both therapeutic and prophylactic indications.1,3,5,7 The benefits of preserving the nipple-areolar complex go beyond mere cosmetic results of the breast reconstruction but also include functional outcomes and patient satisfaction as it can be difficult to match projection, size, color, shape, texture, position, and sensation with nipple reconstruction.7 Ensuring optimal outcomes requires appropriate patient selection from an oncologic, surgical, and anatomic perspective. In patients who meet inclusion criteria from an oncologic standpoint but are limited secondary to anatomic factors such as breast size and degree of breast ptosis, the reconstructive options for preserving the nipple-areolar complex become limited and quite challenging. Newer strategies are being developed to prevent postoperative complications, such as skin f lap and nipple necrosis, which are even more important in this patient population which requires preserving all the native breast skin.5 For women desiring nipple-sparing mastectomy and immediate reconstruction but technically limited by larger breast size or degree of ptosis, we investigated the feasibility of free nipple grafting as a single-stage approach. Akin to a reduction mammaplasty, we experienced good aesthetic results and a low rate of postoperative complications. In contrast, Spear et al has proposed a pre-mastectomy, mastopexy/reduction, staged approach as an alternative to permit nipple-sparing mastectomy in the large- or ptotic-breasted patient.5 This approach entails that the mastopexy or reduction be performed as a pre-mastectomy procedure with repositioning of the nipple and reducing the skin envelope. After a minimum of 4 weeks, a nipplesparing mastectomy through the mastopexy incisions is performed with subsequent final reconstruction.5 Using this staged approach, they report that 17% of the breasts had a complication that required return to the operating room, and 13% had partial nipple-areolar complex necrosis with no total nipple-areolar complex necrosis.5 Patient satisfaction or surgeon satisfaction with final nipple position were not discussed. Although the pre-mastectomy staged approach is an acceptable alternative with comparable complication rates, the major disadvantage is that the patients are subjected to multiple operations, which may increase morbidity and cost, and contribute to patient dissatisfaction. Our single-stage approach using immediate reconstruction with free nipple grafting in patients with anatomic limitations deserves consideration as a viable alternative. Free nipple-areolar grafting has been described for many decades in patients undergoing reduction mammaplasty.8,9 Indications for reduction mammaplasty with free nipple-areolar grafting include patients with massive breast hypertrophy or gigantomastia, previous breast surgery that may risk viability of the nipple, overweight ptotic

TABLE 1. Type of Reconstruction Versus Complication Requiring Intervention Reconstruction LD with implant sparing LD with TE TRAM Total

Total

No Complication

Yes Complication

P

2 (5.6%) 16 (44.4%) 18 (50%) 36

1 (50%) 14 (87.5%) 13 (72.2%) 28 (77.8%)

1 (50%) 2 (12.5%) 5 (27.8%) 8 (22.2%)

0.3207

LD indicates latissimus dorsi; TE, tissue expander.

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FIGURE 2. A, Preoperative, patient with right breast cancer and prior periareolar incision. B, Postoperative, right breast latissimus implant reconstruction and free nipple graft, left breast augmentation for symmetry.

breast, and poor-risk elderly patients or those with severe systemic disease where shorter anesthetic time would be an advantage.8Y10 Disadvantages of free nipple grafting include loss of nipple sensation, loss of projection, hypopigmentation, and graft loss requiring further reconstruction.8Y10 However, a properly prepared full-thickness nippleareolar graft can preserve both projection and nipple contour which leads to improved patient satisfaction and cosmetic outcomes.10 Additionally, there is some evidence that nipple sensation and erotic function can be partially recovered postoperatively with free nipple grafting.9 Our rates of graft loss, loss of projection, and hypopigmentation are comparable to the reported rates in the literature for reduction mammaplasties with free nipple grafts.8Y11 A review of free nipple grafting and patient satisfaction in breast reduction by McGregor et al showed complete loss of the nipple-areolar complex in 1 patient and partial loss in 18% of patients requiring minor interventions.8 Additionally, nipple projection was satisfactory in 14 women (55% of nipples) and nipple sensation was present in 30% of nipples.8 Guven et al retrospectively reviewed 24 patients undergoing reduction mammaplasty with free nipple grafting over a 4-year period. He reported partial nipple-areolar complex loss in 8% of patients, all of which were treated conservatively, and hypopigmentation in 20.8% of patients.11 The major advantage of our method is that the reconstruction can be done in 1 stage, saving the women subsequent operations. The rate of re-operation was low, with no patients requiring nipple reconstruction for graft loss and 3 requiring reconstruction for

complete loss of projection. Adequate cosmetic results were obtained despite having some loss of nipple projection and hypopigmentation as the presence of a native nipple on a reconstructed breast positively inf luences patient satisfaction.12 Previous studies have shown that patients express dissatisfaction with various aspects of their reconstructed nipple including poor shape, size, texture, position, color, and projection.12 Although surgical reconstruction of an absent nipple can provide acceptable aesthetic results, these results are not ideal.12 In this study, criteria for free nipple grafting with nipplesparing mastectomy were a prior periareolar incision, breast size greater than 700 g, grade II-III ptosis, previous radiation treatment, and desire for autologous reconstruction. When the reason for using a free nipple approach was significant breast ptosis, it raises the issue of how did we change the nipple position. On occasion, we recommend performing a small crescent or vertical mastopexy at the time of mastectomy and reconstruction to change the position for placement of the nipple graft. However, we found that this is rarely necessary as the act of removing the breast tissue and shaping with immediate autologous reconstruction allows the nipple position to be adjusted and subsequently the mastectomy skin shrinks to the desired position. As a direct result of this study, we have changed our view on the use of free nipple grafts for the reason of autologous reconstruction alone. Studies have now demonstrated that it is safe to bury f laps, including free f laps, for single-stage breast reconstruction with nipple-sparing mastectomy in the appropriately selected patients.13 Therefore, currently we perform nipple-sparing mastectomy, without free nipple grafts, on patients having autologous and free f lap

FIGURE 3. A, Preoperative, right breast cancer, desire for autologous reconstruction. B, Postoperative, right mastectomy with TRAM reconstruction and free nipple grafting. S114

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reconstruction, as long as they do not have significant breast ptosis or breast size, and we are confident that the nipple will end up in the correct position.

CONCLUSIONS Increasingly popular nipple-sparing mastectomy is an option for women meeting oncologic and anatomic criteria. For those women ineligible for technical reasons, free nipple grafting is an option with complication rates similar to free nipple grafting in reduction mammaplasties. More importantly, free nipple grafting at mastectomy with immediate reconstruction saves these women a subsequent operation for nipple reconstruction. REFERENCES 1. Spear SL, Hannan CM, Wiley SC, et al. Nipple-sparing mastectomy. Plast Reconstr Surg. 2009;123:1665Y1673. 2. Laronga C, Lewis J, Smith P. The changing face of mastectomy: an oncologic and cosmetic perspective. Cancer Control. 2012;19:286Y294. 3. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128:1005Y1014. 4. Davies K, Allan L, Roblin P, et al. Factors affecting post-operative complications following skin sparing mastectomy with immediate reconstruction. Breast. 2011;20:21Y25.

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Free Nipple Grafting for Nipple-Sparing Mastectomy

5. Spear SL, Rottman SJ, Seiboth LA, et al. Breast reconstruction using a staged nipple-sparing mastectomy following mastopexy or reduction. Plast Reconstr Surg. 2012;129:572Y581. 6. Woods JE. Detailed technique of subcutaneous mastectomy with and without mastopexy. Ann Plast Surg. 1987;18:51Y61. 7. Tanna N, Broer PN, Weichman KE, et al. Microsurgical breast reconstruction for nipple-sparing mastectomy. Plast Reconstr Surg. 2013;131:139eY147e. 8. Mcgregor JC, Hafeez A. Is there still a place for nipple areolar grafting in breast reduction surgery? A review of cases over a three year period. J Plast Reconstr Aesthet Surg. 2006;59:213Y218. 9. Ahmed OA, Kolhe PS. Comparison of nipple and areolar sensation after breast reduction by free nipple graft and inferior pedicle techniques. Br J Plast Surg. 2000;53:126Y129. 10. Colen SR. Breast reduction with use of the free nipple graft technique. Aesthetic Surg J. 2001;21:261Y271. 11. Guven E, Aydin H, Basaran K, et al. Reduction mammaplasty using bipedicled dermoglandular flaps and free-nipple transplantation. Aesth Plast Surg. 2010; 34:738Y744. 12. Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipplesparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125:818Y829. 13. Levine SM, Snider C, Gerald G, et al. Buried flap reconstruction after nipplesparing mastectomy: advancing toward single-stage breast reconstruction. Plast Reconstr Surg. 2013;132:489eY497e.

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implant-based breast reconstruction.

Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the trad...
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