VIEWPOINTS ViewpointS GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text—maximum of 500 words (not including references) • References—maximum of five • Authors—no more than five • Figures/Tables—no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

Viewpoints AQ: 1

A ModifiedNecrosis Template Reconstruction Managing of for the Microtia Nipple-Areola Tested by Surgical Simulation on Ipomoea Complex in Breast Reconstruction after N ­ batatas ippleSir: Sparing Mastectomy: Immediate Nipple-Areola icrotia reconstruction with is a Banked challengeSkin for plastic Complex Reconstruction

performed by generating a skin of island under spared simulation allows development these skills,the reducing nipple-areola complex without deepithelialization. mistakes, shortening surgical time, and improving re4 nipple-areola complex necrosis was diagWe performed a surgical simulation exsultsWhen in vivo. nosed 2 to study, 3 weeks after nipple-sparing mastectomy, perimental evaluating traditional and modified débridement of the asnecrotized theframecomauricular templates guides forportion carvingofear plex carriedbatatas, out under local and anesthesia. workswas on Ipomoea comparing analyzingIndithe vidualized reconstruction was planned in accordance obtained results. with thetraditional proportional defectswere afterbased débridement. The templates on sheetsIfofa patient lostsketched the entire nipple-areola complex, thestrucnippaper and lines representing the main ple thenexternal reconstructed a modified op-hat tureswas of the ear (i.e.,with helix, antihelix, t­tragus, flap from the bankedfossa, skin scaphoid (Fig. 1). The antitragus, triangular fossa,remaining and conbanked skin was tailored to fit the defect. cha) (Fig. 1). The proposed modified areolar templates were Necrosis of the part of the areola with the intact nipbased on paper sheets, with lines representing the main ple was managed by filling the areola skin defect with structures and markings detailing the depths of each of banked skin after tailoring. these structures as follows: whole painted, striped, and Among the 52 nipple-sparing mastectomy cases, unpainted (meaning deep, not deep, elevated, reskin banking was performed in 25 and (48.1 percent). spectively). The striped lines, at the same time, repreNipple-areola complex necrosis occurred in six sented corresponding more depth whentodrawn together 1). cases, 11.5 closer percent of all (Fig. nippleIpomoea batatas, also known as sweet potato, was sparing mastectomy cases and 24 percent of the

used because of its similarity in consistency and flexibility to human rib cartilage.5 Each sweet potato model was referred to as an individual case. Five common carving tools with different curves and angles were used to sculpt the models. Eight novel surgeons were tested; half of them used the traditional template and the other half used the modified template. The exercise was repeated twice. The resulting auricular sculptures were evaluated based on aesthetic results, ranked according to resemblance to the real ear model, being classified as poor, fair, or good results. Aesthetically different auricular frameworks were obtained using the two different types of templates. Better definition of three-dimensional structures (i.e., helix, antihelix, tragus, antitragus, scaphoid fossa, triangular fossa, and concha) and better aesthetic results were obtained using the modified template (n  16).

M

presenSir: surgeons because of its variable clinical 1 Although tation and difficult surgical reconstruction. ipple-sparing mastectomy is perceived to have cerseveral methods have been tainreconstructive aesthetic benefits that improve the proposed, outcomes 1,2 reconstruction with autologous costal cartilage, as elabof breast reconstruction. When the spared nipple or orated isand modified however, by Tanzer, Brent, andoutcomes Nagata, areola necrotized, suboptimal remains the best option with which to obtain favorable will follow. Conservative treatment with secondary results with fewer complications than other reconstruchealing has been the main approach to date when options.2 complex necrosis occurs.3,4 An early ntive ­ ipple-areola The three-dimensional topography of the external intervention of débridement of the necrotized portion earthe accurately reflectscomplex the shape the internal cartiof nipple-areola andofprompt individualized reconstruction with banked skin can prevent negaanatomical and struclaginous skeleton.3 Reproducing tive turalconsequences. details of the external ear is a challenge for any If there wasand suspicion nipple plastic surgeon requires of a high levelorof areolar surgical skin skill ischemia, skin planned. Skin banking was and training tobanking fulfill thewas patient’s expectation. Surgical

N

Copyright © 2013 by by the American Society of Plastic Surgeons ©2012

Fig. 1. Total nipple-areola reconstruction via a modified top-hat flap technique in a patient with total necrosis of the ­nipple-areola complex. (Above) Three weeks after initial reconstruction, nipple-areola complex necrosis was confirmed. (Below) After débridement of the necrotized tissue, reconstruction wasTraditional performedand using the previously skin flap. Fig. 1. modified auricularbanked templates.

www.PRSJournal.com

73e 1

rich3/zpr-prs/zpr-prs/zpr01012/zpr6009-12a angnes S8 8/13/12 18:01 4/Color Figure(s): F1-21 Art: PRS204746 Input-nlm

F1

Plastic and Reconstructive Surgery • January 2014 Table 1.  Summary of Cases of Immediate Nipple-Areola Reconstruction Age (yr)

Side

Day of NAC Reconstruction

1

42

Right

POD 21

2* 3* 4 5 6

44 44 64 45 48

Right Left Right Left Left

POD 20 POD 20 POD 17 POD 16 POD 20

Case

Degree of NAC Necrosis Nipple and partial areola necrosis Partial areola necrosis Nipple necrosis Total NAC necrosis Partial areola necrosis Nipple and partial areola necrosis

Reconstruction Nipple and partial areolar reconstruction (top-hat flap) Partial areolar reconstruction Nipple reconstruction (top-hat flap) Total NAC reconstruction (top-hat flap) Partial areolar reconstruction Nipple and partial areolar reconstruction (top-hat flap)

NAC, nipple-areola complex; POD, postoperative day. *Cases 2 and 3 are from the same patient with bilateral breast cancer who underwent bilateral mastectomy and reconstruction.

s­kin-banking cases. In the six cases of immediate nipple-areola complex reconstruction (Table 1), there were no complications such as infection, hematoma, or ischemic necrosis. In the other 19 cases of skin banking, the spared nipple survived and the wound was closed primarily after removal of the banked skin. The reconstructed nipples showed loss of projection with time to a similar degree as seen in standard nipple reconstruction after skinsparing mastectomy. Necrosis of the nipple-areola complex causes loss of projection and depigmentation of the nipple and distortion of the nipple-areola complex by scar formation. Furthermore, attempts to reconstruct the nipple after necrosis are far more difficult than after ­skin-sparing mastectomy, because the surviving skin and tissue around the nipple are frequently scarred and fibrotic. Therefore, in cases of nipple-areola complex necrosis following nipple-sparing mastectomy, patients have worse outcomes than with skin-sparing mastectomy. Immediate nipple-areola complex reconstruction with banked skin can prevent all the negative consequences of the necrosis and provide at least the same outcome as that with skin-sparing mastectomy. The innovative idea of banking the skin and using it in cases of mastectomy skin flap necrosis was introduced as “banked” transverse abdominis musculocutaneous flap reconstruction by Kovach and Georgiade5 in 2006. Banking the skin flap is not a harmful procedure even when the whole mastectomy flap survives. Banked skin can easily be excised 2 or 3 weeks after initial reconstruction. There is concern of an increased risk of infection due to the wound being left open in a necrotic environment. In the current series, however, there were no cases of infection. Nipple-areola complex reconstruction should be performed at an appropriate time, immediately after clear demarcation of the necrotic lesion and before scar contracture and fibrosis occur. Our experience has shown that 2 to 3 weeks from initial reconstruction is an ideal time for diagnosis of nipple-areola complex necrosis as well as for immediate reconstruction. DOI: 10.1097/01.prs.0000436805.58165.d3

74e

Sung Woo Park, M.D. Taik Jong Lee, M.D., Ph.D. Eun Key Kim, M.D., Ph.D. Jin Sup Eom, M.D., Ph.D. Department of Plastic Surgery Asan Medical Center University of Ulsan College of Medicine Seoul, Korea Correspondence to Dr. Eom Department of Plastic Surgery Asan Medical Center University of Ulsan College of Medicine 388-1, Pungnap-dong Songpa-gu, Seoul 138–736, South Korea [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Jabor MA, Shayani P, Collins DR Jr, et  al. Nipple-areola reconstruction: Satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110:457–463. 2. Shaikh-Naidu N, Preminger BA, Rogers K, et  al. Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction. Ann Plast Surg. 2004;52:465– 470. 3. Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki WM, Costa A. Necrotic complications after nipple- and ­areola-sparing mastectomy. World J Surg. 2006;30:1410–1413. 4. Bistoni G, Rulli A, Izzo L, Noya G, Alfano C, Barberini F. Nipple-sparing mastectomy: Preliminary results. J Exp Clin Cancer Res. 2006;25:495–497. 5. Kovach SJ, Georgiade GS. The “banked” TRAM: A method to insure mastectomy skin-flap survival. Ann Plast Surg. 2006;57:366–369.

First Web Space Reconstruction Using a Dorsal Metacarpal Artery Perforator Flap: A Further Application of the Quaba Flap Sir: oft-tissue defects involving the hands are frequently encountered in reconstructive surgery. In 1990, Quaba and Davidson described a series of reverse dorsal

S

Managing necrosis of the nipple-areola complex in breast reconstruction after nipple-sparing mastectomy: immediate nipple-areola complex reconstruction with banked skin.

Managing necrosis of the nipple-areola complex in breast reconstruction after nipple-sparing mastectomy: immediate nipple-areola complex reconstruction with banked skin. - PDF Download Free
664KB Sizes 0 Downloads 0 Views