BREAST SURGERY
New Technique of Immediate Nipple Reconstruction During Immediate Autologous DIEP or MS-TRAM Breast Reconstruction Petr Hyza, MD, PhD,* Libor Streit, MD,* Jiri Vesely, MD, PhD,* Dagmar Stafova, MD,Þ and Petr Sin, MD, PhD* Background: Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local f laps or composite graft from the opposite nipple. Methods: Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local f laps is used. The dermal-fat f laps are lifted and sutured together to form the new nipple. Results: Seventeen patients (average age, 47 years; range, 33Y58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2Y25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity. Conclusions: One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local f laps on skin envelope f lap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous f lap. Our technique is suitable for patients with ptotic or hypertrophic breasts. Key Words: immediate nipple reconstruction, autologous, DIEP, MS-TRAM, breast reconstruction, BRCA (Ann Plast Surg 2015;74: 645Y651)
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kin-sparing mastectomy with immediate autologous deep inferior epigastric perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) breast reconstruction has been used increasingly by our team in recent years. This combination was shown to be safe and gives high-quality aesthetic results.1Y5 The most frequent indications are patients with BRCA1 and BRCA2 gene mutation, women who have a strong family history of breast cancer,
Received April 10, 2013, and accepted for publication, after revision, September 12, 2013. From the *Clinic of Plastic and Aesthetic Surgery, St Anne University Hospital; and †Faculty of Medicine, Masaryk University, Brno, Czech Republic. Conflicts of interest and sources of funding: none declared. Supported by Masaryk University, Brno, Czech Republic. Reprints: Libor Streit, MD, Clinic of Plastic and Aesthetic Surgery, St Anne University Hospital, Berkova 34, 612 00 Brno, Czech Republic. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0645 DOI: 10.1097/SAP.0000000000000006
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and other cases that do not require complementary radiotherapy. All breast parenchyma and the nipple-areola complex is excised during skin-sparing mastectomy.6 The outline of the incision may be a Wise pattern, or a vertical mammoplasty design can be used if the breast is ptotic or hypertrophic. Creation of the nipple-areola complex is the final step in surgical restoration of the breast. It is often considered a secondary complement to breast reconstruction usually done after an interval of several months. Composite graft techniques7Y10 or local f laps are used.11Y17 The position of the new nipple-areola complex is well defined by the shape of the skin envelope.18,19 The excess of the skin envelope in the ptotic or hypertrophic breasts may be left in the proper amount to recreate the nipple in secondary intervention.20 We propose carrying out nipple reconstruction and breast reconstruction during a single procedure to make use of the available skin from the skin envelope, which would be excised during skin-sparing mastectomy otherwise. The aim of this article was to present our technique of immediate nipple reconstruction and to evaluate the results in a series of 17 patients.
PATIENTS AND METHODS Operative Technique We proposed our technique of immediate nipple reconstruction to patients with ptotic or hypertrophic breasts considered for the skin-sparing mastectomy and immediate breast reconstruction. The outline of the incision was designed on patient’s skin in standing and supine positions preoperatively. A Wise pattern design of skinsparing mastectomy was used respecting common principles of the nipple-areolar complex placement on the breast. The center of the reconstructed nipple-areolar complex was marked on the skin as a point. This point was then the center of the common part of 3 local f laps (dermal-fat f laps with common central part). Two lateral and long f laps form an angle of 45 to 90 degrees with a central V-shaped f lap placed between them. External margins of the lateral f laps were marked as the prolongation of the skin incisions that defined internal margins of the skin envelope that would form vertical suture (hereafter called the vertical incisions). The length of this line depended on the desired breast size and projection. For example, if the length of vertical suture below the future areola was expected to be 6 cm, the length of the described skin incision would be 8 cm (Fig. 1). Skin-sparing mastectomy had been carried out. Then an abdominal free f lap (DIEP or MS-TRAM) was transferred to the reconstructed breast in a supine position. The vessels of the pedicle were sutured to the internal thoracic vessels using an operating microscope. The abdominal f lap was deepithelized and a small triangle of the skin used as monitoring skin paddle was situated to inverted-T sutures so 1 corner of the triangle was facing up. The vertical suture was started cranially by 1 single stitch 1 cm apart from the end of the vertical incision. The circular base of the reconstructed nipple was created by this stitch. All the 3 described local f laps were elevated together with the common part of these f laps. A small piece of fat from the skin envelope above the base part of the f laps was taken out for better projection of the nipple. Two www.annalsplasticsurgery.com
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FIGURE 1. Illustration of the fundamental principles of our technique: (1) design of modified Wise pattern skin-sparing mastectomy with 3 local f laps; (2) elevation of the dermal-fat f lap; (3) the first stitch of vertical suture, which is put approximately 1 cm below the base of the dermal-fat f lap, creates a rounded base of the nipple; and (4) the 3 local f laps are brought together with only 1 vertical suture below the new nipple.
lateral dermal-fat f laps were then folded back like 2 embracing arms and the central V-shaped f lap formed the top of the nipple. At first, the lateral f laps were left longer, and then after we assessed their viability by clinical judgment, the appropriate lengths of the f laps were cut. All these were sutured with monofilament sutures
5-0 without tension and with a limited number of stitches (Fig. 2). The dimensions of the f laps (length, width, and thickness) must be proportionate to the desired height of the future nipple. The usual lengths of the f laps were approximately 2.5 and 2 cm for the laterals and 0.8 cm for the central f lap.
FIGURE 2. Creation of the nipple: the local f laps are elevated and sutured in their position to form the new nipple. 646
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For the postoperative management of the nipple-areola complex, the first dressing was replaced with a greasy dressing every 2 days until healed. The new nipple may have appeared blue and turgescent at first, but this subsided after a few days. Tattooing the nipple-areola complex was done at a later stage.
Clinical Review A retrospective study was carried out on 17 patients who had undergone immediate breast and immediate nipple reconstruction with an autologous DIEP or MS-TRAM f lap after prophylactic skinsparing mastectomy and who had been operated on between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). The study comprised of evaluation of photographic documentation
Immediate Nipple Reconstruction
and subjective evaluation of patient satisfaction by means of a questionnaire.
The Evaluation of Photographic Documentation The patients were photographed in a studio of a professional photographer in 5 standard projections (anterior, 2 lateral, and 2 anterior oblique) preoperatively, postoperatively, and after the tattooing (Fig. 3). The evaluation of the photographic documentation was carried out independently in all patients by 2 plastic surgeons, 1 medical student, 1 student of aesthetics, and by 1 independent evaluator. These 2 plastic surgeons were blinded to the other surgeon’s result. A total of 11 requests were evaluated for each breast and a 10-point scale was used for each of them (1 point, very poor results;
FIGURE 3. Evaluation of photographic documentation from 5 standard projections: anterior, 2 lateral, and 2 anterior oblique. A 47-year-old patient with ptotic breasts after breast conservative treatment (left side). Results of bilateral skin-sparing mastectomy with 1-stage immediate autologous breast and nipple reconstruction. Pictures were taken preoperatively, 6 months postoperatively, and 2.5 months after the tattooing. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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TABLE 1. Evaluation of Photographic Documentation
Patient Number
Shape of the Nipple
Size of the Nipple
Scaring Around the Nipple
Appearance of the Nipple
Unilateral 1 7.6 7.2 7.6 8.4 2 7.0 7.2 8.0 7.2 3 7.8 7.4 8.2 7.8 Mean 7.5 7.3 7.9 7.8 Bilateral before tattoo (average value for both breasts) 4 7.0 7.3 8.1 7.1 5 7.5 8.5 8.7 8.1 6 6.9 6.9 8.5 6.8 7 5.5 5.5 6.5 5.7 9 8.0 8.6 8.8 8.4 10 6.9 7.4 8.4 7.2 11 7.9 8.9 8.7 8.0 12 7.6 6.9 8.0 7.7 13 7.7 7.1 7.6 6.9 Mean 7.2 7.4 8.1 7.3 Bilateral after tattoo (average value for both breasts) 4 7.0 7.3 8.1 7.5 6 8.4 7.8 8.6 8.7 8 5.9 5.9 7.0 7.0 9 7.8 8.3 9.0 9.1 Mean 7.3 7.3 8.2 8.1 Total mean 7.3 7.3 8.1 7.5
Color of the Areola
9.4
7.6
8.7 8.7 7.9 9.1 8.6 8.6
Nipple’s Projection
Breast’s Projection
Nipple’s Placement on the BreastV Lateral Projection
8.6 8.0 8.2 8.3
8.8 8.4 7.2 8.1
8.4 8.2 7.4 8
8.2 7.6 8.6 8.1
7.2 7.4 7.0 7.2
8.0 8.2 7.2 7.8
7.2 7.5 6.1 6.6 7.7 7.9 7.7 7.5 7.9 7.3
8.2 7.6 7.5 7.7 8.6 7.7 7.8 7.0 7.9 7.8
8.0 7.3 6.7 7.5 8.6 7.8 7.5 7.3 8.1 7.6
8.5 7.5 7.3 6.8 9.2 8.7 8.3 8.7 7.5 8.1
8.8 6.7 6.1 6.6 9.0 8.9 6.1 8.3 4.8 7.3
7.9 6.9 6.3 6.5 9.3 8.0 6.8 7.6 6.4 7.3
7.2 8.1 7.9 7.8 7.8 7.5
8.2 8.1 6.2 8.6 7.8 7.8
8.0 8.1 6.6 8.6 7.8 7.7
7.5 8.2 7.7 9.0 8.1 8.1
7.4 7.6 5.4 9.5 7.5 7.2
7.8 8.7 6.3 9.6 8.1 7.6
Symmetry of the Nipple-Areola ComplexV Anterior Projection
Total SymmetryV Anterior Projection
Overall Aesthetic Impression
Data from bilateral patients are presented by mean despite the fact that ‘‘total mean’’ was calculated from values for each breast. Patient numbers 3 and 8 were not photographed before tattooing so we were unable to evaluate their photographs before. The color of the areola was evaluated only between tattooed patients and patient number 7, who had the nipple reconstructed from the areolar residue.
10 points, excellent results). The requests are given in Table 1. Unilateral and bilateral cases were evaluated separately. Each breast was assessed separately in bilateral cases and also the cases after areola tattooing were evaluated separately.
perception of breast integrity. All the questions are shown in Table 2. A 10-point scale was used where 10 points mean yes/very positive/ very satisfied/unqualified; 5 point means do not know/less positive/ rather satisfied/I have some minor objections; and 1 point means: no/negative/unsatisfied/I have serious reservations.
Patient Satisfaction Assessment We have created a special questionnaire focused on the subjective perception of the shape of a reconstructed breast and a nipple; the satisfaction with the location of the nipple on the breast; nipple sensitivity; and the importance of the presence of nipples on the
RESULTS This technique of immediate nipple reconstruction has been used to reconstruct 28 nipples in 17 patients. There were no failures, but 2 patients had partial necrosis of the nipple, which maintained
TABLE 2. Evaluation of the Patients’ Satisfaction With the Immediate Nipple Reconstruction Evaluation (Mean)
Question 1. How do you feel about the appearance and the shape of your new reconstructed breasts? 2. How do you feel about the appearance and the shape of your new reconstructed nipples? 3. Are you satisfied with the position of the new nipples on your breasts? 4. Are you satisfied with the sensitivity of the nipples? 5. What do you think about the shape, placement, and the size of the scars around the nipples? 6. Do you find the presence of the nipples crucial for your breast integrity considering what you had undergone prior to the operation? 7. Have you been influenced by the fact that there is a possibility of nipple reconstruction in making a decision about the prophylactic mastectomy? 8. Did the healing of reconstructed nipples have any complication which made healing of reconstructed breast last longer? 9. If you were able to choose the secondary nipple reconstruction, which would mean another operation under local anesthetics and wearing 2 weeks bandage but, on the other hand, the possibility of the change of nipples’ position on the breasts, would you choose this possibility?
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9.6 9.7 9.9 7.2 9.6 5.9 2.2 No No
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adequate projection after excision of the necrotic area during an office visit nevertheless. Average duration of the nipple reconstruction was approximately 10 minutes per 1 side. However, the duration of the whole surgical procedure was not longer in most of the cases than that for immediate DIEP or MS-TRAM breast reconstruction alone because a second plastic surgeon was performing abdominal closure simultaneously and the abdominal closure was limiting for the length of the procedure. Thirteen patients (3 unilateral and 10 bilateral immediate nipple reconstructions) had complete standardized photographic documentation and at the same time were willing to fill out the questionnaire; 5 patients (4 bilateral) had the nipple-areolar complex tattooed. Average age of the patients was 47 years (range, 33Y58 years). Average follow-up, corresponding to the completion of the questionnaires, was 13 months (range, 2Y25 months). The patients were photographed 9 months (range, 3Y18 months) postoperatively before the tattooing and 6 months (range, 3 daysY15 months) postoperatively after the tattooing.
Aesthetic Results The results of the evaluation of the photographic documentation are given in Table 1. A minimum average score of 7.2 points was achieved in all evaluated criteria. The best score was given to the scars around the nipples and the symmetry of the reconstructed nipple or the nipple-areolar complex. One patient was unsatisfied because of asymmetry in the placement of the nipple on the breast. It was resolved with a good result using local V-Y advancement f lap technique. Some of the results are shown in Figures 3Y5.
Immediate Nipple Reconstruction
FIGURE 5. A 52-year-old BRCA1-positive patient with ptotic breasts after breast conservative treatment (right side). Results at 5 months after the tattooing.
Patient Satisfaction Table 2 shows patient satisfaction as assessed by the questionnaire. All the patients were very satisfied with the shape of the breast (average value of 9.6 points), with the shape of the nipple (9.7), with the position of the nipples on the breast (9.9), and with the scars around the nipple (9.6). Variability may be deduced from Table 3. Most of the patients (77%) were also very satisfied (8Y10 points), 2 of them moderately satisfied (5Y7 points), and 1 patient was unsatisfied with the sensitivity of the nipple. The possibility of immediate nipple reconstruction in 1 session with immediate breast reconstruction does not facilitate a decision to undergo prophylactic skin-sparing mastectomy. The healing time of a reconstructed nipple does not prolong the time of the entire healing of the breast and abdomen. And only 1 patient would prefer the possibility of delayed nipple reconstruction retroactively. This patient was already mentioned for the need of a secondary correction of nipple placement.
DISCUSSION
FIGURE 4. Same patient as shown in Figure 3: reconstructed nipple in detail, close-up postoperative view. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Skin-sparing mastectomy is technically more difficult than modified radical mastectomy, but the main advantage of this technique is the aesthetic and psychological result obtained by immediate breast and possibly also nipple reconstruction. At our institution, we reserve this combination for patients who are not being considered for complementary radiotherapy. For reconstruction, we frequently use the autologous-free abdominal f laps (DIEP or MS-TRAM) which give good aesthetic results, a normal appearance, and consistency close to that of a nonoperated breast. Nipple-areolar complex reconstruction is normally the final step in breast reconstruction followed usually by tattooing of nippleareola complex.21Y24 Presence of the nipple on the breast is important for the perception of the breast integrity for the patient after breast reconstruction.25 A nipple is ordinarily reconstructed secondarily under local anesthesia on reconstructed breast using different local f laps. There are several techniques, the most commonly used are Little’s skate f lap, Hartrampf ’s U-shaped f lap, Lossing’s modified S-f lap, Losken S-V f lap, and Kroll’s double-opposing-tab f lap.11Y17 Modified star-f lap technique and Hartrampf ’s wrap around f lap are most commonly used at our department. The technique of immediate nipple-areolar complex reconstruction during immediate latissimus dorsi breast reconstruction using 2 local skin f laps from latissimus dorsi f lap was described by Delay et al19 in group of 30 patients. www.annalsplasticsurgery.com
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TABLE 3. Evaluation of Patients’ Satisfaction Question No. patient Unilateral 1 2 3 Mean Bilateral 4 5 6 7 8 9 10 11 12 13 Mean Total mean
1
2
3
4
5
6
7
9
10
8 10 10 9.3
10 9 7 8.7
10 10 10 10
10 9 1 6.7
10 10 8 9.3
2 1 7 3.3
2 1 0 1
No No No No
Yes No No No
9 10 10 10 10 10 10 10 10 10 9.9 9.6
10 10 10 10 10 10 10 10 10 10 10 9.4
10 10 10 10 7 10 10 10 10 10 9.7 9.9
8 10 5 7 8 8 10 10 10 1 7.7 7.2
10 10 10 8 10 10 10 10 10 10 9.8 9.6
10 1 10 9 5 10 9 10 10 10 8.4 5.9
9 1 1 9 1 0 1 1 10 1 3.4 2.2
No No No No No No No No No 0 No No
No No No No No No No No No No No No
Several authors have described their experience with singlestep breast and nipple-areola complex reconstruction on free or pedicled TRAM f laps.18,26Y31 Colen26 introduced the concept of immediate nipple reconstruction with a bilobed f lap created from a dog-ear of redundant tissue on a folded free TRAM f lap. Beegle28 described immediate TRAM f lap and nipple-areola reconstruction on free TRAM f laps, although he gives little mention as to his preferred technique of nipple reconstruction. Hudson et al29,30 performed immediate nipple reconstruction during a breast reconstruction with a pedicled TRAM using a local C-V f lap in zone 2 of the TRAM f lap and a full-thickness skin graft. Charanek et al31 described their technique of breast reconstruction using a bipedicled TRAM f lap and inclusion of the umbilical scar as an immediate nipple reconstruction. Their breast mound does seem to have good projection using this method, however, the intentional sacrifice of the umbilicus for nipple reconstruction is not ideal. And finally, Williams et al18 compared results of immediate nipple reconstruction on a free TRAM f lap (modification of the Colen’s technique) with delayed nipple reconstruction. They concluded that the patients who had their immediate nipple reconstruction completed earlier required fewer procedures and had aesthetic results comparable to patients having traditional delayed nipple reconstruction. Complications and revision rates were comparable. They also pointed out that close attention to detail and intraoperative planning are essential to a good cosmetic outcome and that if the shape and position of the breast mound reconstruction is not ideal during the initial operation, nipple reconstruction should be delayed. Drazan and Castagnetti designed a modified skin-sparing mastectomy pattern for prophylactic and therapeutic surgery in case of large and ptotic breasts. A basic inverted-T is drawn but modified for the purpose of preserving extra skin for future nipple-areola complex reconstruction.20 The described technique allows for the absence of round scars in the nipple-areola complex and some sensitivity of the reconstructed nipple-areola complex is often preserved because the skin is obtained from local breast skin instead of the f lap skin. Our technique is refinement of the Drazan’s technique. The nipple is reconstructed immediately from relative excess of the skin envelope in patients with large or ptotic breasts. Proportions of the 650
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skin envelope are given by the desired size of the reconstructed breast. The size of the lower abdomen is determinative for the maximal achievable size of the reconstructed breast especially in bilateral breast reconstruction using abdominal f laps, and thus, breast skin reduction is often desirable. The skin-sparing mastectomy pattern is designed immediately with 3 local f laps which are being used to reconstruct the nipple. The resulting scars are placed at the base of the lower part of the nipple and there is only 1 vertical scar below the nipple. This is the reason of high patient satisfaction with the scars around the nipple (average value of 9.7 points). After mastectomy, there is a certain degree of desensitization of the mastectomy skin f laps unlike the abdominal skin paddle of DIEA f laps lobe that completely misses superficial sensitivity. Partially preserved sensitivity of mastectomy skin f laps can be explained by the persistence of some medial and lateral cutaneous branches of intercostal nerves. A high percentage of our patients reported satisfaction with the sensitivity of the nipples (average value of 7.5 points, only 15% patients not satisfiedV less than 5 points). We believe that the declared high satisfaction of the patients with the nipple sensitivity is determined by the partially preserved sensitivity of the mastectomy f laps. Arguments for delaying nipple-areola complex reconstruction focus on the difficulty of determining the appropriate position of the nipple-areola complex because of a healing process and early postoperative breast asymmetries. However, in rather experienced hands, positioning the new nipple-areola complex can be straightforward when skin-sparing mastectomy is performed using a modified Wise pattern design. We are encouraged that the positioning of the nippleareola complex was actually one of the highest ranked characteristics (average values of 8.1 and 7.7 for nipple placement symmetry in anterior and lateral projections from photographic documentation and average value for patient satisfaction with nipple placement on the breast of 9.7). Duration of the operation is not significantly prolonged by the immediate nipple reconstruction. Healing of the nipple does not exceed the healing period of the breast and abdomen (question 8). At our institution, skin-sparing mastectomy is performed by plastic surgeon in prophylactic cases. Despite the utmost attention to gentle handling of tissues, we observed few cases of poor perfusion of * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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mastectomy skin f laps with subsequent difficulties with the skin healing. In the investigated group of patients, marginal skin f lap necrosis has occurred once at the bottom of the vertical scar and the nipple has not been affected. Design of this study was based on the evaluation of photographic documentation by independent observers and on the subjective evaluation by patients. Maintenance of projection is one of the most difficult issues with nipple-areolar creation. In another larger study, we intend to focus closer on objectification of nipple projection by clinical measurements and also possibly on comparison of the nipple projection with other types of nipple reconstruction. Although we have used this technique only during autologous breast reconstruction using abdominal free f laps, we believe that it could be also used during implant-based breast reconstruction when skin-sparing mastectomy is performed. A well-performed immediate breast and nipple-areola complex reconstruction has several advantages. The psychosocial issues surrounding the patient with breast cancer requiring mastectomy may be expected to improve if an aesthetic breast reconstruction can be performed more quickly and with fewer procedures.
CONCLUSIONS We believe that in experienced hands, 1-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local f laps on the skin envelope f lap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. We also believe that 1-stage reconstructive surgery may be psychologically beneficial and cost effective. Although our study is small and there are clear limitations to this retrospective study, our preliminary results are encouraging. REFERENCES 1. Spurna Z, Drazan L, Foretova L, et al. The effect of prophylactic mastectomy reconstruction on quality of life in BRCA positive women. Klin Onkol. 2012;25:74Y77. 2. Drazan L, Vesely J, Hyza P, et al. Surgical prevention of breast carcinoma in patients with hereditary risk. Klin Onkol. 2012;25:78Y83. 3. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814Y819. 4. Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg. 2004;114:1077. 5. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113:1153. 6. Barton FE, English JM, Kingsley WB, et al. Glandular excision in total glandular mastectomy: a comparison. Plast Reconstr Surg. 1991;88:389. 7. Asplund O. Nipple and areola reconstruction: a study in 79 mastectomized women. Scand J Plast Reconstr Surg. 1983;17:233. 8. Bogue DP, Mungara AK, Thompson M, et al. Modified technique for nippleareolar reconstruction: a case series. Plast Reconstr Surg. 2003;112:1274.
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9. Tanabe HY, Tai Y, Kiyokawa K, et al. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. Plast Reconstr Surg. 1997; 100:431. 10. Brent B. Nipple-areola reconstruction following mastectomy: an alternative to the use of labial and contralateral nipple-areolar tissues. Clin Plast Surg. 1979;6:85. 11. Little JW III, Munasifi T, McCulloch DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983;71:126. 12. Little JW. Nipple-areolar reconstruction. In: Cohen M, eds. Mastery of Plastic and Reconstructive Surgery, Vol. 2. Chicago, Ill: Little, Brown; 1994: 1344Y1349. 13. Hartrampf CR Jr, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg. 1984;73:982. 14. Lossing C, Brongo S, Holmstro¨m H. Nipple reconstruction with a modified S-flap technique. Scand J Plast Reconstr Surg Hand Surg. 1998;32:275Y279. 15. Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing-tab flap. Plast Reconstr Surg. 1989;84:520. 16. Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108:361. 17. Kroll SS, Reece GP, Miller M, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997; 99:1602. 18. Williams EH, Rosenberg LZ, Kolm P, et al. Immediate nipple reconstruction on a free TRAM flap breast reconstruction. Plast Reconstr Surg. 2007;120: 1115Y1124. 19. Delay E, Mojallal A, Vasseur C, et al. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006;118:1303Y1312. 20. Drazan L, Castagnetti F. Keeping extra skin for nipple-areola reconstruction during mastectomy. Plast Reconstr Surg. 2007;120:815Y816. 21. Rees TD. Reconstruction of the breast areola by intradermal tattooing and transfer. Case report. Plast Reconstr Surg. 1975;55:620Y621. 22. Becker H. The use of intradermal tattoo to enhance the final result of nippleareola reconstruction. Plast Reconstr Surg. 1986;77:673. 23. Spear SL, Convit R, Little JW III. Intradermal tattoo as an adjunct to nippleareola reconstruction. Plast Reconstr Surg. 1989;83:907. 24. Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg. 1997;50:331. 25. Wellisch DK, Schain WS, Noone R, et al. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80:699. 26. Colen LB. One-stage reconstruction of the breast using autologous tissue with immediate nipple reconstruction. In: Spear S, Little JW, Lippman ME, et al, eds. Surgery of the Breast: Principles and Art. Philadelphia, Pa: LippincottRaven; 1998:491Y509. 27. Eskenazi L. A one-stage nipple reconstruction with the ‘‘modified star’’ flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg. 1993; 92:671. 28. Beegle PH Jr. Immediate single-stage TRAM and nipple areola reconstruction. Clin Plast Surg. 1994;21:321. 29. Hudson DA, Dent DM, Lazarus D. One-stage immediate breast and nippleareolar reconstruction with autologous tissue I: a preliminary report. Ann Plast Surg. 2000;45:471. 30. Hudson DA, Skoll PJ. Single-stage, autologous breast restoration. Plast Reconstr Surg. 2001;108:1163. 31. Charanek AM, Carramaschi FR, Curado JH. Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements. Plast Reconstr Surg. 2000;106:1262.
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New Technique of Immediate Nipple Reconstruction During Immediate Autologous DIEP or MS-TRAM Breast Reconstruction Petr Hyza, MD, PhD,* Libor Streit, MD,* Jiri Vesely, MD, PhD,* Dagmar Stafova, MD,Þ and Petr Sin, MD, PhD* Background: Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local f laps or composite graft from the opposite nipple. Methods: Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local f laps is used. The dermal-fat f laps are lifted and sutured together to form the new nipple. Results: Seventeen patients (average age, 47 years; range, 33Y58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2Y25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity. Conclusions: One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local f laps on skin envelope f lap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous f lap. Our technique is suitable for patients with ptotic or hypertrophic breasts. Key Words: immediate nipple reconstruction, autologous, DIEP, MS-TRAM, breast reconstruction, BRCA (Ann Plast Surg 2015;74: 645Y651)
S
kin-sparing mastectomy with immediate autologous deep inferior epigastric perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) breast reconstruction has been used increasingly by our team in recent years. This combination was shown to be safe and gives high-quality aesthetic results.1Y5 The most frequent indications are patients with BRCA1 and BRCA2 gene mutation, women who have a strong family history of breast cancer,
Received April 10, 2013, and accepted for publication, after revision, September 12, 2013. From the *Clinic of Plastic and Aesthetic Surgery, St Anne University Hospital; and †Faculty of Medicine, Masaryk University, Brno, Czech Republic. Conflicts of interest and sources of funding: none declared. Supported by Masaryk University, Brno, Czech Republic. Reprints: Libor Streit, MD, Clinic of Plastic and Aesthetic Surgery, St Anne University Hospital, Berkova 34, 612 00 Brno, Czech Republic. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0645 DOI: 10.1097/SAP.0000000000000006
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and other cases that do not require complementary radiotherapy. All breast parenchyma and the nipple-areola complex is excised during skin-sparing mastectomy.6 The outline of the incision may be a Wise pattern, or a vertical mammoplasty design can be used if the breast is ptotic or hypertrophic. Creation of the nipple-areola complex is the final step in surgical restoration of the breast. It is often considered a secondary complement to breast reconstruction usually done after an interval of several months. Composite graft techniques7Y10 or local f laps are used.11Y17 The position of the new nipple-areola complex is well defined by the shape of the skin envelope.18,19 The excess of the skin envelope in the ptotic or hypertrophic breasts may be left in the proper amount to recreate the nipple in secondary intervention.20 We propose carrying out nipple reconstruction and breast reconstruction during a single procedure to make use of the available skin from the skin envelope, which would be excised during skin-sparing mastectomy otherwise. The aim of this article was to present our technique of immediate nipple reconstruction and to evaluate the results in a series of 17 patients.
PATIENTS AND METHODS Operative Technique We proposed our technique of immediate nipple reconstruction to patients with ptotic or hypertrophic breasts considered for the skin-sparing mastectomy and immediate breast reconstruction. The outline of the incision was designed on patient’s skin in standing and supine positions preoperatively. A Wise pattern design of skinsparing mastectomy was used respecting common principles of the nipple-areolar complex placement on the breast. The center of the reconstructed nipple-areolar complex was marked on the skin as a point. This point was then the center of the common part of 3 local f laps (dermal-fat f laps with common central part). Two lateral and long f laps form an angle of 45 to 90 degrees with a central V-shaped f lap placed between them. External margins of the lateral f laps were marked as the prolongation of the skin incisions that defined internal margins of the skin envelope that would form vertical suture (hereafter called the vertical incisions). The length of this line depended on the desired breast size and projection. For example, if the length of vertical suture below the future areola was expected to be 6 cm, the length of the described skin incision would be 8 cm (Fig. 1). Skin-sparing mastectomy had been carried out. Then an abdominal free f lap (DIEP or MS-TRAM) was transferred to the reconstructed breast in a supine position. The vessels of the pedicle were sutured to the internal thoracic vessels using an operating microscope. The abdominal f lap was deepithelized and a small triangle of the skin used as monitoring skin paddle was situated to inverted-T sutures so 1 corner of the triangle was facing up. The vertical suture was started cranially by 1 single stitch 1 cm apart from the end of the vertical incision. The circular base of the reconstructed nipple was created by this stitch. All the 3 described local f laps were elevated together with the common part of these f laps. A small piece of fat from the skin envelope above the base part of the f laps was taken out for better projection of the nipple. Two www.annalsplasticsurgery.com
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FIGURE 1. Illustration of the fundamental principles of our technique: (1) design of modified Wise pattern skin-sparing mastectomy with 3 local f laps; (2) elevation of the dermal-fat f lap; (3) the first stitch of vertical suture, which is put approximately 1 cm below the base of the dermal-fat f lap, creates a rounded base of the nipple; and (4) the 3 local f laps are brought together with only 1 vertical suture below the new nipple.
lateral dermal-fat f laps were then folded back like 2 embracing arms and the central V-shaped f lap formed the top of the nipple. At first, the lateral f laps were left longer, and then after we assessed their viability by clinical judgment, the appropriate lengths of the f laps were cut. All these were sutured with monofilament sutures
5-0 without tension and with a limited number of stitches (Fig. 2). The dimensions of the f laps (length, width, and thickness) must be proportionate to the desired height of the future nipple. The usual lengths of the f laps were approximately 2.5 and 2 cm for the laterals and 0.8 cm for the central f lap.
FIGURE 2. Creation of the nipple: the local f laps are elevated and sutured in their position to form the new nipple. 646
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For the postoperative management of the nipple-areola complex, the first dressing was replaced with a greasy dressing every 2 days until healed. The new nipple may have appeared blue and turgescent at first, but this subsided after a few days. Tattooing the nipple-areola complex was done at a later stage.
Clinical Review A retrospective study was carried out on 17 patients who had undergone immediate breast and immediate nipple reconstruction with an autologous DIEP or MS-TRAM f lap after prophylactic skinsparing mastectomy and who had been operated on between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). The study comprised of evaluation of photographic documentation
Immediate Nipple Reconstruction
and subjective evaluation of patient satisfaction by means of a questionnaire.
The Evaluation of Photographic Documentation The patients were photographed in a studio of a professional photographer in 5 standard projections (anterior, 2 lateral, and 2 anterior oblique) preoperatively, postoperatively, and after the tattooing (Fig. 3). The evaluation of the photographic documentation was carried out independently in all patients by 2 plastic surgeons, 1 medical student, 1 student of aesthetics, and by 1 independent evaluator. These 2 plastic surgeons were blinded to the other surgeon’s result. A total of 11 requests were evaluated for each breast and a 10-point scale was used for each of them (1 point, very poor results;
FIGURE 3. Evaluation of photographic documentation from 5 standard projections: anterior, 2 lateral, and 2 anterior oblique. A 47-year-old patient with ptotic breasts after breast conservative treatment (left side). Results of bilateral skin-sparing mastectomy with 1-stage immediate autologous breast and nipple reconstruction. Pictures were taken preoperatively, 6 months postoperatively, and 2.5 months after the tattooing. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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TABLE 1. Evaluation of Photographic Documentation
Patient Number
Shape of the Nipple
Size of the Nipple
Scaring Around the Nipple
Appearance of the Nipple
Unilateral 1 7.6 7.2 7.6 8.4 2 7.0 7.2 8.0 7.2 3 7.8 7.4 8.2 7.8 Mean 7.5 7.3 7.9 7.8 Bilateral before tattoo (average value for both breasts) 4 7.0 7.3 8.1 7.1 5 7.5 8.5 8.7 8.1 6 6.9 6.9 8.5 6.8 7 5.5 5.5 6.5 5.7 9 8.0 8.6 8.8 8.4 10 6.9 7.4 8.4 7.2 11 7.9 8.9 8.7 8.0 12 7.6 6.9 8.0 7.7 13 7.7 7.1 7.6 6.9 Mean 7.2 7.4 8.1 7.3 Bilateral after tattoo (average value for both breasts) 4 7.0 7.3 8.1 7.5 6 8.4 7.8 8.6 8.7 8 5.9 5.9 7.0 7.0 9 7.8 8.3 9.0 9.1 Mean 7.3 7.3 8.2 8.1 Total mean 7.3 7.3 8.1 7.5
Color of the Areola
9.4
7.6
8.7 8.7 7.9 9.1 8.6 8.6
Nipple’s Projection
Breast’s Projection
Nipple’s Placement on the BreastV Lateral Projection
8.6 8.0 8.2 8.3
8.8 8.4 7.2 8.1
8.4 8.2 7.4 8
8.2 7.6 8.6 8.1
7.2 7.4 7.0 7.2
8.0 8.2 7.2 7.8
7.2 7.5 6.1 6.6 7.7 7.9 7.7 7.5 7.9 7.3
8.2 7.6 7.5 7.7 8.6 7.7 7.8 7.0 7.9 7.8
8.0 7.3 6.7 7.5 8.6 7.8 7.5 7.3 8.1 7.6
8.5 7.5 7.3 6.8 9.2 8.7 8.3 8.7 7.5 8.1
8.8 6.7 6.1 6.6 9.0 8.9 6.1 8.3 4.8 7.3
7.9 6.9 6.3 6.5 9.3 8.0 6.8 7.6 6.4 7.3
7.2 8.1 7.9 7.8 7.8 7.5
8.2 8.1 6.2 8.6 7.8 7.8
8.0 8.1 6.6 8.6 7.8 7.7
7.5 8.2 7.7 9.0 8.1 8.1
7.4 7.6 5.4 9.5 7.5 7.2
7.8 8.7 6.3 9.6 8.1 7.6
Symmetry of the Nipple-Areola ComplexV Anterior Projection
Total SymmetryV Anterior Projection
Overall Aesthetic Impression
Data from bilateral patients are presented by mean despite the fact that ‘‘total mean’’ was calculated from values for each breast. Patient numbers 3 and 8 were not photographed before tattooing so we were unable to evaluate their photographs before. The color of the areola was evaluated only between tattooed patients and patient number 7, who had the nipple reconstructed from the areolar residue.
10 points, excellent results). The requests are given in Table 1. Unilateral and bilateral cases were evaluated separately. Each breast was assessed separately in bilateral cases and also the cases after areola tattooing were evaluated separately.
perception of breast integrity. All the questions are shown in Table 2. A 10-point scale was used where 10 points mean yes/very positive/ very satisfied/unqualified; 5 point means do not know/less positive/ rather satisfied/I have some minor objections; and 1 point means: no/negative/unsatisfied/I have serious reservations.
Patient Satisfaction Assessment We have created a special questionnaire focused on the subjective perception of the shape of a reconstructed breast and a nipple; the satisfaction with the location of the nipple on the breast; nipple sensitivity; and the importance of the presence of nipples on the
RESULTS This technique of immediate nipple reconstruction has been used to reconstruct 28 nipples in 17 patients. There were no failures, but 2 patients had partial necrosis of the nipple, which maintained
TABLE 2. Evaluation of the Patients’ Satisfaction With the Immediate Nipple Reconstruction Evaluation (Mean)
Question 1. How do you feel about the appearance and the shape of your new reconstructed breasts? 2. How do you feel about the appearance and the shape of your new reconstructed nipples? 3. Are you satisfied with the position of the new nipples on your breasts? 4. Are you satisfied with the sensitivity of the nipples? 5. What do you think about the shape, placement, and the size of the scars around the nipples? 6. Do you find the presence of the nipples crucial for your breast integrity considering what you had undergone prior to the operation? 7. Have you been influenced by the fact that there is a possibility of nipple reconstruction in making a decision about the prophylactic mastectomy? 8. Did the healing of reconstructed nipples have any complication which made healing of reconstructed breast last longer? 9. If you were able to choose the secondary nipple reconstruction, which would mean another operation under local anesthetics and wearing 2 weeks bandage but, on the other hand, the possibility of the change of nipples’ position on the breasts, would you choose this possibility?
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9.6 9.7 9.9 7.2 9.6 5.9 2.2 No No
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adequate projection after excision of the necrotic area during an office visit nevertheless. Average duration of the nipple reconstruction was approximately 10 minutes per 1 side. However, the duration of the whole surgical procedure was not longer in most of the cases than that for immediate DIEP or MS-TRAM breast reconstruction alone because a second plastic surgeon was performing abdominal closure simultaneously and the abdominal closure was limiting for the length of the procedure. Thirteen patients (3 unilateral and 10 bilateral immediate nipple reconstructions) had complete standardized photographic documentation and at the same time were willing to fill out the questionnaire; 5 patients (4 bilateral) had the nipple-areolar complex tattooed. Average age of the patients was 47 years (range, 33Y58 years). Average follow-up, corresponding to the completion of the questionnaires, was 13 months (range, 2Y25 months). The patients were photographed 9 months (range, 3Y18 months) postoperatively before the tattooing and 6 months (range, 3 daysY15 months) postoperatively after the tattooing.
Aesthetic Results The results of the evaluation of the photographic documentation are given in Table 1. A minimum average score of 7.2 points was achieved in all evaluated criteria. The best score was given to the scars around the nipples and the symmetry of the reconstructed nipple or the nipple-areolar complex. One patient was unsatisfied because of asymmetry in the placement of the nipple on the breast. It was resolved with a good result using local V-Y advancement f lap technique. Some of the results are shown in Figures 3Y5.
Immediate Nipple Reconstruction
FIGURE 5. A 52-year-old BRCA1-positive patient with ptotic breasts after breast conservative treatment (right side). Results at 5 months after the tattooing.
Patient Satisfaction Table 2 shows patient satisfaction as assessed by the questionnaire. All the patients were very satisfied with the shape of the breast (average value of 9.6 points), with the shape of the nipple (9.7), with the position of the nipples on the breast (9.9), and with the scars around the nipple (9.6). Variability may be deduced from Table 3. Most of the patients (77%) were also very satisfied (8Y10 points), 2 of them moderately satisfied (5Y7 points), and 1 patient was unsatisfied with the sensitivity of the nipple. The possibility of immediate nipple reconstruction in 1 session with immediate breast reconstruction does not facilitate a decision to undergo prophylactic skin-sparing mastectomy. The healing time of a reconstructed nipple does not prolong the time of the entire healing of the breast and abdomen. And only 1 patient would prefer the possibility of delayed nipple reconstruction retroactively. This patient was already mentioned for the need of a secondary correction of nipple placement.
DISCUSSION
FIGURE 4. Same patient as shown in Figure 3: reconstructed nipple in detail, close-up postoperative view. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Skin-sparing mastectomy is technically more difficult than modified radical mastectomy, but the main advantage of this technique is the aesthetic and psychological result obtained by immediate breast and possibly also nipple reconstruction. At our institution, we reserve this combination for patients who are not being considered for complementary radiotherapy. For reconstruction, we frequently use the autologous-free abdominal f laps (DIEP or MS-TRAM) which give good aesthetic results, a normal appearance, and consistency close to that of a nonoperated breast. Nipple-areolar complex reconstruction is normally the final step in breast reconstruction followed usually by tattooing of nippleareola complex.21Y24 Presence of the nipple on the breast is important for the perception of the breast integrity for the patient after breast reconstruction.25 A nipple is ordinarily reconstructed secondarily under local anesthesia on reconstructed breast using different local f laps. There are several techniques, the most commonly used are Little’s skate f lap, Hartrampf ’s U-shaped f lap, Lossing’s modified S-f lap, Losken S-V f lap, and Kroll’s double-opposing-tab f lap.11Y17 Modified star-f lap technique and Hartrampf ’s wrap around f lap are most commonly used at our department. The technique of immediate nipple-areolar complex reconstruction during immediate latissimus dorsi breast reconstruction using 2 local skin f laps from latissimus dorsi f lap was described by Delay et al19 in group of 30 patients. www.annalsplasticsurgery.com
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TABLE 3. Evaluation of Patients’ Satisfaction Question No. patient Unilateral 1 2 3 Mean Bilateral 4 5 6 7 8 9 10 11 12 13 Mean Total mean
1
2
3
4
5
6
7
9
10
8 10 10 9.3
10 9 7 8.7
10 10 10 10
10 9 1 6.7
10 10 8 9.3
2 1 7 3.3
2 1 0 1
No No No No
Yes No No No
9 10 10 10 10 10 10 10 10 10 9.9 9.6
10 10 10 10 10 10 10 10 10 10 10 9.4
10 10 10 10 7 10 10 10 10 10 9.7 9.9
8 10 5 7 8 8 10 10 10 1 7.7 7.2
10 10 10 8 10 10 10 10 10 10 9.8 9.6
10 1 10 9 5 10 9 10 10 10 8.4 5.9
9 1 1 9 1 0 1 1 10 1 3.4 2.2
No No No No No No No No No 0 No No
No No No No No No No No No No No No
Several authors have described their experience with singlestep breast and nipple-areola complex reconstruction on free or pedicled TRAM f laps.18,26Y31 Colen26 introduced the concept of immediate nipple reconstruction with a bilobed f lap created from a dog-ear of redundant tissue on a folded free TRAM f lap. Beegle28 described immediate TRAM f lap and nipple-areola reconstruction on free TRAM f laps, although he gives little mention as to his preferred technique of nipple reconstruction. Hudson et al29,30 performed immediate nipple reconstruction during a breast reconstruction with a pedicled TRAM using a local C-V f lap in zone 2 of the TRAM f lap and a full-thickness skin graft. Charanek et al31 described their technique of breast reconstruction using a bipedicled TRAM f lap and inclusion of the umbilical scar as an immediate nipple reconstruction. Their breast mound does seem to have good projection using this method, however, the intentional sacrifice of the umbilicus for nipple reconstruction is not ideal. And finally, Williams et al18 compared results of immediate nipple reconstruction on a free TRAM f lap (modification of the Colen’s technique) with delayed nipple reconstruction. They concluded that the patients who had their immediate nipple reconstruction completed earlier required fewer procedures and had aesthetic results comparable to patients having traditional delayed nipple reconstruction. Complications and revision rates were comparable. They also pointed out that close attention to detail and intraoperative planning are essential to a good cosmetic outcome and that if the shape and position of the breast mound reconstruction is not ideal during the initial operation, nipple reconstruction should be delayed. Drazan and Castagnetti designed a modified skin-sparing mastectomy pattern for prophylactic and therapeutic surgery in case of large and ptotic breasts. A basic inverted-T is drawn but modified for the purpose of preserving extra skin for future nipple-areola complex reconstruction.20 The described technique allows for the absence of round scars in the nipple-areola complex and some sensitivity of the reconstructed nipple-areola complex is often preserved because the skin is obtained from local breast skin instead of the f lap skin. Our technique is refinement of the Drazan’s technique. The nipple is reconstructed immediately from relative excess of the skin envelope in patients with large or ptotic breasts. Proportions of the 650
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skin envelope are given by the desired size of the reconstructed breast. The size of the lower abdomen is determinative for the maximal achievable size of the reconstructed breast especially in bilateral breast reconstruction using abdominal f laps, and thus, breast skin reduction is often desirable. The skin-sparing mastectomy pattern is designed immediately with 3 local f laps which are being used to reconstruct the nipple. The resulting scars are placed at the base of the lower part of the nipple and there is only 1 vertical scar below the nipple. This is the reason of high patient satisfaction with the scars around the nipple (average value of 9.7 points). After mastectomy, there is a certain degree of desensitization of the mastectomy skin f laps unlike the abdominal skin paddle of DIEA f laps lobe that completely misses superficial sensitivity. Partially preserved sensitivity of mastectomy skin f laps can be explained by the persistence of some medial and lateral cutaneous branches of intercostal nerves. A high percentage of our patients reported satisfaction with the sensitivity of the nipples (average value of 7.5 points, only 15% patients not satisfiedV less than 5 points). We believe that the declared high satisfaction of the patients with the nipple sensitivity is determined by the partially preserved sensitivity of the mastectomy f laps. Arguments for delaying nipple-areola complex reconstruction focus on the difficulty of determining the appropriate position of the nipple-areola complex because of a healing process and early postoperative breast asymmetries. However, in rather experienced hands, positioning the new nipple-areola complex can be straightforward when skin-sparing mastectomy is performed using a modified Wise pattern design. We are encouraged that the positioning of the nippleareola complex was actually one of the highest ranked characteristics (average values of 8.1 and 7.7 for nipple placement symmetry in anterior and lateral projections from photographic documentation and average value for patient satisfaction with nipple placement on the breast of 9.7). Duration of the operation is not significantly prolonged by the immediate nipple reconstruction. Healing of the nipple does not exceed the healing period of the breast and abdomen (question 8). At our institution, skin-sparing mastectomy is performed by plastic surgeon in prophylactic cases. Despite the utmost attention to gentle handling of tissues, we observed few cases of poor perfusion of * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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mastectomy skin f laps with subsequent difficulties with the skin healing. In the investigated group of patients, marginal skin f lap necrosis has occurred once at the bottom of the vertical scar and the nipple has not been affected. Design of this study was based on the evaluation of photographic documentation by independent observers and on the subjective evaluation by patients. Maintenance of projection is one of the most difficult issues with nipple-areolar creation. In another larger study, we intend to focus closer on objectification of nipple projection by clinical measurements and also possibly on comparison of the nipple projection with other types of nipple reconstruction. Although we have used this technique only during autologous breast reconstruction using abdominal free f laps, we believe that it could be also used during implant-based breast reconstruction when skin-sparing mastectomy is performed. A well-performed immediate breast and nipple-areola complex reconstruction has several advantages. The psychosocial issues surrounding the patient with breast cancer requiring mastectomy may be expected to improve if an aesthetic breast reconstruction can be performed more quickly and with fewer procedures.
CONCLUSIONS We believe that in experienced hands, 1-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local f laps on the skin envelope f lap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. We also believe that 1-stage reconstructive surgery may be psychologically beneficial and cost effective. Although our study is small and there are clear limitations to this retrospective study, our preliminary results are encouraging. REFERENCES 1. Spurna Z, Drazan L, Foretova L, et al. The effect of prophylactic mastectomy reconstruction on quality of life in BRCA positive women. Klin Onkol. 2012;25:74Y77. 2. Drazan L, Vesely J, Hyza P, et al. Surgical prevention of breast carcinoma in patients with hereditary risk. Klin Onkol. 2012;25:78Y83. 3. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814Y819. 4. Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg. 2004;114:1077. 5. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113:1153. 6. Barton FE, English JM, Kingsley WB, et al. Glandular excision in total glandular mastectomy: a comparison. Plast Reconstr Surg. 1991;88:389. 7. Asplund O. Nipple and areola reconstruction: a study in 79 mastectomized women. Scand J Plast Reconstr Surg. 1983;17:233. 8. Bogue DP, Mungara AK, Thompson M, et al. Modified technique for nippleareolar reconstruction: a case series. Plast Reconstr Surg. 2003;112:1274.
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9. Tanabe HY, Tai Y, Kiyokawa K, et al. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. Plast Reconstr Surg. 1997; 100:431. 10. Brent B. Nipple-areola reconstruction following mastectomy: an alternative to the use of labial and contralateral nipple-areolar tissues. Clin Plast Surg. 1979;6:85. 11. Little JW III, Munasifi T, McCulloch DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983;71:126. 12. Little JW. Nipple-areolar reconstruction. In: Cohen M, eds. Mastery of Plastic and Reconstructive Surgery, Vol. 2. Chicago, Ill: Little, Brown; 1994: 1344Y1349. 13. Hartrampf CR Jr, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg. 1984;73:982. 14. Lossing C, Brongo S, Holmstro¨m H. Nipple reconstruction with a modified S-flap technique. Scand J Plast Reconstr Surg Hand Surg. 1998;32:275Y279. 15. Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing-tab flap. Plast Reconstr Surg. 1989;84:520. 16. Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108:361. 17. Kroll SS, Reece GP, Miller M, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997; 99:1602. 18. Williams EH, Rosenberg LZ, Kolm P, et al. Immediate nipple reconstruction on a free TRAM flap breast reconstruction. Plast Reconstr Surg. 2007;120: 1115Y1124. 19. Delay E, Mojallal A, Vasseur C, et al. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006;118:1303Y1312. 20. Drazan L, Castagnetti F. Keeping extra skin for nipple-areola reconstruction during mastectomy. Plast Reconstr Surg. 2007;120:815Y816. 21. Rees TD. Reconstruction of the breast areola by intradermal tattooing and transfer. Case report. Plast Reconstr Surg. 1975;55:620Y621. 22. Becker H. The use of intradermal tattoo to enhance the final result of nippleareola reconstruction. Plast Reconstr Surg. 1986;77:673. 23. Spear SL, Convit R, Little JW III. Intradermal tattoo as an adjunct to nippleareola reconstruction. Plast Reconstr Surg. 1989;83:907. 24. Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg. 1997;50:331. 25. Wellisch DK, Schain WS, Noone R, et al. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80:699. 26. Colen LB. One-stage reconstruction of the breast using autologous tissue with immediate nipple reconstruction. In: Spear S, Little JW, Lippman ME, et al, eds. Surgery of the Breast: Principles and Art. Philadelphia, Pa: LippincottRaven; 1998:491Y509. 27. Eskenazi L. A one-stage nipple reconstruction with the ‘‘modified star’’ flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg. 1993; 92:671. 28. Beegle PH Jr. Immediate single-stage TRAM and nipple areola reconstruction. Clin Plast Surg. 1994;21:321. 29. Hudson DA, Dent DM, Lazarus D. One-stage immediate breast and nippleareolar reconstruction with autologous tissue I: a preliminary report. Ann Plast Surg. 2000;45:471. 30. Hudson DA, Skoll PJ. Single-stage, autologous breast restoration. Plast Reconstr Surg. 2001;108:1163. 31. Charanek AM, Carramaschi FR, Curado JH. Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements. Plast Reconstr Surg. 2000;106:1262.
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