A New Approach to Nipple Reconstruction: The Modified S-Flap

Abstract

Sir: Many different techniques have been described by plastic surgeons to achieve nipple reconstruction. The most important aspect of nipple reconstruction is persistence in nipple projection and its comparison to the contralateral nipple.1,2 In an attempt to maintain nipple projection and aesthetics, we have devised a new approach to nipple construction using what we call a modified S-flap. The S-flap nipple reconstruction technique was designed to address certain characteristics of other nipple reconstruction techniques that may lead to unwanted contraction of nipple or loss of projection, shape, and size. The S-flap nipple reconstruction was performed on all patients requesting nipple reconstruction following breast reconstruction over a 5-year period (July of 1999 through July of 2004). The technique was described to our patients as a modified S-flap reconstruction. An elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. The faces of the randomized skin flaps were opposed to each other. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. Figures 1 and 2 illustrate the design of our proposed reconstruction. Areola tattooing was performed approximately 8 to 10 weeks after surgery if satisfactory wound healing was achieved. The base of the nipple was also tattooed, but the S-flap walls and tip of the nipple were left untattooed to decrease injury and contraction. This would preserve the nipple projection.Fig. 1.: The modified S-flap design. A 4 × 2-cm elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. Each letter corresponds to the specific points of angulations of the S incision. (Reprinted with permission from Frank Papay, M.D.)Fig. 2.: The modified S-flap design. The faces of the randomized skin flaps were opposed by matching A to A′ and B to B′ as described in Figure 1. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. (Reprinted with permission from Frank Papay, M.D.)As the final stage of breast reconstruction, nipple reconstruction changes the breast mound into a complete anatomical breast by achieving the aesthetics of the contralateral breast. Nipple reconstruction also increases self-esteem in the patient.1,3 Nipple projection, areola color, and symmetry are extremely vital for complete nipple reconstruction.4 A number of flap designs for nipple reconstruction have been well described in the literature. The techniques that have withstood the test of time are those that are surgically reliable and maintain nipple projection. The main obstacle in achieving acceptable nipple shape and size is contraction.4 The current standard of nipple-areola reconstruction is a technique that includes pulled-out flaps or star flaps to increase nipple projection and intradermal tattooing for areola pigmentation.1,2,4,5 Some authors believe that there should be stratification of nipple reconstruction depending on the type of breast reconstruction used. 5 Moreover, some authors believe that nipple projection is determined by the quality of the reconstructed skin dermis, namely, its thickness and vascularity. Our proposed method of the modified S-flap nipple reconstruction has not only preserved size and shape of the nipple-areola complex but also proved to be aesthetically acceptable to our patients. Kiran Narra, M.D. Department of General Surgery L. Michael Diaz, M.D. Department of Plastic Surgery Louisiana State University Baton Rouge, La. Frank A. Papay, M.D. Department of Plastic Surgery The Cleveland Clinic Foundation Cleveland, Ohio