Immediate Nipple Reconstruction Using the Everted Umbilicus

Abstract

Sir: A young patient with a small to moderate body habitus with minimal ptosis, requiring unilateral reconstruction, may benefit from immediate nipple reconstruction using the everted umbilical stalk (Fig. 1). In unilateral cases, the contralateral nipple may be of substantial size and difficult to match using routine nipple reconstruction techniques.1 Furthermore, in a young patient with a sensate contralateral nipple, nipple sharing may induce additional psychological stress.Fig. 1.: Three-month postoperative view. The right nipple is reconstructed by everting the umbilicus. Note the high location of the abdominal scar, natural crease forming around the neonipple, small central depression in the neonipple, and texture of skin around the everted navel. Umbilicoplasty is performed by tethering splayed dermal edges to underlying fascia. Note the color and texture of skin around the reconstructed nipple, and the depth of the reconstructed umbilicus. The patient refused any further reconstructive procedures.Other patients may be averse to surgical manipulation of the contralateral breast, for either personal or cultural reasons, and present a particular challenge to the reconstructive surgeon seeking symmetry. It is possible to design a transverse rectus abdominis musculocutaneous flap more or less centered around the umbilicus, even though flap design and inset become more challenging. Patients with grade 2 and 3 contralateral ptosis have undergone reconstruction in this fashion (Fig. 2).Fig. 2.: A patient with grade 3 ptosis who refused any contralateral procedures underwent single-stage nipple-mound reconstruction using the everted navel. Note the projection and texture of skin in the site of the areola.De Cholnoky described the use of the everted navel for nipple reconstruction using abdominal tubed flaps in 1966.2 More recently, commonly used techniques are the C-V flap and its modifications (e.g., trilobed, star, arrow)3–5 and skate and its modifications (e.g., box-top),6,7 all of which are known to induce local architectural distortion that accentuates periareolar flattening. Long-term projection is approximately 40 to 60 percent at best.8 Bell flaps have been described with the hypothetical potential of increasing nipple and areola projection but have been marred by risks of partial flap loss and poor long-term projection.8 Double tab flaps9 are safe and reliable but maintain poor projection long term. The skin around the everted umbilicus is often glabrous, thicker, and of different texture than surrounding abdominal skin. In very-light-pigmented nipples, this difference in texture may be enough to delineate an areola without further reconstructive steps. The periumbilical skin is otherwise a good recipient for intradermal pigmentation. Umbilical reconstruction after ablation has been described previosuly.10 Although it may seem like an additional step, it actually decreases surgical time and allows for more liberal closure of the abdominal fascia, without concern for maintaining the midline location for the umbilical stalk. This should avoid the off-centered umbilicus sometimes observed after unilateral transverse rectus abdominis musculocutaneous flaps. Whenever possible, we approximate the fascial edges primarily, mobilizing the remaining rectus muscle medially, and attach the umbilicoplasty flaps to the now medialized contralateral rectus sheath. Long-term nipple projection has been maintained in all our patients except for one patient who underwent partial necrosis. For the other eight patients, nipple height is 8 to 12 mm and nipple width is 12 to 15 mm after a follow-up ranging from 3 to 27 months. After several months, some settling occurs, but the neonipple remains conspicuous, with formation of a peripheral crease that accentuates its visibility, probably because of periumbilical skin and subcutaneous tethering architecture. A sharp angle between the breast mound and the neonipple is emphasized by several authors.9 Christian A. El Amm, M.D. Josephine S. Sung, M.D. Kamal T. Sawan, M.D. Bishara S. Atiyeh, M.D. Meredith C. Workman, M.D. University of Oklahoma Oklahoma City, Okla. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.