Primary Nipple Reconstruction with AlloDerm: Is a Dermal Flap Always Necessary?

Abstract

Sir: Nipple reconstruction in patients following mastectomy and placement of breast implants can be hazardous if the soft-tissue envelope is thin. To circumvent potential implant exposure, we have been introducing an AlloDerm (LifeCell Corp., Branchburg, N.J.) cylinder into a subdermal pocket to simulate a normal nipple. This construct offers the look and feel of the autologous nipple-areola complex without jeopardizing the underlying implant. Although AlloDerm (cadaveric dermis) has been used as an adjunct to primary or secondary nipple reconstruction with dermal flaps, the use of AlloDerm alone for this purpose has not been reported.1,2 We describe the successful implementation of primary AlloDerm nipple constructs without the use of autologous dermal flaps for select patients with thin skin following breast implant reconstruction. The patient is anesthetized with 1% lidocaine with epinephrine. A 10-mm semicircular incision is then created along the inferior base of the proposed nipple. A subdermal pocket measuring approximately 1.5 × 1.5 cm is made using sharp dissection. A 4 × 7-cm piece of AlloDerm 0.76 mm in thickness is reconstituted according to protocol. The AlloDerm is folded onto itself and held together with through-and-through 5-0 nylon sutures, creating a cylinder or oblong construct. The grafts are then placed into the subdermal pockets and anchored to the base by a single simple interrupted Monocryl (Ethicon, Inc., Somerville, N.J.) suture (Fig. 1). The skin is draped over the graft and incisions are closed with 5-0 Monocryl deep dermal stitches followed by simple interrupted stitches with 6-0 nylon. A protective dressing is placed over the nipple until the follow-up visit in 2 weeks.Fig. 1.: Technique for primary nipple reconstruction with AlloDerm construct. A 10-mm semicircular incision is marked and a subdermal pocket is created for the AlloDerm cylinder. The construct is inserted (above) and the skin closed with Monocryl deep dermal sutures followed by nylon simple interrupted skin sutures (below).AlloDerm has been used widely in aesthetic and reconstructive plastic surgery secondary to its biological inertness, strength, and stretchability. In this article, we describe the use of AlloDerm grafts in primary nipple reconstruction in patients after breast implant reconstruction whose thin skin prevents the use of autologous dermal flaps. This simple technique is performed safely and retains nipple projection over time. Our favorable experience with AlloDerm in implant breast reconstruction led us to use this material in other aspects of our practice.3,4 Like others, we feel it is an adjunct to autologous dermal flaps for primary or secondary nipple reconstruction in patients who desire moderate to superior nipple projection. We have also been pleased with long-term maintenance of low-profile projection in 55 nipple reconstructions followed over 3 years. An important modification of our original technique is to use permanent sutures to create the AlloDerm cylinder to prevent graft unrolling following dissolution of the absorbable suture. We have not experienced graft unrolling or suture extrusion since this modification. In conclusion, primary nipple reconstruction with AlloDerm can be used without the need for dermal flaps in select patients with thin skin following breast implant reconstruction. DISCLOSURE Karl H. Breuing, M.D., is on the speaker's bureau for LifeCell. Amy S. Colwell, M.D. Division of Plastic Surgery Massachusetts General Hospital Karl H. Breuing, M.D. Division of Plastic Surgery Brigham and Women's Hospital Boston, Mass.