High-Riding Nipple Research Articles

Upper Footprint Dependent Nipple Position to Avoid High-Riding Nipple after Reduction Mammoplasty

Introduction: High-riding nipple following reduction mammoplasty is a challenging problem for the plastic surgeons. To avoid such problem, many methods have been described for marking the correct nipple position but still controversial. We aimed in this study to present our experience in preventing excessive nipple elevation after reduction mammoplasty by using the upper footprint to set the new nipple position. Material and Methods: From March 2019 to March 2022, 25 female patients at a mean age of 38.3 years were included in this prospective study. They underwent reduction mammoplasty with inverted T scar and a combination of inferior pedicle and Würinger’s septum techniques. Resection weights, pre- and postoperative anthropometric measures were recorded. All patients were photographed at the follow-up visits and evaluated for complications if any, the nipple-areola complex (NAC) sensation, and subjective patient satisfaction using “The Breast Evaluation Questionnaire”. Results: The mean preoperative midclavicular point to nipple distance was 37.40 and 37.18 cm for the right and left breasts, respectively. The mean resection weight was 1270 and 1242 g from the right and left sides, respectively. None of our patients experienced NAC necrosis, while 2 breasts had minor wound dehiscence treated conservatively. After a mean follow-up period of 12 months, the NAC descended by an average of 1.40 cm, the distance from the IMF to nipple had an average increase of 2.24 cm, and all of patients were satisfied with the esthetic outcomes and convinced with their breast shape. Conclusion: The upper footprint dependent nipple position seems to have a real role in preventing high-riding nipple after breast reduction in hypertrophic and gigantomastic breasts. Moreover, it can be applied easily and allow for more satisfying outcomes than other methods for setting the new nipple position.

Upper Footprint Dependent Nipple Position to Avoid High-Riding Nipple after Reduction Mammoplasty

Upper Footprint Dependent Nipple Position to Avoid High-Riding Nipple after Reduction Mammoplasty

Evaluating Long-Term Outcomes following Nipple-Sparing Mastectomy and Reconstruction in the Irradiated Breast.

BACKGROUND: Although it is well established that reconstruction of the irradiated breast is associated with diminished cosmetic results and more frequent complications, little is known about the specific effects of radiation therapy on the reconstructive outcomes after nipple-sparing mastectomy. METHODS: Patients who had nipple-sparing mastectomy and had either previous radiation therapy for breast-conservation therapy or postmastectomy radiation therapy were reviewed. Patient demographics, reconstructive details, and postoperative outcomes were analyzed. Patient photographs were used to evaluate aesthetic parameters. Fisher's exact and t tests were used for comparison of groups, with a value of p < 0.05 considered significant. RESULTS: Eighteen patients were identified as having nipple-sparing mastectomy either after breast-conservation therapy (72.2 percent) or before postmastectomy radiation therapy (27.8 percent), with an average follow-up of 3 years. First-stage complications occurred in six patients (33.3 percent). Nipple position was classified as high-riding in 55.6 percent of patients. Average time to revision was 13.3 months. Most common revisions were for correction of malposition (27.8 percent), capsular contracture (16.7 percent), and high-riding nipple (22.4 percent). Capsular contracture occurred more commonly in patients who needed postmastectomy radiation therapy compared with those who had previously undergone breast-conservation therapy (40 percent versus 7.8 percent). Maintenance of reconstruction occurred in 88.9 percent patients, with eventual implant loss occurring in two patients (11.1 percent). CONCLUSIONS: Nipple-sparing mastectomy and implant reconstruction should be approached cautiously in the setting of radiation therapy. When early complications are present, significant morbidity may occur. Late revision surgery is common in this subset of patients. Implant malposition and a high-riding nipple occur most frequently. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evaluating long-term outcomes following nipple-sparing mastectomy and reconstruction in the irradiated breast.

Although it is well established that reconstruction of the irradiated breast is associated with diminished cosmetic results and more frequent complications, little is known about the specific effects of radiation therapy on the reconstructive outcomes after nipple-sparing mastectomy. Patients who had nipple-sparing mastectomy and had either previous radiation therapy for breast-conservation therapy or postmastectomy radiation therapy were reviewed. Patient demographics, reconstructive details, and postoperative outcomes were analyzed. Patient photographs were used to evaluate aesthetic parameters. Fisher's exact and t tests were used for comparison of groups, with a value of p < 0.05 considered significant. Eighteen patients were identified as having nipple-sparing mastectomy either after breast-conservation therapy (72.2 percent) or before postmastectomy radiation therapy (27.8 percent), with an average follow-up of 3 years. First-stage complications occurred in six patients (33.3 percent). Nipple position was classified as high-riding in 55.6 percent of patients. Average time to revision was 13.3 months. Most common revisions were for correction of malposition (27.8 percent), capsular contracture (16.7 percent), and high-riding nipple (22.4 percent). Capsular contracture occurred more commonly in patients who needed postmastectomy radiation therapy compared with those who had previously undergone breast-conservation therapy (40 percent versus 7.8 percent). Maintenance of reconstruction occurred in 88.9 percent patients, with eventual implant loss occurring in two patients (11.1 percent). Nipple-sparing mastectomy and implant reconstruction should be approached cautiously in the setting of radiation therapy. When early complications are present, significant morbidity may occur. Late revision surgery is common in this subset of patients. Implant malposition and a high-riding nipple occur most frequently. Therapeutic, III.

Repairing the High-Riding Nipple with Reciprocal Transposition Flaps; and Classification and Management of the Postoperative, High-Riding Nipple

Sir: We read with interest the recent article by Spear et al.1 describing a useful technique for correction of the postoperative, high-riding nipple, and the subsequent review and classification.2 We too have found nipple-sparing mastectomy reconstruction with either expanders or single-stage implants to confer an excellent aesthetic outcome in suitable patients. With increasing volume and laxity of the skin envelope, however, the potential for shear at the mastectomy flap/implant pocket interface increases, manifest by a tendency for the nipple-areola complex to migrate superolaterally during the postoperative recovery and/or expansion phase. This aesthetically undesirable outcome may also be exacerbated by, but is not exclusive to, postreconstruction radiotherapy. Several other solutions have been described in the literature, including techniques where the nipple is lowered through a buttonhole,3 transposed as a flap, or Z-plasty.4 Excision and repositioning as a graft may result in the least scarring, but at the risk of nipple loss. Techniques that involve elevating the entire breast relative to the nipple have been described both by elevating the inframammary fold3 and with the use of implants or tissue expanders,3,5 but are less useful for correcting multiple vectors of displacement. Thus, given that these techniques may be complex and often provide suboptimal results,4 prevention should be preferable to cure. We currently use a simple suture technique to anchor the spared nipple-areola complex to the underlying implant pocket, which maintains its position on the breast mound throughout the expansion/postoperative period. The nipple-sparing mastectomy is performed and submuscular pocket created as described previously. Care is taken to ensure optimal placement of the device such that the nipple-areola complex is located and marked at the pinnacle of the breast mound, or for expanders, once the desired intraoperative fill volume is achieved. The nipple-areola complex dermis is then tacked to the muscle pocket using three 4-0 absorbable monofilament anchoring sutures (Fig. 1). The radial mastectomy scar may also be anchored in this way (Fig. 2). Intraoperative sitting of the patient is invaluable, not only in the key assessment of the final nipple-areola complex placement but also in ensuring that no adverse skin folding or traction on the nipple-areola complex is caused by the anchoring sutures. A drain placed between the muscle and skin flap reduces potential shear. The remainder of the procedure and postoperative management is unaltered.Fig. 1: On-table marking of the nipple-areola complex.Fig. 2: Three-point fixation of the nipple-areola complex to the underlying implant pocket.We have successfully used this technique over a series of 25 consecutive alloplastic reconstructions following nipple-sparing mastectomy, evenly split between two-stage expander and single-stage reconstructions. Postoperative irradiation was also administered in 16 percent. No revisions to the nipple-areola complex were required over the median 6-month follow-up period (range, 2 to 12 months). Given that the technique results in negligible additional operative time, complications, and costs, we suggest that it be included among solutions to this difficult problem. DISCLOSURE Dr. Lennox is a speaker for LifeCell Corp. Esta S. Bovill, Ph.D., F.R.C.S.(Plast.) Sheina A. Macadam, M.D. Peter A. Lennox, F.R.C.S. Division of Plastic Surgery University of British Columbia, and Burn, Plastic & Trauma Unit Vancouver General Hospital Vancouver, British Columbia, Canada

Defining Nipple Displacement, and the Prevention and Treatment of the High-Riding Nipple

Defining Nipple Displacement, and the Prevention and Treatment of the High-Riding Nipple

Repairing the High-Riding Nipple with Reciprocal Transposition Flaps

Repairing the High-Riding Nipple with Reciprocal Transposition Flaps

Classification and Management of the Postoperative, High-Riding Nipple

Postoperative nipple malposition can be an aesthetically devastating problem for patients and a formidable challenge for surgeons. The authors' aim was to identify the common antecedent events leading to high-riding nipples, provide a classification system for these problems, and discuss management. A retrospective review of medical records was conducted for patients who presented to the senior surgeon (S.L.S.) for management of a postoperative, excessively high nipple-areola complex over an 8-year period from January of 2004 to March of 2012. Demographic information, medical histories, operative details, and office records were reviewed for each patient. The high nipple-areola complex was classified as mild, moderate, or severe depending on the distance from the superior breast border to the top of the nipple-areola complex in relation to the vertical breast height. Twenty-five women met study criteria, with 41 breasts determined to have an excessively high nipple-areola complex. The average patient was aged 44.3 years and had undergone 2.5±1.3 operations before the development of a notably high nipple-areola complex, including nipple-sparing mastectomy (32 percent), augmentation/mastopexy (29 percent), augmentation (27 percent), mastopexy (10 percent), and skin-sparing mastectomy with nipple reconstruction (2 percent). Patients were classified as having mild (27 percent), moderate (56 percent), or severe (17 percent) nipple-areola complex displacement; surgical correction was attempted in 54 percent of cases. A high-riding nipple-areola complex can develop following aesthetic or reconstructive surgery. Although many patients may not need or choose correction, there are surgical options that may be helpful in improving the nipple-areola complex position.

Repairing the High-Riding Nipple with Reciprocal Transposition Flaps

The high-riding nipple-areola complex is a clinical problem that can be encountered following cosmetic and reconstructive breast surgery. Because of the desire to avoid scars on the superior aspect of the breast and the limited availability of superior breast skin, it can be technically challenging to place the nipple-areola complex in a lower position. Multiple surgical strategies have attempted to lower it, and each has its advantages and disadvantages. Reciprocal rotation flaps have been used by the authors with success. They describe the surgical technique and outcomes in five breasts. The medical records of all patients who had reciprocal rotation flaps for high-riding nipple-areola complexes performed by the senior author (S.L.S.) were reviewed. The institutional review board-approved review included preoperative history and examination, surgical findings, surgical technique, and postoperative course. Five reciprocal rotation flap procedures were performed on four patients between 2005 and 2012 for high-riding nipple-areola complexes. The high-riding nipple-areola complexes were all iatrogenic, following reconstruction for nipple-sparing mastectomy or mastopexy. All nipple-areola complexes were successfully lowered with an average follow-up duration of 2.1 years. One breast that had undergone previous radiation therapy had a nipple-areola complex flap that appeared ischemic; the patient underwent hyperbaric oxygen therapy and the flap fully survived. Reciprocal rotation flaps are an effective strategy for management of the high-riding nipple-areola complex and can be safely performed with thoughtful planning and careful surgical technique. This technique is riskier in the irradiated breast but may be facilitated with hyperbaric oxygen therapy.

A Solution to the High-Riding Nipple–Areola Complex

There are limited techniques described in the literature on how to lower the nipple-areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty.

Lowering the Postoperative High-Riding Nipple

Lowering the Postoperative High-Riding Nipple

Lowering the Postoperative High-Riding Nipple

Boston, Mass. From the Department of Surgery, Division of Plastic Surgery, Massachusetts General Hospital, and Beth Israel Deaconess Hospital, Harvard Medical School. Received for publication June 24, 2006; accepted August 31, 2006. Presented at the New England Society of Plastic Surgeons Meeting, in New Castle, New Hampshire, June 4, 2006. Sumner A. Slavin, M.D., 1101 Beacon Street, Brookline, Mass. 02446, [email protected]

The use of the inframammary ligament in reduction mammaplasty

The inframammary fascial system has been dissected by us in the last 7 years in over 150 reduction mammaplasties or corrections of ptosis, as well as in cadaver dissections. We have found its anatomy to be consistent, notwithstanding differences in its descriptions in the literature. In this presentation, we describe the anatomy of the fascial structures in the inframammary region as described in the literature and as we have found it. We have used our findings to improve our technique of reduction mammaplasty. In our opinion, preservation of the inframammary ligament is essential to avoid postoperative ‘luxation’ of the breast and the high-riding nipple deformity.

Preventing the high-riding nipple after McKissock breast reductions.

We reviewed 50 patients who had reduction mamaplasties done by us using the McKissock vertical pedicle technique. The results were satisfactory, except for the high-riding nipple which developed. We describe a minor modification which seems to prevent this complication.