Nipple-areola Complex Reconstruction Research Articles

Safe delayed procedure of nipple reconstruction in poorly circulated nipple.

Nipple-areolar complex reconstruction represents the final step in breast reconstruction. However, there is no gold standard nipple reconstruction technique that addresses the issue of blood circulation in the flap, which is the most basic complication. Nipple reconstruction was performed in 21 patients. A delayed procedure was performed when a poor outcome was expected due to marginal pinpoint bleeding in the distal tip after flap elevation during nipple reconstruction. The delayed nipple reconstruction can be viewed as a safe and reliable method for improving nipple blood circulation, reducing complications, and enabling long-term nipple projection maintenance in high-risk patients.

Nipple Reconstruction Techniques: Which is the Best Choice?

Nipple-Areolar Complex (NAC) reconstruction represents the final, concluding journey of breast reconstruction by being able to give to reconstructed breasts the shape of a natural breast mound. Nevertheless an enormous amount of nipple reconstruction techniques are described in literature, given the fact that most reconstructive options fail to give satisfactory outcomes in relation to the long-term nipple projection. In this review, the authors will browse most common nipple reconstruction techniques, taking into account: Indication, outcome, and side effect. Composite nipple grafts, traditional flaps, flaps with autologous graft augmentation, flaps with allograft augmentation, and flaps with alloplastic augmentation are the main strategies employed nowadays. Composite nipple grafts give the best guarantee of color-texture match with the contralateral side and show satisfactory nipple projection even at long-term follow-up. Skate, star, C-V, and arrow flap are by far the most commonly employed and the most reliable local flaps, however loss of projection of up to 70 percent are reported in literature. Alloplastic grafts were associated with the lowest rates of projection loss followed by autologous and allogenic ones. Nevertheless allogenic grafts are also associated with the highest complication rate, while autologous and allogenic ones have similar rates. Infection, seroma, and fat necrosis are the more commonly reported complications of autologous grafting along with donor site morbidity, while allogenic and alloplastic augmentation grafts may also experience the risk of overcorrection and graft exposure. Given the numerous techniques described in literature it is clear that the ideal nipple reconstruction hasn’t been found yet. Whereas it should be chosen on case to case basis depending on type of mastectomy, radiotherapy, type of reconstruction, skin thickness, tissue condition, and patients’ expectations to ensure the best cosmetic outcome.

Simultaneous Nipple-Areola Complex Reconstruction Technique: Combination Nipple Sharing and Tattooing.

Nipple-areola complex (NAC) reconstruction is the final critical process used to achieve breast symmetry, patient satisfaction, and overall reconstruction completeness. Here, we introduce our simplified simultaneous NAC reconstruction approach with nipple sharing and tattooing that resulted in minimal morbidity, high patient satisfaction, and a shortened total reconstructive period. Patients who underwent simultaneous nipple sharing and tattooing between July 2012 and December 2017 after the final operative procedure or adjuvant therapy were included. We retrospectively evaluated breast reconstruction type, interval between breast and NAC reconstruction, mean operation time for simultaneous nipple sharing and tattooing, and postoperative complications. Overall patient satisfaction and willingness to undergo simultaneous NAC reconstruction again were assessed. The mean interval between the final operative procedure or adjuvant therapy and NAC reconstruction was 4.4, 4.4, and 6.7months in non-adjuvant patients, those who underwent chemotherapy, and those who underwent radiotherapy, respectively. The mean operation time for simultaneous NAC reconstruction was 46min. No major complications such as infection or total nipple loss were observed regardless of breast reconstruction type at least 6months postoperatively. The average overall satisfaction was 8.0 on a 10-point scale, and 96.9% of patients indicated that they would undergo this simultaneous NAC reconstruction again. Our simplified technique of simultaneous nipple sharing and tattooing is safe and reliable and features high patient satisfaction rates. Additionally, it can be performed in the clinical setting and is convenient for patients and surgeons alike since it features a decreased total reconstruction period. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Severe gynaecomastia associated with highly active antiretroviral therapy

The association between gynaecomastia and HIV infection was first reported in 1987; however, there were no subsequent published reports of gynaecomastia linked to HIV infection until highly active antiretroviral therapy (HAART) was introduced. Although HAART significantly improves the prognosis of HIV infection, its extensive use has resulted in multiple adverse effects, including benign breast enlargement. We present a rare case of severe gynaecomastia in a male patient with vertically transmitted HIV on HAART. He was surgically treated with mastectomy with no nipple-areolar complex reconstruction. The pathology report confirmed the benign nature of the breast tissue. Surgical intervention resulted in an improvement of daily activities and enhanced psychosocial wellbeing. Benign bilateral breast enlargement of this magnitude in a male patient has never been reported. Keywords: gynaecomastia; HIV; highly active antiretroviral therapy; efavirenz

A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft.

Nipple-areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola. From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple-areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12months postoperatively. At the final visit, the patient's subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale. Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12months postoperatively, respectively. Patients' overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a 'good' satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be 'poor' and 'disappointing' each accounted for 1 and 3 patients. The combination of nipple-areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction.

The morphological result of nipple-areola complex (NAC) reconstruction may be disappointing for patients who undergo skin-sparing mastectomies and immediate breast reconstruction, followed by secondary reconstruction of the nipple-areola complex.The aim of this study was to analyze patient satisfaction after nipple-sparing mastectomy and immediate breast reconstruction with a deep inferior epigastric perforator flap. Our retrospective study involved all patients who underwent an immediate breast reconstruction after unilateral mastectomy with conservation of the NAC. The following three kinds of surgical approach were used: mastectomy with periareolar incision, mastectomy with hemiperiareolar incision and lateral extension, and mastectomy with inverted-T mammoplasty incision. Our study was based on a survey using a standardized questionnaire and a Likert scale to report patient satisfaction on the basis of criteria defined by the investigators. We evaluated 17 patients. All reconstruction patients were satisfied or very satisfied with the overall aesthetic appearance, projection, and volume as well as the appearance of scarring on the reconstructed breast. None of our patients reported dissatisfaction in response to the criteria under evaluation. A periareolar incision was used most often to perform the mastectomy (10 patients). Partial NAC necrosis was observed in five patients, without negatively influencing their perception of the morphological outcome of their reconstruction. Immediate breast reconstruction using a deep inferior epigastric perforator free flap after nipple-sparing mastectomies met with a high rate of general satisfaction among patients and resulted in a low rate of nipple-areola complex necrosis.

Reply: Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe.

Sir: We thank Dr. Parisi and colleagues for their interesting response to our article.1 Conceptually, we completely agree that it is always better to have as much coverage of the implant as possible. In our practice, this is muscle, a deepithelialized dermal flap, or even potentially an acellular dermal matrix or mesh. This will provide potentially less rippling in the long term, as there is thicker coverage of the implant. However, it may not necessarily decrease the complication rates as far as sepsis and seroma are concerned, especially if an acellular dermal matrix or mesh is used. Coverage of the implant by whatever manner also does not necessarily change the perfusion of the mastectomy flaps, although tension in the repair may. Well established is the practice that unless an acellular dermal matrix or mesh is used, the surgeon is limited to using a skin-reducing mastectomy pattern with inferior deepithelialized dermocutaneous flap to cover the lower pole of the implant. If total muscular coverage is desired, a combination of the pectoralis major and the serratus anterior muscle is used. This will obviously limit the size of the prosthesis that can be placed in this relatively small pocket, as described in Dr. Parisi et al.’s letter. From a postoperative cosmetic point of view, in the lazy-S approach, the upper two-thirds of the implant is covered by the mastectomy flap and the pectoralis major muscle; thus, it is uncommon to have postoperative rippling in this area. If the lower mastectomy flap is very thin (<1 cm) then, not uncommonly, there will be some rippling in this area. This is usually corrected at the time of nipple-areola complex reconstruction with lipofilling of the lower mastectomy flap. It is also vital that the inframammary fold is retained during the mastectomy and that a tight snug pocket is reconstructed around the implant; otherwise, there is a high chance that the patient may end up with implant malposition or implant rotation. Mastectomy flap necrosis is one of the major concerns of which any breast reconstructive surgeon is acutely aware. The mastectomy needs to be performed in the mastectomy plane, and this can be vague; however, with appropriate traction on the skin and countertraction on the breast organ itself, the avascular white line can be seen and the mastectomy needs to be performed in this plane. If the mastectomy is performed in the correct plane, all that remains is the subcutaneous fat and the overlying skin. Although the patient’s body habitus often dictates the flap thickness, this is not always the case. The premise that the more weight the patient is carrying, generally the thicker the flap, cannot solely predict mastectomy flap. The blood supply to the mastectomy flaps after mastectomy is provided by the subdermal plexus, and if it is removed or damaged at the time of mastectomy, the surgeon should expect to have mastectomy flap necrosis. We do not routinely evaluate the mastectomy flap thickness before surgery and therefore there is no absolute number to use for the thickness of the mastectomy flap, as it varies from patient to patient. The most accurate way to determine perfusion and viability of the mastectomy flaps is to use intraoperative laser angiography [such as the SPY system (LifeCell Corp., Branchburg, N.J.)],2 which we do not use. If this is not available, débridement of the edges of the mastectomy flap will indicate the perfusion of that specific flap, and if there is doubt about the perfusion, the flaps can be trimmed back until the surgeon is happy with the perfusion. If there is not enough remaining skin to cover a large enough implant, the patient can then be converted to an expander prosthesis reconstructive pathway. Some patients are prone to wound healing problems, such as those with a high body mass index, diabetic patients, poorly controlled human immunodeficiency virus–positive patients, previously irradiated patients, and smokers. These women may have a higher postoperative complication rate in relation to wound healing and minor flap necrosis and should be approached and counseled with care. The reconstructive surgeon should have a much lower threshold to use an expander prosthesis reconstructive pathway for these high-risk patients. ACKNOWLEDGMENT The study received ethics approval from the Human Research Ethics Committee of the University of the Witwatersrand (M111121). DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. L. Charles J. Serrurier, F.C.S.Plast.Surg.(C.M.S.A.)Sarah Rayne, B.Sc.(U.C.L.), M.R.C.S.(Eng.), F.C.S.(S.A.)Marisse Venter, F.C.S.Plast.Surg.(C.M.S.A.)Carol-Ann Benn, F.C.S.(S.A.)University of the Witwatersrand and Milpark Breast Care Centre of ExcellenceJohannesburg, South Africa

Immediate Nipple-Areolar Complex Reconstruction for Patients Undergoing Implant-Based Reconstruction or Therapeutic Mammoplasty.

Background:We report a technique of immediate nipple-areolar complex (NAC) reconstruction for patients undergoing skin-sparing mastectomy and implant-based breast reconstruction or therapeutic mammoplasty with central excision.Methods:Immediate nipple reconstruction is performed using a modified C-V flap planned along the edge of the incision. The areola is reconstructed using a full-thickness skin graft taken from skin usually discarded during the procedure. Immediate NAC reconstruction using this technique was performed on 32 breasts in 21 patients. This included 19 risk-reducing mastectomies, 9 therapeutic mastectomies, and 2 major revisions to existing implant reconstruction. Reconstruction was direct to implant in 29 breasts and by expander in 1 breast. The device was placed in a pre- or post-pectoral plane utilizing dermal sling and/or acellular dermal matrix as determined on a case-by-case basis. Immediate NAC reconstruction was also performed on 2 patients undergoing therapeutic mammoplasty with central excision.Results:Mean follow-up is 12 months (5–27 months), and cosmetic results have been good. There have been no significant complications, and no revisional surgery has been required.Conclusion:The application of simple techniques for NAC reconstruction in the primary procedure allows reconstruction of the whole breast in a single stage. There is an immediate focal point to the reconstruction to improve cosmesis, patient satisfaction, and psychosocial function without delay.

Augmentation de la projection du mamelon dans les reconstructions mammaires par injection de derme artificiel

The reconstruction of the Nipple-Areola Complex (NAC) is the last step and a key part in breast reconstruction. The technique to be used should be chosen as to avoid any complications on previous reconstruction steps. The use of local flaps for NAC reconstruction could be associated with implant exposure especially in the presence of a history of radiation therapy. The pure dermal flap could be indicated for the nipple reconstruction after breast reconstruction by implant after radiotherapy. The limit stay in the nipple hypoprojection. We suggest to assess the increase of the nipple projection, reconstructed by pure dermal flap, by injection of Integra® Flowable Wound Matrix (Integra LifeSciences®, Plainsboro, New jersey). Nipple projection has been measured among patients enclosed from february to March 2016reconstructed by pure dermal flap: before, after and also at a 6months term from the injection of Integra® Flowable Wound Matrix. Patient satisfaction and complications have been measured retrospectively. Tenpatients with an average of 55years have been enclosed, with an average limit of time of 19months (7to 33months) between the breast nipple reconstruction by dermal flap and the injection. A volume of 1to 1.6cc has been injected. A significative increase projection of 2mm at a 6months term has been measured (1.5to 2.5mm, P<0.01), without complication and a satisfaction rate of 4.5/5. The injection of an artificial derm-like Integra® Flowable Wound Matrix seems to be efficient to increase the nipple projection reconstructed by pure dermal flap after a breast reconstruction and moreover, without complications.

Immediate nipple-areolar complex reconstruction for patients undergoing skin sparing mastectomy and implant based reconstruction or therapeutic mammoplasty

Immediate nipple-areolar complex reconstruction for patients undergoing skin sparing mastectomy and implant based reconstruction or therapeutic mammoplasty

Nipple-areolar complex reconstruction and patient satisfaction: a systematic review and meta-analysis.

Nipple-areola complex (NAC) reconstruction transforms a mound of soft tissue into a breast and often marks the final stage of breast reconstruction after mastectomy. A systematic review and meta-analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles were classified based on the nipple reconstructive technique-either composite nipple sharing or local flap with nipple-sparing mastectomy (NSM) used as a control. A standardized "Satisfaction Score" (SS) for "nipple appearance" and "nipple sensation" was calculated for each technique. A Fisher's exact test was used to compare the SS with local flap reconstruction with NSM. Twenty-three studies met the systematic review inclusion criteria. Nine NSM articles were identified with patient satisfaction data from 473 patients. The weighted average SS for NSM was 80.5%. Fourteen local flap technique articles were identified with satisfaction data from 984 patients and a weighted average SS of 73.9%. This was a statistically significant difference (P=0.0079). C-V and badge local flap techniques were associated with the highest SS, 92.6% and 90.5%, respectively. C-V and modified C-V flap technique was associated with a higher SS when compared to those using one or more other flap techniques (P=0.0001). While patient satisfaction with nipple reconstruction is high regardless of technique, it is higher with NSM. When NSM is not an option, local flap reconstruction with a C-V or modified C-V flap may be associated with higher satisfaction than alternative local flap techniques.

Characterization of an Acellular Scaffold for a Tissue Engineering Approach to the Nipple-Areolar Complex Reconstruction

A significant number of patients undergo mastectomies and breast reconstructions every year using many surgical-based techniques to reconstruct the nipple-areolar complex (NAC). Described herein is a tissue engineering approach that may permit a human NAC onlay graft during breast reconstruction procedures. By applying decellularization, which is the removal of cellular components from tissue, to an intact whole donor NAC, the extracellular matrix (ECM) structure of the NAC is preserved. This creates a biologically derived scaffold for cells to repopulate and regenerate the NAC. A detergent-based decellularization method was used to derive whole NAC scaffolds from nonhuman primate rhesus macaque NAC tissue. Using both histological and quantitative analyses for the native and decellularized tissues, the derived ECM graft was assessed. The bioactivity of the scaffold was evaluated following cell culture with bone marrow-derived mesenchymal stem cells (BMSCs). The data presented here demonstrate that scaffolds are devoid of cells and retain ECM integrity and a high degree of bioactivity. The content of collagen and glycosaminoglycans were not significantly altered by the decellularization process, whereas the elastin content was significantly decreased. The proliferation and apoptosis of seeded BMSCs were found to be approximately 65 and <1.5%, respectively. This study characterizes the successful decellularization of NAC tissue as compared to native NACs based on structural protein composition, lubricating protein retention, the maintenance of adhesion molecules, and bioactivity when reseeded with cells. These histological and quantitative analyses provide the foundation for a novel approach to NAC reconstruction.

Nipple Reconstruction After Autologous or Expander Breast Reconstruction: A Multimodal and 3-Dimensional Analysis.

Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume. The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses. Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10). A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5). Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4.

Nipple–areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer

Women choose to undergo nipple-areola complex (NAC) reconstruction as part of breast reconstruction following breast cancer treatment. However, the effectof this procedure on psychosocial and sexual well-being is not well studied. The present study aimed to evaluate how NAC reconstruction affects patient satisfaction with regard to psychosocial and sexual well-being. A retrospective chart review was performed for all patients who underwent NAC reconstruction at Magee-Women's Hospital from January 1, 2004 to July 31, 2011. A letter and questionnaire based on the BREAST-Q were mailed to patients to request their participation in the study. Patient satisfaction and health-related quality of life were measured before and after NAC reconstruction. In total, 107 of 328 patients (32.6%) completed the survey. The BREAST-Q scale score for satisfaction with outcome following NAC reconstruction was 85.1±15.8, with higher satisfaction scores for patients with a follow-up of <1.5 years than those with a follow-up of >2.5 years (82.5±21.7 vs. 69.5±19.5; p<0.01). No significant differences were found in satisfaction with the breast mound before and after NAC reconstruction. Women scored significantly higher on the psychosocial and sexual well-being scales after NAC reconstruction (p<0.002 and 0.00004, respectively). This study indicates that patients are highly satisfied after undergoing NAC reconstruction. Satisfaction with the procedure, however, may decrease over time. NAC reconstruction significantly contributes to patient psychosocial and sexual well-being, and this effect did not change over time. NAC reconstruction improves patient outcomes in those who choose to undergo the procedure.

A Novel Nipple Reconstruction Technique for Maintaining Nipple Projection: The Boomerang Flap.

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C–V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection.

Immediate nipple reconstruction with a C-V flap and areolar reconstruction with an autograft of the ipsilateral areola.

The authors report a new nipple-areolar complex (NAC) reconstruction technique using an autograft of the ipsilateral areola for breast cancer with nipple invasion. A total of 43 patients with breast cancer involving nipple invasion underwent oncoplastic surgery with NAC reconstruction. The nipple was reconstructed with a C-V flap, and the areola was autografted onto the new areola bed after the ipsilateral areola was confirmed to be tumour-free. The cosmetic results were self-evaluated by the patients after chemotherapy or radiotherapy according to a 4-point scoring system. Overall satisfaction with the cosmetic result was assessed as follows: excellent (n = 14), good (n = 19), fair (n = 7) or poor (n = 3). Oncological evaluation revealed no cases of local recurrence and five cases of distant metastasis. The immediate NAC reconstruction technique involving a C-V flap and autografting of the ipsilateral areola is a feasible method for obtaining realistic areolar reconstruction.

Patient Satisfaction and Nipple-Areola Sensitivity After Bilateral Prophylactic Mastectomy and Immediate Implant Breast Reconstruction in a High Breast Cancer Risk Population: Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy.

Prophylactic skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) both are associated with major risk reduction in women with high breast cancer risk. Skin-sparing mastectomy followed by nipple-areola complex (NAC) reconstruction is standard of care, but NSM is increasingly being performed. Preservation of the NAC in NSM may increase patient satisfaction. Therefore, we measured NAC sensitivity after NSM and compared patient satisfaction as well as body image after SSM with NSM. Women who underwent prophylactic bilateral SSM or NSM and immediate implant breast reconstruction between 2002 and 2012 were eligible. Patient satisfaction was assessed using the Breast-Q reconstruction questionnaire, body image using Hopwood's body image scale (BIS), and satisfaction with the (reconstructed) NAC using a study-specific questionnaire. In the NSM group, NAC sensitivity was assessed using Semmes Weinstein monofilaments with a 5-point scale and compared with NAC sensitivity in a nonoperated control group. The SSM group comprised 25 women (50 SSMs) and the NSM group 20 women (39 NSMs). Median follow-up was 65 months in the SSM group compared with 27 months in the NSM group (P < 0.01). In univariable analyses, Breast-Q scores were favorable in the SSM group compared with the NSM group with trends for higher "satisfaction with breasts" (66.2 vs 56.6; P = 0.06) and "satisfaction with outcome" (76.1 vs 61.5; P = 0.09). Mean BIS score of 7.1/30 in the SSM group and 9.3/30 in the NSM group (P = 0.35). Adjusted for follow-up, there were no significant differences in Breast-Q scores, nor in BIS scores. Interestingly, satisfaction with the (reconstructed) NAC was similar after SSM and NSM. Nipple-areola complex sensitivity was lower in the NSM group (mean score, 1.9; 95% confidence interval, 1.5-2.3) compared with the control group (mean score, 4.7; 95% confidence interval, 4.6-4.9; P < 0.01). Breast-Q scores regarding satisfaction with breasts and overall outcome were in favor of the SSM group. Residual NAC sensitivity after NSM was low. This suggests that SSM followed by NAC reconstruction is a balanced alternative to NSM. We observed no significant differences in body image and NAC-specific satisfaction between the NSM and SSM groups.

The optimal reconstruction size of nipple-areola complex following breast implant in breast cancer patients.

BackgroundChanges in the areola size after reconstruction of the nipple-areola complex (NAC) following mastectomy and breast reconstruction with a silicon implant in primary breast cancer patients have not been well examined. This study aimed to investigate time-dependent changes in the size of the donor and graft NACs and to assess clinical factors influencing these changes.MethodsFifty-eight consecutive patients who underwent nipple-areola reconstruction were retrospectively evaluated. Nipple-areola diameter was measured immediately after the NAC reconstruction and at each follow-up visit for at least 36 months.ResultsThe donor NAC constituted 81 % of the graft NAC at the time of operation. The size of the donor NAC gradually increased by up to 36.8 % after the operation. The size of the graft NAC showed a decrease by 4.5 % at 7 months, followed by recovery to the initial value. The ratio of the donor site size to the graft site size was increased at month 1 and then showed a gradual decrease to 1.08 at 36 months. A history of mastopexy or reduction for the donor site was independent factors associated with changes in the NAC size.ConclusionsTo achieve symmetry, the diameter of the donor NAC immediately after the reconstruction should be at least 20 % smaller than that of the graft NAC, especially for patients without a history of additional operations.

Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?--A Survey of Surgeon and Patient Preference.

Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results. A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome. In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03). More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.

Nipple-Areola Complex Reconstruction.

After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions. Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices.