Nipple-areola Complex Research Articles

Discussion: Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy.

Santa Monica and Los Angeles, CA From the 1Division of Plastic Surgery, David Geffen School of Medicine at the University of California, Los Angeles 2Division of Surgical Oncology, Cedars Sinai Medical Center. Received for publication March 5, 2022; accepted June 27, 2022. Disclosure: The authors have no financial interests to report. No funding was received for this Discussion. Jay Arthur Jensen, MD, Division of Plastic Surgery, David Geffen School of Medicine at the University of California, Los Angeles, 2001 Santa Monica Boulevard, Suite 1180W, Santa Monica, CA 90404, [email protected]

Surgical Nipple Delay and its Expanded Indications for Nipple-sparing Mastectomy.

A single-institution retrospective review was done of patients who underwent ND and NSM or NSM alone from 2012 to 2022. Patient demographics, risk factors, and outcomes were compared. Forty-two breasts received ND-NSM and 302 breasts received NSM alone. The ND-NSM group had significantly more high-risk factors, including elevated BMI (26.3 versus 22.9; P < 0.001), elevated prior breast surgery (50% versus 25%; P < 0.001), and greater mastectomy specimen weight (646.6 versus 303.2 g; P < 0.001). ND-NSM was more likely to have undergone preparatory mammoplasty before NSM (27% versus 1%; P < 0.001). There was no delay in NSM treatment from decision to pursue NSM (P = 0.483) or difference in skin necrosis (P = 0.256), NAC necrosis (P = 0.510), hematoma (P = 0.094), seroma (P = 0.137), or infection (P = 0.437) between groups. ND-NSM and NSM patients differed in total NAC necrosis (0% versus 3%) and implant loss (0% vs 13%), but not significantly. We demonstrated no NAC necrosis and no significant delay of treatment in higher risk ND-NSM patients. ND may allow higher risk patients to undergo NSM with similar morbidity as lower risk patients.

Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy

BackgroundSurgical delay (SD) techniques, performed before the nipple sparing mastectomy (NSM), are procedures conceived to improve the blood supply to the nipple-areola complex (NAC) in order to overcome the ischemic risk. The aim of the study is reporting our experience with SD of the NAC in the setting of NSM, identify the rate of nipple and skin necrosis and other complications and to evaluate patient satisfaction with cosmetic outcome. Patients and MethodsA retrospective review of female patients, who underwent NSM and breast reconstruction between the July 2014 and the July 2019, was performed at the Breast Unit of San Giovanni-Addolorata Hospital in Rome. Eighty-nine NSM after SD procedure were performed in 66 patients. In all cases immediate breast reconstruction was performed with a direct to implant technique and polyurethane implants in prepectoral plan were used in all reconstructions. ResultsWe registered only 1 case of total NAC necrosis and 3 skin flap necrosis. Furthermore, patient satisfaction with breast reconstruction resulted excellent or good in 23 cases and good in 36 cases; the external plastic surgeon considered the breast reconstruction excellent or good in 63 cases. ConclusionWe support the thesis that SD techniques may expand indications for NAC sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.MicroabstractThis is the largest single center series on surgical delay of nipple areola complex providing interesting data on follow-up and complication rates and we support the thesis that surgical delay techniques may expand indications for nipple-areola complex sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.

Anthropometric Measurements and Analysis for Objective Assessment of Gynecomastia Surgery Results.

Gynecomastia surgery is one of the most common aesthetic procedures in males. There is a lack of objective analytical parameters to judge outcomes. In this study, the authors aim to introduce novel anthropometric measurements and analysis techniques for the objective assessment of surgical outcomes based on specific aesthetic targets. To introduce quantification of gynecomastia surgery outcomes and compare the results among the different grades of gynecomastia. A total of 192 patients with gynecomastia were included. The patient cases were grouped according to grades and a set of anthropometric measurements were taken both before the operation and 6 months postoperatively. Liposuction and glandular excision were done through minimal incisions in all grades of gynecomastia, with the addition of ultrasound and nipple areola complex (NAC) lifting plaster in selected Grade 3 and all Grade 4 cases. A statistically significant improvement in the perimeter of the triangular relationship of sternal notch and nipples, the elevation of the NAC, the reduction of the area of the NAC, and the correction of asymmetry of the chest were seen in all grades of gynecomastia, with increased differences in higher grades. A systematic objective analysis of the specific aesthetic targets helps to reliably compare results in a standard way and for carrying out improvisation of surgeons' techniques. Meanwhile, this approach helps identifying the need for customization, eventually providing symmetric and aesthetically pleasing surgical results.

Immediate Breast Reconstruction in Skin-Reducing Mastectomy with Prepectoral Polyuretane (Pu) Implant Covered with an Autologous Dermo-Adipose Flap.

The aim of this study was to present our new technique of immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, in skin-reducing mastectomy both for risk-reducing (prophylactic mastectomy) and therapeutic cases. We performed a single-center, retrospective review of 21 patients (mean age 47 years), undergone skin-reducing mastectomy and immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, un the period January 2018-June 2021. All procedures were performed by the same surgeon. A total of 36 skin-reducing mastectomies (6 curative, 15 prophylactic) with one-stage prepectoral PU foam-coated implant and autologous dermo-adipose flap reconstruction were performed. All postoperative complications were collected. Quality of life (QoL) and satisfaction with reconstruction were evaluated through the BREAST-Q questionnaire, administered preoperatively and at 12 months after surgery. Independent Student's t tests were used to compare means of continuous variables and Chi-square test was used for ordinal variables. A p-value ≤0.05 was considered statistically significant. Uni- and multiple linear regression analyses were used to confirm all results. Out of 21 patients, we observed one small wound dehiscence and one partial Nipple-Areola Complex (NAC) necrosis. All cases of minor complications were managed conservatively and did not affect the quality of the final outcome. No implant loss was observed. No significant severe capsular contracture (grade III or IV) was detected at follow-up. Overall satisfaction with breasts, psychosocial, physical and sexual well-being all significantly increased, analyzing BRAST-Q data. Statistical analysis showed a significant influence of diabetes on the risk of complications. Our experience suggests that the procedure described is effective, feasible and cost-effective. It is easier to perform compared to similar and more demanding procedure, reduces operative time, and minimizes complications related to manipulation of the pectoralis major muscle, while also contributing to the containment of costs. Moreover, it appears to be oncologically safe, provides good esthetic results with low postoperative complication rate and leads to high level of patients' satisfaction. 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 .

Aesthetic Refinements in Male Chest Lifting.

Abstract The authors describe aesthetic refinements to the approach for male chest lifting in male patients with grade 3 gynecomastia and/or significant chest skin excess. An inferior pedicle is used to transpose the nipple–areolar complex allowing preservation of pigment and sensation, liposuction and direct excision are used to reduce volume and excess skin, and the resulting curvilinear scar along the inferior and lateral border of the chest provide a more masculine appearance. Early experience with this technique has shown it to be safe and effective. Perioperative management and the detailed steps of the procedure are outlined. Level of Evidence: 5

100 years of Thorek method - is this technique of breast reduction still actual?

In 1922, Max Thorek described the method of breast reduction with the transfer of the nipple-areola complex as free grafts. Initially, this method met with quite a lot of criticism. Therefore, the search for solutions guaranteeing better aesthetic results of breast reduction have been evolved.The aim of the study is to present our own experiences related to the Thorek method of breast reduction in patients with gigantomastia and to consider whether this technique is still relevant in the 21st century.The study included women operated on for large breasts at the Plastic, Reconstructive and Aesthetic Surgery Clinic between 2012-2021. In the analysis 95 women aged 17 to 76 were involved.In the analyzed group of 95 women, 14 patients underwent breast reduction with transfer of the nipple-areola complex as a free graft (modified Thorek&apos;s method). In the remaining 81 cases, breast reduction was performed with the transfer of the nipple areola complex on the pedicle (upper-medial - 78, lower - 1, upper-lower - McKissock&apos;s method - 2).The usage of Thorek&apos;s method is still actual in a selected group of women. This technique seems to be the only safe one in patients with gigantomastia, with a high risk of nipple-areola complex necrosis related to the distance of nipple transfer, as well as after the end of the reproductive period. Its main disadvantages (tendency to breasts being too wide and flat, unpredictable nipple projection and nipple pigmentation) can be minimized by modification of the Thorek method or minimally invasive follow-up techniques.

Nipple-Sparing Mastectomy After Neoadjuvant Chemotherapy: Definitive Results with a Long-Term Follow-Up Evaluation.

Nipple-sparing mastectomy (NSM) is increasingly used for women with breast cancer who are not candidates for conservative surgery. The authors previously reported satisfying results with NSM after neoadjuvant chemotherapy (NACT). From 2010 to 2020, 1072 women underwent mastectomy at the authors' institution. In this group, 433 NSMs were performed (40%). The only contraindications to NSM were close proximity to the nipple-areola complex (NAC), bloody discharge, and Paget disease. In 112 cases involving 111 women, NSM followed NACT (group 1), whereas it was performed as primary surgery in 321 instances involving 306 women (group 2). At 5 years, local relapse was 7% in group 1 and 2% in group 2, although in the multivariate analysis, locoregional relapses (LRRs) did not differ between the two groups. An increased incidence of local relapse was associated with higher tumor stage (stage III; p = 0.046) and age younger than 51 years (p = 0.038). For 34 (30.3%) of the 111 women in group 1 with a pathologic complete response (pCR), no LRRs were recorded. Only one NAC recurrence was observed. Overall survival with each tumor stage did not differ between the two groups. No differences in complications were observed. Cosmetic results were satisfying in 83.8% of the cases and did not get worse after NACT. The study data definitively confirm that NSM is safe even after NACT, with good cosmetic results and complications comparable with those in the primary surgery setting. Tumor stage and age were the only independent factors for local relapse. Patients with pCR enjoyed optimal locoregional control.

Expanding Usage of Superior Pedicled Techniques with Reducing Resistance in the Pedicle by Lipoaspiration.

Despite the advantages of the superior pedicles in breast reduction, there are some limitations with this technique. The mobility of the pedicle may be augmented by liposuction in the pedicle area which may relieve tissue resistance and decrease pedicle compression in order to overcome circulation problems. In fact, the indications of breast reduction using superior pedicles may be expanded by liposuction in the pedicle area. The patients who underwent breast reduction with superior pedicle techniques between March 2014 and November 2020 and whose pedicle resistances were decreased by liposuction were included in this study. Internal breast morphology was classified into three groups based on the morphology of the periareolar tissues. Group 1 breasts were lipomatous, Group 2 breasts were lipo-glandular and Group 3 breasts were fibroglandular. During the short-term follow-up, the circulation of the nipple-areola complex (NAC) was evaluated both clinically and with an hand held Doppler device. The long-term aesthetic results were evaluated at the postoperative twelfth month with a visual analogue scale. One hundred eighty-nine patients with either Group 1 or Group 2 breasts were included in this study. The mean age of the patients was 38.3 years. The mean follow-up period was 31.7 months. Neither partial nor total NAC loss was observed and none of the patients had bottoming-out deformity. Liposuction to the pedicle area is an effective and reliable method that both reduces the resistance in the pedicle and overcomes the circulation problems in certain patient groups (groups 1 and 2), increases the mobilization of the pedicle, reduces the breast to the desired size and prevents bottoming-out in the long term and increases the use of superior pedicle techniques. According to our clinical results, it was demonstrated that pedicle vascular mapping with preoperative Doppler sonography was not necessary in these patients. 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 .

A Single-Center Experience With Gynecomastia Treatment Using Liposuction, Complete Gland Removal, and Nipple Areola Complex Lifting Plaster Technique: A Review of 448 Patients.

Gynecomastia is defined as a benign enlargement of male breast glandular tissue. It is the most common breast condition in male, and the prevalence ranges from 32% to 72%. No standardized treatment exists for gynecomastia. The authors treat gynecomastia patient with liposuction and complete gland excision through periareolar incision without skin excision. In case of skin redundancy, the authors use their special technique called nipple areola complex (NAC) plaster lift technique. The authors conducted the retrospective analysis of patient who underwent gynecomastia surgery between January 2020 and December 2021 at Chennai Plastic Surgery. All patients were treated with liposuction, gland excision, and NAC lifting plaster when required. The follow-up period ranges from 6 to 14 months. A total of 448 patients (896 breasts) were included in our study with average age of 26.6 years. Grade II gynecomastia was most common in our study. The average BMI of the patients was 27.31 kg/m2. One hundred and sixteen patients (25.9%) experienced some form of complication. Seroma was most common complications in our study followed by superficial skin necrosis. Patient satisfaction rate was high in our study. Gynecomastia surgery is safe and highly rewarding procedure for surgeons. Various technologies and methods like liposuction, complete gland excision, and NAC lifting plaster technique should be adopted in gynecomastia treatment to give a better patient satisfaction. Complications are common in gynecomastia surgery but easily manageable.

Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer. The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values. Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%. Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.

Breast Reduction with Total Superior Pedicle.

A single-center descriptive study was performed in Santiago de los Caballeros, Dominican Republic, from 2006 to 2022. A total pedicle lifting technique from a vertical marking with horizontal modification was performed on approximately 283 patients, where 232 had a resection greater than or equal to 500 grams in one or both breasts with NAC descending lengths greater than 30 cm. All cases were resolved without presenting tissue damage or NAC necrosis. The average patient's age was 34.5, and surgery time was approximately 3 hours. Considering both breasts, the average tissue extracted in the population was 1441.4 ± 589.6 grams (SD, 95%) with a median of 1211.5 grams. The total pedicle lifting approach is a safe and reproducible procedure, distinguished by the regard for the upper circulation of the breast.

Special Applications of Medical Tattooing: Contouring and 3D Exemplified by Tattooing of the Nailbed and the Gingiva.

Medical tattooing aims to restore the normality of skin structures in patients who have skin diseases or suffer sequelae after surgical interventions or hazards. There are numerous applications, with tattooing of vitiligo and the nipple areola complex after breast cancer surgery as leading fields. The use of 3D or realistic tattoo techniques has increased the potential of medical tattooing and improved the aesthetic results. The tattooist must have good technical training combined with artistic and creative talents. In this chapter, two innovative applications of medical tattooing will be presented as examples, i.e. tattooing of the nailbed and the gingiva. Nailbed tattooing reconstructs the normal perception of the nailbed and the nail plate when the nails have previously been removed though a surgical procedure. Tattoo of the gingiva performed after a connective tissue implant of the gum is a new application. These treatments, approved by a physician and performed by a tattooist with proven experience in medical tattooing, also involve the use of specific color nuances that produce an extremely realistic outcome.

Micap flap as an alternative to the Grisotti Flap for the reconstruction of the areola after central quadrantectomy – preliminary experience

Introduction: The Grisotti Flap is an excellent oncoplastic option for patients with retro-areolar cancer, whereas a short nipple areolar complex (NAC) to inferior mammary fold (IMF) distance pose a challenge to the surgeon due to lack of skin that can be transposed with the rotational flap.

The Study of the Correlation between the Surgeon and the Patient Perspective in the Outcome Analysis of Patients Undergoing Liposuction and Excision for Gynaecomastia

Background: Most patients with gynaecomastia seek surgical treatment because it causes embarrassment as well as anxiety for them. Hence, apart from cosmesis, mental satisfaction also plays an important role in the surgical treatment of gynaecomastia. This study was aimed at evaluating the outcome of gynaecomastia treated by liposuction and excision. Materials Methods: A retrospective analysis of patients who underwent liposuction and excision for gynaecomastia was done. Cosmetic results were assessed at least 6 months after the surgery and included factors like breast size, breast symmetry, the shape of the Nipple areolar Complex (NAC), symmetry of NAC and quality and visibility of scars. For each of these factors, a score from 1 to 10 was given by the patient as well as the surgeon. Results: Out of 58 patients included in this study, the overall mean patient score and surgeon score were 42.53 and 42.74, respectively. Grade I patients were having the best final aesthetic result (score = 44.28) and Grade III patients were having the least score (37.66) There was a good correlation between patients’ scores and surgeons’ scores on the symmetry of breasts, size of the breast and shape of the nipple-areolar complex. The mean value for overall satisfaction was 9.15. The overall complication rate was 17.2%. Conclusions: Gynaecomastia patients treated with liposuction and excision were having very good results in terms of aesthetic outcomes. There was a good correlation between patients’ perspectives and surgeons’ perspectives on the symmetry of breasts, size of breasts and shape of the nipple-areolar complexes. They also had good overall satisfaction and confidence levels.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review.

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored. We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed. Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed. ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Nerve-Preserving Superomedial Pedicle Breast Reduction Approach for Chest Wall Masculinization: A Case Report

Introduction: Gender affirming chest surgeries are a treatment for transgender and gender diverse individuals who suffer from gender dysphoria. Double incision mastectomy with free nipple grafts is the most common technique used for masculinization of the chest for Fischer grade 2B to 4 patients. However, this technique sacrifices the nerves to the nipple-areolar complex (NAC). While multiple nipple pedicles have been described in cisgender reduction mammoplasty, only an inferior pedicled mammaplasty approach has been described for chest wall masculinization for Fischer grade 2B to 4 patients. Case Presentation: We describe the surgical technique of a superomedial pedicle chest masculinization surgery for an individual with Fischer grade 2B breasts. Sensation was preserved at 2-weeks post-surgery. At 4-months, using a 0 to 10 numeric rating scale, patient satisfaction was 9 for the overall cosmetic outcome and a 9 for the masculinization. Using inferior sternum sensation as a reference (10), areola sensation on the superior side adjacent the nipple was a 6.5 on the right and an 8 on the left. Chest sensation was a 10 in the superolateral, inferolateral, and superomedial quadrants bilaterally, and was an 8 in bilateral inferomedial quadrants. 2-point discrimination of the areola was assessed on the inferior side adjacent the nipple and was 13mm on the left and 14mm on the right. Semmes-Weinstein monofilament testing of the areola was performed adjacent to the nipple superiorly (R: 4.31, L: 4.56), inferiorly (R: 4.31, L: 6.65), medially (R: 4.31, L: 6.65), and laterally (R: 4.31, L: 6.65). Conclusion: A mastectomy technique using a superomedial pedicle can preserve the nerve to the nipple-areolar complex to retain sensation while providing sufficient cosmetic outcome.

Prospective observational study of Nipple–Areola Complex Position post breast reduction

Prospective observational study of Nipple–Areola Complex Position post breast reduction

Bilateral Reduction Mammoplasty with Nipple Areola Complex Graft in Ten Years Old Girl with Juvenile Gigantomastia: A First Case Report from Arabian Gulf Region

Bilateral Reduction Mammoplasty with Nipple Areola Complex Graft in Ten Years Old Girl with Juvenile Gigantomastia: A First Case Report from Arabian Gulf Region

Surgical treatment of grade III gynecomastia with the horizontal scar technique and transposition of the nipple-areolar complex - "No vertical scar"

Surgical treatment of grade III gynecomastia with the horizontal scar technique and transposition of the nipple-areolar complex - "No vertical scar"