Subscribe to RSS
Please copy the URL and add it into your RSS Feed Reader.
https://www.thieme-connect.de/rss/thieme/en/10.1055-s-00000029.xml
Download PDF
J Reconstr Microsurg 2010; 26(9): 589-600
DOI: 10.1055/s-0030-1263290
© Thieme Medical PublishersDOI: 10.1055/s-0030-1263290
Surgical Correction and Reconstruction of the Nipple-Areola Complex: Current Review of Techniques
Further Information
Publication History
Publication Date:
18 August 2010 (online)
ABSTRACT
Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.
KEYWORDS
Nipple areola complex - breast - reconstruction - autologous - aesthetic
REFERENCES
- 1 Farhadi J, Maksvytyte G K, Schaefer D J, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg. 2006; 59(1) 40-53
- 2 Kroll S S, Reece G P, Miller M J et al.. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997; 99(6) 1602-1605
- 3 Crestinu J M. The correction of inverted nipples without scars: 17 Years' experience, 452 operations. Aesthetic Plast Surg. 2000; 24(1) 52-57
- 4 Serra-Renom J, Fontdevila J, Monner J. Correction of the inverted nipple with an internal 5-point star suture. Ann Plast Surg. 2004; 53(3) 293-296
- 5 Caviggioli F, Ventura D, Andretto Amodeo C, Klinger F. Inverted nipple: use of an effective and personalized splint after surgical correction with Pitanguy's technique to avoid relapse of the inversion in 28 cases. Plast Reconstr Surg. 2008; 121(3) 139e-140e
- 6 Kolker A R, Torina P J. Minimally invasive correction of inverted nipples: a safe and simple technique for reliable, sustainable projection. Ann Plast Surg. 2009; 62(5) 549-553
- 7 Chen S H, Gedebou T, Chen P H. The endoscope as an adjunct to correction of nipple inversion deformity. Plast Reconstr Surg. 2007; 119(4) 1178-1182
- 8 Crestinu J M. Inverted nipple: the new method of correction. Aesthetic Plast Surg. 1989; 13(3) 189-197
- 9 Lee H B, Roh T S, Chung Y K, Kim S W, Kim J B, Shin K S. Correction of inverted nipple using strut reinforcement with deepithelialized triangular flaps. Plast Reconstr Surg. 1998; 102(4) 1253-1258
- 10 Lee K Y, Cho B C. Surgical correction of inverted nipples using the modified Namba or Teimourian technique. Plast Reconstr Surg. 2004; 113(1) 328-336 discussion 337-338
- 11 Megumi Y. Correction of inverted nipple with periductal fibrous flaps. Plast Reconstr Surg. 1991; 88(2) 342-346
- 12 Teimourian B, Adham M N. Simple technique for correction of inverted nipple. Plast Reconstr Surg. 1980; 65(4) 504-506
- 13 Pompei S, Tedesco M. A new surgical technique for the correction of the inverted nipple. Aesthetic Plast Surg. 1999; 23(5) 371-374
- 14 Aiache A. Surgical repair of the inverted nipple. Ann Plast Surg. 1990; 25(6) 457-460
- 15 Min K H, Park S S, Heo C Y, Min K W. Scar-free technique for inverted-nipple correction. Aesthetic Plast Surg. 2010; 34(1) 116-119
- 16 Ritz M, Silfen R, Morgan D, Southwick G. Simple technique for inverted nipple correction. Aesthetic Plast Surg. 2005; 29(1) 24-27
- 17 Yamamoto Y, Furukawa H, Oyama A et al.. Two innovations of the star-flap technique for nipple reconstruction. Br J Plast Surg. 2001; 54(8) 723-726
- 18 el Sharkawy A G. A method for correction of congenitally inverted nipple with preservation of the ducts. Plast Reconstr Surg. 1995; 95(6) 1111-1114
- 19 Basile F V, Chang Y C. The triple-flap nipple-reduction technique. Ann Plast Surg. 2007; 59(3) 260-262
- 20 Lai Y L, Weng C J, Noordhoff M S. Areolar reduction with inner doughnut incision. Plast Reconstr Surg. 1998; 101(6) 1695-1699
- 21 Vecchione T. The reduction of the hypertrophic nipple. Aesthetic Plast Surg. 1979; 3 343-345
- 22 Marshall K A, Wolfort F G, Cochran T C. Surgical correction of nipple hypertrophy in male gynecomastia: case report. Plast Reconstr Surg. 1977; 60(2) 277-279
- 23 Regnault P. Nipple hypertrophy. A physiologic reduction by circumcision. Clin Plast Surg. 1975; 2(3) 391-396
- 24 Lai Y L, Wu W C. Nipple reduction with a modified circumcision technique. Br J Plast Surg. 1996; 49(5) 307-309
- 25 Sperli A E. Cosmetic reduction of the nipple with functional preservation. Br J Plast Surg. 1974; 27(1) 42-43
- 26 Ferreira L M, Neto M S, Okamoto R H, Andrews J de M. Surgical correction of nipple hypertrophy. Plast Reconstr Surg. 1995; 95(4) 753-754
- 27 Cheng M H, Smartt J M, Rodriguez E D, Ulusal B G. Nipple reduction using the modified top hat flap. Plast Reconstr Surg. 2006; 118(7) 1517-1525
- 28 O'Donnell M AHJ. What does the patient consider the important features of the reconstructed nipple and the donor nipple?. Winter Meeting of the British Association of Plastic Surgeons December 1, 1994 London;
- 29 Little J W. Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast. Plast Reconstr Surg. 2003; 111 148
- 30 Nakagawa T, Yano K, Hosokawa K. Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast. Plast Reconstr Surg. 2003; 111(1) 141-147 discussion 148-149
- 31 Broadbent T R, Woolf R M, Metz P S. Restoring the mammary areola by a skin graft from the upper inner thigh. Br J Plast Surg. 1977; 30(3) 220-222
- 32 Adams W M. Labial transplant for correction of loss of the nipple. Plast Reconstr Surg (1946). 1949; 4(3) 295-298
- 33 Hartrampf Jr C R, Culbertson J H. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg. 1984; 73(6) 982-986
- 34 Ng S, Tan B K, Sharma N, Leow M, Sim R, Song C. Use of anodermal tissue for nipple reconstruction following breast reconstruction. ESPRAS (European Societies of Plastic, Reconstructive and Aesthetic Surgery) 10th Congress 2005 August 30, 2005 Vienna;
- 35 Bhatty M A, Berry R B. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg. 1997; 50(5) 331-334
- 36 Hugo N E, Sultan M R, Hardy S P. Nipple-areola reconstruction with intradermal tattoo and double-opposing pennant flaps. Ann Plast Surg. 1993; 30(6) 510-513
- 37 Dean N R, Neild T, Haynes J, Goddard C, Cooter R D. Fading of nipple-areolar reconstructions: the last hurdle in breast reconstruction?. Br J Plast Surg. 2002; 55(7) 574-581
- 38 Hammond D C, Khuthaila D, Kim J. The skate flap purse-string technique for nipple-areola complex reconstruction. Plast Reconstr Surg. 2007; 120(2) 399-406
- 39 Little J. Nipple-Areolar Reconstruction. Boston; Little, Brown 1994
- 40 Bogue D P, Mungara A K, Thompson M, Cederna P S. Modified technique for nipple-areolar reconstruction: a case series. Plast Reconstr Surg. 2003; 112(5) 1274-1278
- 41 Anton M, Eskenazi L B, Hartrampf C R. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg. 1991; 5 67
- 42 Wong R K, Banducci D R, Feldman S, Kahler S H, Manders E K. Pre-reconstruction tattooing eliminates the need for skin grafting in nipple areolar reconstruction. Plast Reconstr Surg. 1993; 92(3) 547-549
- 43 Jones G, Bostwick J. Nipple-areolar reconstruction. Oper Tech Plast Reconstr Surg. 1993; 92 547
- 44 Little III J W, Munasifi T, McCulloch D T. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983; 71(1) 126-133
- 45 Shestak K C, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002; 110(3) 780-786
- 46 Eng J S. Bell flap nipple reconstruction—a new wrinkle. Ann Plast Surg. 1996; 36(5) 485-488
- 47 Weiss J, Herman O, Rosenberg L, Shafir R. The S nipple-areola reconstruction. Plast Reconstr Surg. 1989; 83(5) 904-906
- 48 Chang W H. Nipple reconstruction with a T flap. Plast Reconstr Surg. 1984; 73(1) 140-143
- 49 Hallock G G, Altobelli J A. Cylindrical nipple reconstruction using an H flap. Ann Plast Surg. 1993; 30(1) 23-26
- 50 Cohen I K, Ward J A, Chandrasekhar B. The pinwheel flap nipple and barrier areola graft reconstruction. Plast Reconstr Surg. 1986; 77(6) 995-999
- 51 Guerra A B, Khoobehi K, Metzinger S E, Allen R J. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg. 2003; 50(1) 31-37
- 52 Yanaga H. Nipple-areola reconstruction with a dermal-fat flap: technical improvement from rolled auricular cartilage to artificial bone. Plast Reconstr Surg. 2003; 112(7) 1863-1869
- 53 Mukherjee R P, Gottlieb V, Hacker L. Nipple-areolar reconstruction with buried dermal hammock technique. Ann Plast Surg. 1987; 19(5) 421-423
- 54 Di Benedetto G, Sperti V, Pierangeli M, Bertani A. A simple and reliable method of nipple reconstruction using a spiral flap made of residual scar tissue. Plast Reconstr Surg. 2004; 114(1) 158-161
- 55 Little III J W. Nipple-areola reconstruction. Clin Plast Surg. 1984; 11(2) 351-364
- 56 Cao Y L, Lach E, Kim T H, Rodríguez A, Arévalo C A, Vacanti C A. Tissue-engineered nipple reconstruction. Plast Reconstr Surg. 1998; 102(7) 2293-2298
- 57 Shestak K C, Nguyen T D. The double opposing periareola flap: a novel concept for nipple-areola reconstruction. Plast Reconstr Surg. 2007; 119(2) 473-480
- 58 Little J. Nipple-Areolar Reconstruction. Chicago; Year Book Medical Publishers 1987
- 59 Alfano C, Tenna S, Caggiati A, Campanella A. Nipple reconstruction by local flaps: a long-term comparative study between star and skate techniques. Acta Chir Plast. 2004; 46 127-131
- 60 Motamed S, Davami B. Postburn reconstruction of nipple-areola complex. Burns. 2005; 31(8) 1020-1024
- 61 Valdatta L, Montemurro P, Tamborini F, Fidanza C, Gottardi A, Scamoni S. Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation. J Plast Reconstr Aesthet Surg. 2009; 62(10) 1293-1298
- 62 Losken A, Mackay G J, Bostwick III J. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001; 108(2) 361-369
- 63 El-Ali K, Dalal M, Kat C C. Modified C-V flap for nipple reconstruction: our results in 50 patients. J Plast Reconstr Aesthet Surg. 2009; 62(8) 991-996
- 64 Spyropoulou G A, Sterne G D. Algorithm for an aesthetically pleasing nipple-areola complex with the use of the C-V flap in cases of skin-sparing mastectomy and immediate reconstruction. Aesthetic Plast Surg. 2009; 33(2) 240-242
- 65 Eo S, Kim S S, Da Lio A L. Nipple reconstruction with C-v flap using dermofat graft. Ann Plast Surg. 2007; 58(2) 137-140
- 66 Weinfeld A B, Somia N, Codner M A. Purse-string nipple areolar reconstruction. Ann Plast Surg. 2008; 61(4) 364-367
- 67 Few J W, Marcus J R, Casas L A, Aitken M E, Redding J. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg. 1999; 104(5) 1321-1324
- 68 Rubino C, Dessy L A, Posadinu A. A modified technique for nipple reconstruction: the ‘arrow flap’. Br J Plast Surg. 2003; 56(3) 247-251
- 69 Banducci D R, Le T K, Hughes K C. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg. 1999; 43(5) 467-469 discussion 469-470
- 70 Klatsky S A, Manson P N. Toe pulp free grafts in nipple reconstruction. Plast Reconstr Surg. 1981; 68(2) 245-248
- 71 Hasham S, Whitaker I S, Matteucci P, Fourie Le R. Prospective audit of free toe pulp grafts in nipple reconstruction. ESPRAS (European Societies of Plastic, Reconstructive and Aesthetic Surgery) 10th Congress August 30–September 3, 2005 Vienna;
- 72 Whitaker I SHS, Matteucci P, Fourie Le R. An algorithm for nipple-areola reconstruction. ESPRAS (European Societies of Plastic, Reconstructive and Aesthetic Surgery) 10th Congress August 30–September 3, 2005 Vienna;
- 73 Amarante J T, Santa-Comba A, Reis J, Malheiro E. Halux pulp composite graft in nipple reconstruction. Aesthetic Plast Surg. 1994; 18(3) 299-300
- 74 Wong R K, Wichterman L, Parson S D. Skin sparing nipple reconstruction with polytetrafluoroethylene implant. Ann Plast Surg. 2008; 61(3) 256-258
- 75 Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: an original easy technique. Aesthetic Plast Surg. 2005; 29(4) 287-294
- 76 Evans K K, Rasko Y, Lenert J, Olding M. The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction: early results. Ann Plast Surg. 2005; 55(1) 25-29 discussion 29
- 77 Garramone C E, Lam B. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. Plast Reconstr Surg. 2007; 119(6) 1663-1668
- 78 Niechajev I, Sevćuk O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. 1994; 94(3) 496-506
- 79 Laronga C, Kemp B, Johnston D, Robb G L, Singletary S E. The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol. 1999; 6(6) 609-613
- 80 Beegle Jr P H. Immediate single-stage TRAM and nipple-areola reconstruction. Clin Plast Surg. 1994; 21(2) 321-326
- 81 Toth B A, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991; 87(6) 1048-1053
- 82 Andersen J A, Gram J B, Pallesen R M. Involvement of the nipple and areola in breast cancer. Value of clinical findings. Scand J Plast Reconstr Surg. 1981; 15(1) 39-42
- 83 Parry R G, Cochran Jr T C, Wolfort F G. When is there nipple involvement in carcinoma of the breast?. Plast Reconstr Surg. 1977; 59(4) 535-537
- 84 Menon R S, van Geel A N. Cancer of the breast with nipple involvement. Br J Cancer. 1989; 59(1) 81-84
- 85 Simmons R M, Brennan M, Christos P, King V, Osborne M. Analysis of nipple/areolar involvement with mastectomy: can the areola be preserved?. Ann Surg Oncol. 2002; 9(2) 165-168
- 86 Wirth R, Banic A, Erni D. Aesthetic outcome and oncological safety of nipple-areola complex replantation after mastectomy and immediate breast reconstruction. J Plast Reconstr Aesthet Surg. 2009; (October) 3 , [Epub ahead of print]
- 87 Hudson D A, Dent D M, Lazarus D. One-stage immediate breast and nipple-areolar reconstruction with autologous tissue I: a preliminary report. Ann Plast Surg. 2000; 45(5) 471-476
- 88 Colen L B.
One-stage reconstruction of the breast using autologous tissue with immediate nipple reconstruction . In: Spear SL, Little JW, Lippman ME, Wood WC Surgery of the Breast: Principles are Art. Philadelphia, PA; Lippincott-Raven 1998: 491-510 - 89 Delay E, Mojallal A, Vasseur C, Delaporte T. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006; 118(6) 1303-1312
- 90 Williams E H, Rosenberg L Z, Kolm P, de la Torre J I, Fix R J. Immediate nipple reconstruction on a free TRAM flap breast reconstruction. Plast Reconstr Surg. 2007; 120(5) 1115-1124
- 91 Thomas S V, Gellis M B, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg. 1996; 97(5) 1053-1056
- 92 Nakajima T, Yoshimura Y, Kami T. The subcutaneous pedicle flap: widening of its applications. Ann Plast Surg. 1987; 19(2) 103-116
- 93 Hyakusoku H, Okubo M, Fumiiri M. Combination of the square flap method and the dermal sling to correct flat or inverted nipples. Aesthetic Plast Surg. 1988; 12(2) 107-109
- 94 Kurihara K, Maezawa N, Yanagawa H, Imai T. Surgical correction of the inverted nipple with a tendon graft: hammock procedure. Plast Reconstr Surg. 1990; 86(5) 999-1003
- 95 Yamamoto Y, Sugihara T. Correction of inverted nipple with modified star flap technique. Aesthetic Plast Surg. 1997; 21(3) 193-195
- 96 Pribaz J J, Pousti T. Correction of recurrent nipple inversion with cartilage graft. Ann Plast Surg. 1998; 40(1) 14-17
- 97 Sakai S, Sakai Y, Izawa H. A new surgical procedure for the very severe inverted nipple. Aesthetic Plast Surg. 1999; 23(2) 139-143
- 98 Pereira Filho O J, Bins-Ely J, Granemann A S, Bertelli J A, Abdalla S C. Closed inverted nipple treatment through a microincision procedure. Plast Reconstr Surg. 2001; 108(4) 1000-1005
- 99 Scholten E. A contemporary correction of inverted nipples. Plast Reconstr Surg. 2001; 107(2) 511-513
- 100 Huang W C. A new method for correction of inverted nipple with three periductal dermofibrous flaps. Aesthetic Plast Surg. 2003; 27(4) 301-304
- 101 Lee M J, Depoli P A, Casas L A. Aesthetic and predictable correction of the inverted nipple. Aesthet Surg J. 2003; 23(5) 353-356
- 102 Kim D Y, Jeong E C, Eo S R, Kim K S, Lee S Y, Cho B H. Correction of inverted nipple: an alternative method using two triangular areolar dermal flaps. Ann Plast Surg. 2003; 51(6) 636-640
- 103 Stevens W G, Fellows D R, Vath S D, Stoker D A. An integrated approach to the repair of inverted nipples. Aesthet Surg J. 2004; 24(3) 211-215
- 104 Yamada N, Kakibuchi M, Kitayoshi H, Kurokawa M, Hosokawa K, Hashimoto K. A method for correcting an inverted nipple with an artificial dermis. Aesthetic Plast Surg. 2004; 28(4) 233-238
- 105 Kim J T, Lim Y S, Oh J G. Correction of inverted nipples with twisting and locking principles. Plast Reconstr Surg. 2006; 118(7) 1526-1531
- 106 Burm J S, Kim Y W. Correction of inverted nipples by strong suspension with areola-based dermal flaps. Plast Reconstr Surg. 2007; 120(6) 1483-1486
- 107 Bosch G, de los Ríos G, Giachero V. Nipple invagination: the umbrella effect. Aesthetic Plast Surg. 2007; 31(1) 76-84
- 108 Wu H L, Huang X, Zheng S S. A new procedure for correction of severe inverted nipple with two triangular areolar dermofibrous flaps. Aesthetic Plast Surg. 2008; 32(4) 641-644
- 109 Karacaoglu E. Correction of recurrent grade III inverted nipple with antenna dermoadipose flap: case report. Aesthetic Plast Surg. 2009; (March) 19 , (Epub ahead of print)
- 110 Marshall K A, Wolfort F G, Cochran T C. Surgical correction of nipple hypertrophy in male gynecomastia: case report. Plast Reconstr Surg. 1977; 60(2) 277-279
- 111 Skillman J M, Ahmed O, Dheansa B, Rowsell A R. The Marshall technique: an economic one-stage technique for nipple-areola reconstruction. Br J Plast Surg. 2002; 55(6) 504-506
- 112 Nohira K, Shintomi Y, Ohura T. Nipple-areola reconstruction using a skate flap and an intradermal tattoo. Jpn J Plast Reconstr Surg. 1991; 34 67-72
- 113 Eskenazi L. A one-stage nipple reconstruction with the “modified star” flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg. 1993; 92(4) 671-680
- 114 Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009; 62(5) 591-595
- 115 Hallock G G. Polyurethane nipple prosthesis. Ann Plast Surg. 1990; 24(1) 80-85
- 116 Tanabe H Y, Tai Y, Kiyokawa K, Yamauchi T. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. Plast Reconstr Surg. 1997; 100(2) 431-438
- 117 Bernard R W, Beran S J. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg. 2003; 112(4) 964-968
- 118 Cheng M H, Ho-Asjoe M, Wei F C, Chuang D C. Nipple reconstruction in Asian females using banked cartilage graft and modified top hat flap. Br J Plast Surg. 2003; 56(7) 692-694
- 119 Nahabedian M Y. Secondary nipple reconstruction using local flaps and AlloDerm. Plast Reconstr Surg. 2005; 115(7) 2056-2061
- 120 Cheng M H, Rodriguez E D, Smartt J M, Cardenas-Mejia A. Nipple reconstruction using the modified top hat flap with banked costal cartilage graft: long-term follow-up in 58 patients. Ann Plast Surg. 2007; 59(6) 621-628
- 121 Lipa J E, Addison P D, Neligan P C. Patient satisfaction following nipple reconstruction incorporating autologous costal cartilage. Can J Plast Surg. 2008; 16(2) 85-88
Warren RozenM.B.B.S. B.Med.Sc. P.G.Dip.Surg.Anat. Ph.D.
Jack Brockhoff Reconstructive Plastic Surgery Research Unit
Room E533, Department of Anatomy, University of Melbourne, Grattan St, Parkville,
3050 Victoria, Australia
Email: warrenrozen@hotmail.com