Keywords
nipple-sparing mastectomy - nipple-areolar complex malposition - two-stage implant-based
breast reconstruction - breast reconstruction
Introduction
Symmetric and anatomical positioning of the nipple-areolar complex (NAC) and a well-balanced
breast mound on both sides are the primary goals in nipple-sparing mastectomy (NSM).[1] NAC position is the most significant factor,[2] and prevention of NAC malposition in NSM provides excellent esthetic outcomes which
increase patient satisfaction and improve psychological outcomes.[3] However, nipple malposition after NSM is common and is sometimes called “high-riding
nipple.” Choi et al reported an incidence of 14 to 75% of NAC malposition.[1]
The risk factors and secondary revision of NAC malposition have been reported. Such
secondary revision of NAC malposition is a major concern for the patient,[4] because it results in the formation of extra scars on the breast. This extra scar
is often observed and is much more visible in Asian women than in Caucasians.[5]
The prevention method of NAC malposition and results of such technique have not yet
been reported. We have been trying to prevent NAC malposition during expander insertion
to properly fix the NAC to the pectoralis major fascia. Therefore, this study aimed
to evaluate the efficacy of this technique in preventing NAC malposition in patients
undergoing two-stage implant-based breast reconstruction following NSM.
Methods
This study was reviewed and approved by the Institutional Review Board (IRB) of the
University (IRB no.: T2020–0291), and informed consent was obtained from all patients.
All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee
and with the 1964 Helsinki Declaration and its later amendments or comparable ethical
standards.
This retrospective cohort study included data obtained from medical charts and clinical
photographs. Patients who underwent two-stage implant-based breast reconstruction
with NSM at the Tokyo Medical University Hospital (Tokyo), Tokyo Medical University
Hachioji Medical Center (Tokyo), and Tokyo Medical University Ibaraki Medical Center
(Ibaraki) between January 2012 and December 2019 were included. The exclusion criteria
were as follows: bilateral cases, NSM after partial mastectomy, periareolar incision,
irradiated cases, secondary reconstruction, augmentation on the healthy side, recurrence,
a history of surgical site infection (SSI) and other complications, additional resection
required, and reconstruction by surgeons other than plastic surgeons.
Surgical Techniques to Prevent Nipple-Areolar Complex Malposition
A preventive technique of NAC malposition was performed at the time of expander insertion
in supine position ([Fig. 1]).
Fig. 1 Prevention technique of nipple-areola complex (NAC) malposition during expander insertion
in the supine position. NAC was fixed on the pectoralis major fascia to ensure symmetry.
(A) Before fixation of NAC in supine position: The symmetrical nipple-areola height was
marked on the skin on the sternum by drawing across the horizontal line to the unaffected
side and chest midline, with the patient in the standing position (black arrow). This
is the proper NAC position in the supine position. As shown in the photograph, the
NACs of the right healthy and left postmastectomy sides are both deviated upward compared
with the proper NAC position in the standing position. (B) Eight-point fixation of NAC: A rigid base resembling a pocket is created to fix the
NAC with the pectoralis major muscle and the lateral adipofascial flap. This pocket
wraps the expander, and the expander and muscle are rigidly on the chest wall. Eight
periareolar points of the dermal tissue deep to the superficial layer of the superficial
fascia (white arrow) were sutured to the fascia of the pectoralis major (black arrow).
If there is no fascia, the pectoral muscles are threaded tightly. These sutures were
made to maintain the NAC shape, similar to that of the unaffected side, and prevent
distorting the oval shape. (C) After fixation of NAC in supine position: Left affected NAC was fixed at the proper
level of NAC position while in the supine position. (D) After fixation of NAC in sitting position: finally, the symmetry was checked in the
sitting position.
NAC was fixed on the pectoralis major fascia to ensure symmetry while paying attention
to the following three steps:
-
Proper NAC position (step 1): before the operation, symmetrical nipple-areola height
was marked on the skin over the sternum by drawing across the horizontal line to the
unaffected side and chest midline, with the patient in the standing position. Intraoperatively,
in the supine position, this mark is the correct position of the NAC height. Fixation
is performed in the supine position.
-
The area of the fascia where NAC is sutured should not move easily (step 2): an expander
was inserted under the pectoralis major with approximately 10% of the expander volume
filled with saline solution. The pectoralis major fascia was preserved if it was permitted
oncologically. A pocket was made by suturing the pectoralis major muscle and lateral
adipofascial flap. This pocket covered the expander tightly, establishing a rigid
base for suture fixation of the NAC.
-
Symmetrical shape of NAC (step 3): The eight periareolar points of the dermal tissue
deep to the superficial layer of the superficial fascia were sutured to the pectoralis
major fascia with 4–0 PDS II (Ethicon Inc., Somerville, NJ) absorbable thread. These
sutures were made to maintain the NAC shape, similar to the unaffected side, and prevent
the distortion of the oval shape. Finally, the expander was filled with saline equal
to the volume of the removed mammary gland; subsequently, the symmetry was checked
in the sitting position.
Patients were classified into the following two groups based on the performance of
the prevention technique of NAC malposition: group 1 (which comprised patients in
whom the prevention technique was not performed) and group 2 (which comprised patients
in whom the prevention technique was performed).
Data regarding the age at initial diagnosis, region of cancer, ptosis, volume of the
removed mammary gland, implant volume, and body mass index (BMI; as measured at the
time of TE insertion) were obtained.
Evaluation of Nipple-Areolar Complex Malposition Using Clavicle-to-Nipple Distance
Ratio
A 6-month postoperative standing frontal view was evaluated. Six months after implant
replacement, frontal view photographs were taken in the standing position. First,
a horizontal line was drawn at the top of the clavicle. Subsequently, a perpendicular
line to the previous line was drawn through the nipple on each side. The length of
the perpendicular line from the clavicle to the nipple was measured on the photograph.
The malposition rate was calculated as the ratio of the clavicle-to-nipple distance
on the reconstructed side compared with that on the healthy side. The clavicle-to-nipple
distance ratio was defined as the ratio of the distance on the affected side to that
on the healthy side (b/a; %); this ratio was compared between the two groups ([Fig. 2]).
Fig. 2 Evaluation of nipple-areola complex (NAC) malposition after a postoperative period
of 6 months (frontal view). First, a horizontal line was drawn at the top of the clavicle.
Subsequently, perpendicular to that line, a line was drawn through the nipple on each
side. The length of the perpendicular line from the level of the upper end of the
clavicle to the nipple on the photograph was measured. The malposition rate—defined
as the ratio of the distance on the affected side to that on the healthy side (B/A;
%)—was compared between the groups.
Statistical analyses, including Mann–Whitney and Chi-square tests, were performed
using IBM SPSS Statistics (International Business Machines Corporation, New York,
NY). A p-value of <0.05 was considered statistically significant. Allergan Natrelle 133 Tissue
Expander and Allergan Natrelle 410 Breast Implant (Allergan, NJ), which had an anatomical
shape, were used in all cases.
Results
Overall, 78 patients who underwent two-stage expander and implant-based breast reconstruction
after NSM in the study period were included. The exclusion criteria were as follows:
bilateral cases (n = 6); NSM after partial mastectomy (n = 6); periareolar incision (n = 7); secondary reconstruction (n = 2); corrected ptosis augmentation on the healthy side (n = 2); recurrence (n = 1); SSI (n = 2); additional resection due to pathological examination (n = 1); operated by nonplastic surgeons (n = 9); and radiation therapy (n = 7). Subsequently, 35 patients/breasts were included. All patients were operated
by the first author.
The clavicle-to-nipple distance ratios (mean ± standard deviation) at 6 months after
implant insertion in groups 1 and 2 were 86.1 ± 11.5 and 96.0 ± 5.0%, respectively
([Fig. 3]). There was a significant difference in the nipple height malposition ratio between
groups 1 and 2 (p = 0.003). Demonstrative case photographs are presented in [Fig. 4].
Fig. 3 There was a significant difference in nipple height malposition ratio (clavicle-to-nipple
distance ratio) between groups 1 and 2 after 6 months of implant insertion (p = 0.003).
Fig. 4 Demonstrative case photographs are shown. Patients were classified into two groups
according to the performance of the prevention technique of nipple-areola complex
(NAC) malposition at the time of tissue expander (TE) insertion. (A) Group 1: With NAC position correction at TE insertion (right breast was reconstructed).
(B) Group 2: Without NAC position correction at TE insertion (right breast was reconstructed).
The changes over time in group 1, the NAC fixation group, are shown in [Fig. 5]. Immediately after TE insertion, edema around the areola was severe; however, it
improves over time. Six months after silicone breast implant (SBI) replacement surgery,
the patient's appearance was good.
Fig. 5 The temporal changes in group 2. (A) Preoperation, 48 years of age. BMI, 22.6 kg/m2. (B) One month after TE insertion at right breast. The volume of the removed mammary gland
was 221 mL. MX 400 TE was inserted. NAC was 4.2 cm pulled down and corrected. Edema
around the nipple was severe. (C) Three months after TE insertion. Edema improved over time. (D) Six months after TE insertion. (E) Six months after the implant replacement. LF 270 implant was replaced, and the patient's
appearance is good.
The number of patients in groups 1 and 2 was 10 and 25, respectively. The demographic
data of the patients are presented in [Table 1]. All patient background factors were not significantly different between the groups.
The data regarding the volume of the removed mammary glands were missing in 5 of the
35 patients; the other data were collected in all 35 patients.
Table 1
Patients' characteristics
|
Patients' demographics
|
Group 1
|
Group 2
|
p-Value
|
|
n
|
|
10
|
25
|
|
|
Age (y)
|
|
46.6 ± 10.4
|
46.12 ± 7.3
|
0.815
|
|
Ptosis
|
Non
|
7
|
23
|
0.128
|
|
Glandular/pseud
|
3
|
2
|
|
Removed mammary gland (mL)
|
|
269.3 ± 149.0
|
171.8 ± 60.8
|
0.104
|
|
Tissue expander volume (mL)
|
|
410.5 ± 133.5
|
312.4 ± 88.1
|
0.053
|
|
Implant volume (mL)
|
|
273.0 ± 100.9
|
217.0 ± 60.7
|
0.186
|
|
Waiting period until implant insertion (day)
|
|
276.7 ± 53.2
|
286.5 ± 49.4
|
0.622
|
|
Body mass index (%)
|
|
22.8 ± 2.2
|
21.1 ± 2.5
|
0.054
|
Discussion
NAC deviation worsens esthetic outcomes and reduces patient's satisfaction,[6] and secondary NAC revision surgery leaves new scarring on the breast.[7] We were motivated to conduct this study because we believed that it was crucial
to prevent NAC deviation during the immediate two-stage breast reconstruction, since
there have been no studies that have investigated the effects of surgical techniques
to prevent NAC deviation.
The study results revealed that fixing the NAC on the pectoralis major fascia at the
time of TE insertion is effective. This procedure intraoperatively prevents NAC malposition,
and this technique has favorable effects in two-stage implant-based breast reconstruction.
When NAC malposition occurs following NSM, even if the symmetry of the breast mound
is good, malposition extremely reduces patient satisfaction.[6] Additional revision surgery to correct NAC malposition would result in the formation
of new scars in addition to the existing scar,[7] especially in Asians in whom mammary scars often are more visible.[5] Based on these findings, we believe that NAC malposition should be prevented rather
than corrected. Therefore, we believe in preventing NAC malposition at mound reconstruction
intraoperatively rather than correcting it later with additional revision surgery.
This might reasonably be less burdensome, both emotionally and physically, for the
patient and would not result in the formation of extra scars.
Takayanagi stated that the goal of NSM is symmetry, including for the NAC.[5] The frequency of malposition of NAC has been reported to be 75% by Wagner et al,[8] 14 to 75% by Choi et al,[1] and 41.9% by Swanson.[9] The degree as vertical distance ratio has been reported to be 88% by Mori et al.[10] A few studies have analyzed the causes of NAC malposition and postoperative corrections.[1]
[7]
The risk factors for malposition include periareolar mastectomy incision with lateral
extension, older age, wider preoperative width of breast base, a history of radiation,
longer preoperative sternal notch-to-nipple distance,[7] vertical radical mastectomy incisions,[1] ptotic, and large resection tissue weight.[10]
Secondary revision techniques for NAC include free nipple grafting,[4] subdermal pedicle flap reconstruction,[5] crescentic excision,[1] capsule modification,[1] Z-plasty technique,[11] U-plasty,[12] transposition technique,[13] and crescent periareolar skin excision.[1]
In comparison with these reports, the nipple malposition rate calculated as the clavicle-to-nipple
distance ratio on the affected side to that on the healthy side (the affected/healthy
[b/a] ratio [%]) in group 1 without preventive technique was 86.1%, which is close
to the rate of 88% reported in the literature as vertical distance ratio by Mori et
al.[10] In contrast, the nipple malposition ratio was 96.0% in group 2, wherein the preventive
technique of NAC fixation was performed at TE insertion. The nipple malposition ratio
was significantly higher (p = 0.003) in group 2 than in group 1, thus suggesting that NAC fixation at the time
of TE insertion may have significantly prevented NAC malposition. Moreover, no studies
have precisely described the prevention methods and their effectiveness. Thus, the
present study results can be considered valuable.
This study had a retrospective design; hence, the number of patients in each group
differed. However, no significant differences were noted in the patient background
factors between the two groups.
Regarding the fixation of NAC during TE insertion, our meticulous technique had satisfactory
outcomes. The appropriate fixed position of the NAC was determined based on the reference
point of the healthy nipple height marked on the sternum in the standing position,
since the point on the midline of the chest did not shift in supine position intraoperatively.
In the supine position, the healthy NAC moves upward. In contrast, Flessas et al reported
that the appropriate NAC position was determined by comparing it with the healthy
lateral nipple position in the seated position intraoperatively.[14] However, in obese patients, the accurate NAC position may not be determined because
the abdomen compresses the breast upward. Even in patients with breast ptosis, it
is difficult to obtain adequate ptosis while seated on the operation table. In contrast,
the point marked on the midline of the sternum is less likely to move and is more
accurate. If the preoperative NAC position and breast size are asymmetrical, the reconstruction
can be considered to have matched the healthy side.
A rigid base resembling a pocket was created to fix the NAC with the pectoralis major
muscle and the lateral adipofascial flap . The dissected area under the pectoralis
major muscle should match the base area of the TE to create a tight space. We used
the superficial fascia at the margin of the areola as the suture site on the skin
flap. The pectoralis major fascia, which serves as the site of anchoring NAC, should
be rigid and tight. If there is no fascia, the pectoral muscles are tightly threaded.
This pocket wraps the expander, and the expander and muscle are rigidly on the chest
wall. Without this pocket, the NAC can easily move and be pulled by the skin flap
which can result in poor fixation.
We measured the contralateral NAC diameter to evaluate the symmetry and size and subsequently
fixated eight points of the areola margin to the pectoralis major fascia using 4–0
PDS II (Ethicon Inc.). With this approach, a natural oval-shaped nipple with minimal
strain can be created. The time required to perform this procedure was approximately
15 minutes; Flessas et al reported fixing the subpapillary tissue to the pectoralis
major with two to three sutures using 3–0 Vicryl with the serratus anterior overlying
the implant.[14] In our experience, the nipple shape was deformed into an inverted triangle at only
one subnipple suturing and a square shape due to four sutures; therefore, we sutured
the nipple in eight locations to reproduce a proper nipple contour. The method of
fixing NAC not only corrects the NAC position but also consciously fixes the NAC shape.
This concept has not been described previously.
A limitation of this study was that only patients with pseudoptosis and glandular
ptosis, according to Regnault's classification, were included, whereas other major
ptosis cases are excluded. The other major ptosis cases were either indicated for
autologous tissue reconstruction or NAC repositioning surgery after implant insertion
in case of implant-based breast reconstruction. Similarly, Mori et al reported that
small and nonptotic breasts showed relatively acceptable symmetry, whereas large or
ptotic breasts tend to develop NAC deviation. In a large or ptotic breast, NSM and
expander-implant reconstruction should be performed, considering additional surgery.
Doren et al showed that there were anatomical criteria for the indication of NSM,
and free nipple grafting was selected for the excluded cases.[15] Small et al reported a low rate of NAC malposition of 13.8% with a stricter patient
selection.[7] Choi et al described that patients underwent reduction or mastopexy of the healthy
breast at 1 to 3 months before mastectomy, and consequently, none of them underwent
NAC repositioning after mastectomy.[1] Better results can be achieved by evaluating the patient's breast shape.
Prevention of NAC malposition was possible using our technique “NAC fixation at TE
insertion” in two-stage implant-based breast reconstruction, following NSM without
major ptosis. Additionally, NAC fixation at TE insertion was found to be extremely
effective.
