Keywords
Mammaplasty - Nipples - Dermis - Transplants
INTRODUCTION
Creating a natural nipple completes the aesthetics of breast reconstruction. Although
a variety of techniques have been described, the long-term loss of nipple projection
is disappointing to both patients and surgeons [1]. Nipple flattening is attributed to factors such as contractures within the reconstructed
nipple and external pressure.
To overcome these factors, many surgeons have advocated the insertion of a graft,
which acts as an internal strut in nipple reconstruction. The use of both autologous
grafts and alloplastic materials has been widely reported. Rib or stacked auricular
cartilage grafts produce long-lasting nipple projection but have the disadvantage
of an extra donor site. Stacked dermal grafts incur less donor site morbidity, but
the grafts, being non-rigid, are less effective in the maintenance of nipple projection.
Using a tightly rolled dermal graft, we can create a graft with axial rigidity, thereby
achieving long-lasting nipple projection with minimal donor site morbidity.
METHODS
Patients
Between 2007 and 2011, 37 patients with an average age of 46 years (range, 27-66 years)
underwent nipple reconstruction (34 unilateral and 3 bilateral cases). This was performed
between 3 and 6 months after the completion of breast mound reconstruction. Nineteen
patients underwent autologous breast reconstruction with the transverse rectus abdominis
myocutaneous (TRAM) flap, and 10 patients had latissimus dorsi (LD) flap reconstruction
with or without an implant. The remaining 11 patients had two-stage breast reconstruction
using expanders and implants. The projection of the reconstructed nipple was measured
using calipers at the time of surgery and at 12 months postoperatively.
Surgical technique
With the patient standing, the C-V flap [2] is marked using the contralateral breast as a reference for the nipple position
and dimensions. In patients with skin paddles that have a relatively long transverse
diameter, the C-V flap is orientated vertically. This will shorten the horizontal
width of the skin paddle and create a more circular nipple-areolar complex. Under
local anesthesia, the "C" and "V" flaps are raised at the superficial subcutaneous
level to preserve the subdermal plexus ([Fig. 1A]). The tips of the "V" flaps are blunted to avoid skin tip necrosis, and the donor
sites are closed with subdermal Monocryl 5-0 and interrupted Ethilon 5-0 sutures (Ethicon
Inc., Somerville, NJ, USA). The "V" flaps are sutured together in a ying-yang fashion
using Ethilon 5-0 sutures.
Fig. 1 Operative technique using rolled dermal graft
Operative technique of nipple reconstruction using a rolled dermal graft. (A) The
"C" and "V" flaps are elevated, and the "V" flap tips are blunted to prevent skin
tip necrosis. (B) The rolled graft is threaded, in its erect position, into the trough
formed by the V flaps. (C) The C flap is folded over and sutured to the V flaps.
An ellipse of the dermal graft, measuring approximately 3 cm×1.5 cm, is harvested
from the "dog ear" portion of a previous incision. If this is not available, the dermis
can be harvested from skin adjacent to previous scars. This has the advantage of allowing
concurrent revision of "dog ears" or breast mound excess. It is crucial to include
only dermis and as little scar tissue as possible. The overlying epidermis is de-epithelialized
very thinly with a size 10 blade to an approximate depth of 8/1,000th inch. The maximal
thickness of the dermis is preserved, and fat is not included as it resorbs and interferes
with grafting rolling. The donor site is closed primarily.
The dermal graft is wound tightly around an artery forceps clipped to one end, and
interrupted Monocryl sutures are placed at intervals to prevent the graft from unraveling
([Fig. 2]). A suture is tied to one end of the graft, and the cylindrical graft is threaded
in its erect position into the trough formed by the V flaps ([Fig. 1B]). To complete the reconstruction, the C flap is folded over and sutured to the V
flaps by using Monocryl 6-0 sutures ([Fig. 1C]). Postoperatively, Allevyn (Smith & Nephew, London, UK) sponge dressings are cut
into doughnut shapes and stacked to protect the nipple from compression ([Fig. 3]). This splinting is continued for a minimum of 6 months to one year. Tattooing of
the nipple-areolar complex is performed 3 to 6 months later.
Fig. 2 Rolling of the dermal graft
(A) The dermal graft is rolled tightly, with the aid of an artery forceps clipped
to one end of the graft. (B, C) Sutures are placed at intervals to keep the roll compact
and to prevent it from unraveling. (D) Appearance of dermal graft after rolling.
Fig. 3 Postoperative stacked Allevyn sponge dressing
Stacked Allevyn sponge dressing is used for protecting the nipple from compression.
RESULTS
Mean nipple projection at the time of surgery was 1.15 cm (range, 0.8-1.7 cm). The
average follow-up period was 25 months (range, 13-38 months). At one year, the mean
projection was 0.80 cm (range, 0.62-1.22 cm). [Figs. 4], [5] show the postoperative results of patients who underwent nipple reconstruction using
our technique following TRAM and LD reconstructions, respectively.
The maintenance of nipple projection is the percentage of projection at one year in
relation to the projection immediately after the reconstruction. The average maintenance
of nipple projection was 69.6% (70.2% for the TRAM flap group, 76.3% for the LD flap
group, and 61.8% for the tissue-expanded group). In four patients with previous irradiation
of the reconstructed breasts, relatively poor maintenance of nipple projection was
noted (45.7%). In our series, no immediate or delayed postoperative complications,
such as infection, extrusion of dermal graft, or donor site morbidity, were noted.
Fig. 4 Patient with previous TRAM flap reconstruction
Postoperative photos. (A) Immediate. (B) At 1 year. TRAM, transverse rectus abdominis
musculocutaneous.
Fig. 5 Patient with previous LD flap reconstruction
Postoperative photograph of a patient who had previous latissimus dorsi (LD) flap
reconstruction. (A) Anterior view. (B) Lateral view.
DISCUSSION
The maintenance of nipple projection can be as low as 30% following nipple reconstruction
[3]. A significant loss of projection occurs during the first 3 months, but it stabilizes
by 1 year after reconstruction [4],[5]. In the C-V flap reconstruction, a central dead space that extends beyond the level
of the skin into the subcutaneous layer is present when the V flaps are inset. We
postulate that contracture within this deep trough contributes to the eventual nipple
flattening.
The inclusion of a pillar of tissue as an internal strut to obliterate the dead space
is a useful technique to resist these deformational forces. Valdatta et al. [6] demonstrated that in patients who underwent the C-V flap reconstruction without
a graft, the mean nipple projection at one year was 0.35 cm and the mean maintenance
was 68%. In our series, the mean projection at one year was 0.80 cm and the mean maintenance
was 69.6%.
The use of dermal grafts has the advantage of allowing simultaneous scar revision,
and as an autologous tissue, the risk of exposure and extrusion is very low. Long-term
histologic evaluation of dermal grafts revealed degeneration of epithelial remnants
with eventual transformation of the implanted dermis into well-vascularized fibrous
tissue [7]. Eo et al. [8] described the use of stacked dermal grafts at the base of the nipple to improve
projection. In our technique, the dermal graft is rolled tightly to form a compact
cylinder, providing axial rigidity and immediately reinforcing the nipple shape and
height.
Other grafts, such as auricular cartilage [9], rib cartilage [10], and toe pulp [11], have been described. The drawback of these options is the need for an extra donor
site. An exception is the rib cartilage, which can be harvested and banked when the
internal mammary vessels are used for the reconstruction of the breast. Although rib
cartilage is superior in maintaining nipple projection, the excessive rigidity of
the reconstructed nipple may not be desired. An alternative technique is the use of
local de-epithelialized dermal flaps, but these are limited by the quantity and quality
of the local breast skin. Guerra et al. [10] reported 454 nipple reconstructions combining cartilage graft with a local arrow
flap. Four percent of nipples in this study suffered cartilage graft loss due to exposure
of the graft or ischemia of the flaps.
Synthetic materials used to augment nipple projection include polytetrafluoroethylene
implants [12], artificial bone [13], and semipermanent injectable fillers, such as calcium hydroxylapatite [14]. Alloplastic materials are readily available and do not require a donor site. However,
these options have an increased risk of extrusion and may predispose the patient to
infections and wound-healing complications. Alloderm (LifeCell, Bridgewater, NJ, USA),
an acellular human dermal substitute, was used as an internal strut with favorable
results [15],[16],[17]. Our study has demonstrated that it is possible to improve the maintenance of nipple
projection with an autologous dermal graft, without incurring the cost of Alloderm.
Although our results could not reach statistical significance, it supported previous
findings that nipples reconstructed from the thicker dermis of latissimus dorsi skin
islands were more resistant to contractures than those reconstructed from the thinner
skin of the breast and abdomen [18]. In patients with previous adjuvant radiotherapy, poor wound healing and significant
contracture of the reconstructed nipple were noted. In most cases, where the recipient
vascular supply is robust and the graft is not excessively thick, a resorption rate
of 25% to 30% [19] is predicted. A corresponding overcorrection should be performed to compensate for
this sequelae.
