Keywords
Nipples - Reconstructive surgical procedures - Surgical flaps
INTRODUCTION
Reconstruction of the nipple-areolar complex in breast reconstruction is a very important
process in terms of postoperative psychological and/or aesthetic satisfaction. Multiple
studies have demonstrated that patients’ satisfaction with breast reconstruction largely
depends on the presence of the nipple-areolar complex [1]
[2]. Nipple reconstruction also plays an important role in psychosocial function [3]. Therefore, nipple reconstruction is the last step when completing breast reconstruction.
Nipple reconstructive surgery is usually done 3 to 6 months after breast reconstruction
with the goal of creating a nipple similar to that on the contralateral side. Several
methods for nipple reconstruction, such as grafting, local flaps, internal nipple
prostheses, and autogenous implants, have been introduced during the past 30 years
[4]. In the early days, methods such as skin grafts or contralateral nipple grafts were
mainly used. However, in recent years, the most common technique is a local flap using
autologous tissue without damaging the opposite nipple. Several “pull-out” local flap
techniques using breast tissue, such as the star flap, C-V flap, and bell flap, have
been reported [5]
[6]
[7]
[8]
[9].
Although the initial projection after primary nipple reconstruction with these techniques
is excellent, projection gradually flattens in most cases. Shestak et al. [6] compared the star, skate, and bell flaps and showed a flattening rate of 30%–75%
within a 2-year follow-up period. Nipple flattening is a multifactorial phenomenon,
with causes including an insufficient amount of subcutaneous fat, pressure (both internal
and external), poor flap design, and tissue memory.
To date, several studies have reported methods of secondary nipple revision [10]
[11]
[12]
[13]. Nahabedian [11] used local flaps and AlloDerm (LifeCell Corp.) to augment nipple projection. Kim
and Ahn [10] restored nipple projection by burying four triangular dermal flaps. However, there
is still no consensus on when to perform secondary nipple reconstruction and which
method to choose. The objective of this study was to review our institution’s experiences
with secondary nipple reconstruction and to propose a surgical strategy for nipple
revision.
METHODS
Patients
This retrospective study was approved by the Institutional Review Board of Korea University
Anam Hospital (IRB No. 2020-AN0174). We retrieved the clinical details of all patients
who underwent secondary nipple reconstruction at our hospital from March 2012 to January
2019 from their medical records, including detailed operation notes and a photography
database. In this 7-year period, the senior author performed 138 primary nipple reconstructions.
Of these, 27 nipples (19.6%) required secondary reconstruction due to excessive flattening,
defined as a difference of more than 6 mm from the height of the opposite nipple.
The patients provided written informed consent for the publication and the use of
their images.
Surgical techniques
We performed the surgical technique for each patient using either a star flap or purse-string
suture according to an assessment of tissue scarring and the remaining nipple projection.
Specifically, if the remaining nipple showed excessive flattening of less than 2 mm
in height, a purse-string suture or star flap was used depending on the scarring.
However, if the remaining nipple had a height of more than 2 mm, a purse-string suture
was used. The degree of scarring in the tissue was checked through the pinch test
([Fig. 1]). A nipple projection of over 5 mm was defined as acceptable, because the average
height of the nipple was reported to be approximately 5 mm [14].
Fig. 1. A treatment algorithm for patients presenting with a flattened nipple.
Star flap method
We usually performed the operation under local anesthesia using lidocaine without
epinephrine. We outlined the superior star flap by placing the remaining nipple in
the center in order not to change the position of the existing nipple while preventing
constriction of the lower pole of the breast ([Fig. 2A]). When outlining, the length of each part depended on the width of the base and
the extent of the projection of the opposite nipple, since the base width of the new
nipple must be the same as that of the opposite nipple. In star flaps, the width of
the lateral limbs is the final determinant of nipple projection. When deciding on
the preoperative design and size, it should be expected that the projection may be
reduced by 30% to 40% over time. For this reason, we recommend that the lateral limbs
have a width of at least 1.5 cm and a length of 2 cm or more, and that the total height
of the nipples is at least 1 cm.
Fig. 2. Schematic illustration of a superiorly based star flap. (A) We outlined the superiorly
based star flap by placing the remaining nipple in the center in order not to change
the position of the existing nipple, while preventing constriction of the lower pole
of the breast. (B) We made the skin incision and elevated the star flap in the subcutaneous
plane, incorporating some fat while checking the viability of the central and lateral
limbs. (C) The lateral limbs were first wrapped and sutured to each other. Then, we
placed the central limb on top to complete the nipple reconstruction. Finally, the
flap donor wounds were closed.
We made the skin incision and elevated the star flap in the subcutaneous plane, incorporating
some fat ([Fig. 2B]). Upon ensuring the viability of the central and lateral limbs, we first wrapped
the lateral limbs and sutured them to each other using polydioxanone 4-0 (PDS II;
Ethicon, Raritan, NJ, USA). We then placed the central limb on top to complete the
nipple reconstruction ([Fig. 2C]). We closed the flap donor wounds of the lateral limbs primarily using Vicryl 4-0.
Following nipple reconstruction, we used a doughnut-shaped foam (Ildong Pharmaceutical
Co., Seoul, Korea) for approximately 1 month to mitigate projection loss caused by
early compressive forces ([Fig. 3]).
Fig. 3. Doughnut-shaped foam dressing for prevention of compressive forces. Doughnut-shaped
foam (Ildong Pharmaceutical Co., Ltd.) was used to reduce external pressure, one of
the causes of nipple flattening.
Purse-string suture method
We also performed this procedure under local anesthesia using lidocaine without epinephrine.
Eight small (approximately 1 mm each) curvilinear skin incisions were spaced evenly
along the margin of the existing nipple with a no. 11 blade scalpel ([Fig. 4A]). We then placed a polypropylene 3-0 suture in one direction through the previously
created skin incisions, starting at the 12 o’clock position. This was maintained relatively
deep to prevent the suture from becoming extruded or visible through the skin. We
completed the purse-string suture where both ends met at the 12 o’clock position ([Fig. 4B]). We then achieved the desired nipple projection by countering the radial pull of
the surrounding tissue. Finally, we closed the curvilinear incisions with Prolene
6-0 sutures ([Fig. 4C]).
Fig. 4. Schematic illustration of the purse-string suture technique. (A) Eight small (approximately
1 mm each) curvilinear skin incisions were spaced evenly along the margin of the existing
nipple with a no. 11 blade scalpel. (B) We then placed a polypropylene 3-0 suture
in one direction through the previously created skin incisions, starting at the 12
o’clock position. This was maintained relatively deep to prevent the suture from becoming
extruded or visible through the skin. We completed the purse-string suture where both
ends met at the 12 o’clock position. (C) Next, we achieved the desired nipple projection
by countering the radial pull of the surrounding tissue. Finally, we closed the curvilinear
incisions with Prolene 6-0 sutures.
Questionnaire and assessment
We measured and photographed nipple projection in the operating room and the clinic.
At postoperative 3 months, patients were asked to evaluate their level of satisfaction
regarding the secondarily reconstructed nipple with a 5-point Likert scale (1 = very
poor, 2 = poor, 3 = fair, 4 = good, and 5 = excellent).
Statistical analysis
All statistical analyses were carried out using SPSS version 24.0 software (IBM Corp.,
Armonk, NY, USA). The Mann-Whitney U test, independent t-test, and Fisher exact test
were used for statistical comparisons between groups. For all analyses, a P-value
< 0.05 was considered to indicate statistical significance.
RESULTS
Patient demographics and operative information
We analyzed a total of 27 patients, including eight who underwent surgery with the
star flap technique and 19 who had surgery with the purse-string suture technique.
There were no significant differences between these two groups in age (49.2 years
for the star flap group vs. 54.5 years for the purse string group; P = 0.176), body
mass index (24.0 kg/m2 for the star flap group vs. 24.4 kg/m2 for the purse string group; P = 0.781), comorbidities, breast reconstruction type,
or the number of patients who received radiation therapy. [Table 1] summarizes the patient demographics and operative information.
Table 1.
Patient demographics
|
Variable
|
Technique
|
P-value
|
|
Star flap
|
Purse-string suture
|
|
Values are presented as the mean±SD or number (%).
BMI, body mass index; NA, not available.
a) Mann-Whitney U test;
b) Fisher exact test.
|
|
No. of patients
|
8
|
19
|
|
|
Age (yr)
|
54.5 ± 6.6
|
49.2 ± 9.7
|
0.18
|
|
BMI (kg/m2)
|
23.95 ± 2.18
|
24.36 ± 3.82
|
0.78a)
|
|
Comorbidities
|
|
|
|
|
Hypertension
|
1 (12.5)
|
1 (5.3)
|
0.51b)
|
|
Diabetes
|
1 (12.5)
|
1 (5.3)
|
0.51b)
|
|
Active smoker
|
0
|
0
|
NA
|
|
Breast reconstruction type
|
|
|
0.64
|
|
Implant
|
2 (25.0)
|
9 (47.4)
|
|
|
Autologous
|
6 (75.0)
|
7 (36.8)
|
|
|
Implant + autologous
|
0
|
3 (15.8)
|
|
|
Adjuvant radiotherapy
|
0
|
1 (5.3)
|
1.00b)
|
Patients’ mean age and the median follow-up period after the final reconstruction
were 50.8 years (range, 33–66 years) and 8 months (range, 6–19 months), respectively.
The types of breast reconstruction were implants in 11 breasts, autologous tissue
in 13 breasts, and autologous tissue with implants in three breasts. Data on nipple
projection before and after surgery, the time for the final projection height of the
nipple, and the types of procedures performed are provided in [Table 2]. Of the eight patients who received a star flap as the secondary reconstruction
method, the primary reconstruction method was a star flap in three cases, a C-V flap
in three cases, and a skate flap in two cases. Instead, most patients who received
a purse-string suture as the secondary reconstruction method had received a C-V flap
as the primary method (14/19). In all nipples, wound healing was uneventful, without
skin flap necrosis or local infection.
Table 2.
Characteristics of patients and operative information
|
Patient No.
|
Age (yr)
|
Procedure
|
Primary nipple reconstruction
|
Secondary nipple reconstruction
|
|
Breast reconstruction
|
Primary/secondary nipple reconstruction
|
Initial projection (mm)
|
Final projection (mm)
|
Time (mo)
|
Initial projection (mm)
|
Final projection (mm)
|
Time (mo)
|
|
LD, latissimus dorsi; MS-2 TRAM, muscle sparing-2 transverse rectus myocutaneous;
DIEP, deep inferior epigastric perforator; CV, C-V flap; PS, purse string; SF, star
flap; SkF, skate flap.
|
|
1
|
58
|
LD + implant
|
CV/PS
|
10
|
2
|
24
|
8
|
5
|
7
|
|
2
|
50
|
Implant
|
SF/PS
|
11
|
5
|
5
|
10
|
6
|
8
|
|
3
|
34
|
Implant
|
CV/PS
|
10
|
2
|
24
|
7
|
6
|
6
|
|
4
|
50
|
LD + implant
|
SF/PS
|
9
|
2
|
48
|
6
|
4
|
6
|
|
5
|
51
|
Implant
|
CV/PS
|
10
|
3
|
6
|
9
|
4
|
12
|
|
6
|
53
|
MS-2 TRAM
|
SkF/SF
|
10
|
2
|
24
|
10
|
8
|
7
|
|
7
|
56
|
MS-2 TRAM
|
CV/PS
|
10
|
3
|
5
|
8
|
6
|
6
|
|
8
|
57
|
LD
|
SF/SF
|
8
|
2
|
12
|
8
|
7
|
6
|
|
9
|
41
|
Implant
|
CV/PS
|
8
|
2
|
24
|
5
|
2
|
15
|
|
10
|
33
|
Implant
|
CV/PS
|
9
|
2
|
6
|
7
|
5
|
7
|
|
11
|
59
|
DIEP
|
CV/PS
|
10
|
4
|
11
|
8
|
4
|
9
|
|
12
|
36
|
LD
|
CV/PS
|
10
|
5
|
4
|
9
|
6
|
8
|
|
13
|
53
|
Implant
|
CV/PS
|
10
|
5
|
4
|
9
|
5
|
10
|
|
14
|
60
|
MS-2 TRAM
|
CV/SF
|
10
|
2
|
12
|
10
|
4
|
6
|
|
15
|
63
|
MS-2 TRAM
|
CV/SF
|
10
|
2
|
8
|
10
|
6
|
19
|
|
16
|
52
|
Implant
|
CV/PS
|
9
|
4
|
3
|
7
|
6
|
6
|
|
17
|
53
|
MS-2 TRAM
|
CV/PS
|
10
|
2
|
7
|
10
|
4
|
10
|
|
18
|
48
|
Implant
|
CV/PS
|
10
|
3
|
3
|
9
|
8
|
6
|
|
19
|
66
|
LD
|
CV/PS
|
10
|
2
|
5
|
8
|
6
|
6
|
|
20
|
50
|
Implant
|
CV/SF
|
8
|
2
|
5
|
9
|
5
|
19
|
|
21
|
52
|
MS-2 TRAM
|
SF/PS
|
9
|
2
|
6
|
7
|
2
|
9
|
|
22
|
34
|
Implant
|
SF/PS
|
9
|
2
|
7
|
7
|
3
|
10
|
|
23
|
58
|
Implant
|
SF/SF
|
10
|
1
|
45
|
10
|
7
|
10
|
|
24
|
42
|
MS-2 TRAM
|
SkF/SF
|
10
|
1
|
7
|
10
|
4
|
8
|
|
25
|
48
|
DIEP
|
CV/PS
|
10
|
5
|
6
|
8
|
4
|
10
|
|
26
|
53
|
MS-2 TRAM
|
SF/SF
|
10
|
2
|
24
|
10
|
7
|
12
|
|
27
|
62
|
LD + implant
|
SF/PS
|
10
|
1
|
12
|
6
|
3
|
9
|
Outcomes of secondary nipple reconstruction
According to the authors’ algorithm, 19 patients received purse-string sutures and
eight received star flaps. Of the 19 nipples with purse-string sutures, 10 (52.6%)
demonstrated acceptable projection. Among the eight nipples with star flaps, six (75.0%)
demonstrated acceptable projection. [Figs. 5] and [6] illustrate the clinical results of our patients in each group.
Fig. 5. Secondary nipple reconstruction using purse-string suture (patient no. 18). A 48-year-old
woman who underwent two-stage breast implant reconstruction received a star flap for
primary nipple reconstruction. (A, B) At 3 months after primary nipple reconstruction,
nipple projection had flattened (estimated projection, 3 mm). At this time, secondary
nipple reconstruction using a purse-string suture was performed. (C, D) At 6 months
after secondary nipple reconstruction, the nipple demonstrated acceptable projection
(estimated projection, 8 mm). (E) Enlarged view of the reconstructed nipple.
Fig. 6. Secondary nipple reconstruction using a star flap (patient no. 6). A 53-year-old
woman who underwent a muscle sparing-2 transverse rectus abdominis musculocutaneous
flap received a C-V flap for primary nipple reconstruction. (A-C) At 2 years after
primary nipple reconstruction, nipple projection had flattened (2 mm). At this time,
secondary nipple reconstruction using a star flap was performed. (D-F) At 7 months
after we performed a star flap for secondary nipple reconstruction, the nipple demonstrated
acceptable projection (8 mm).
Specifically, in the cases of secondary nipple reconstruction using the purse-string
suture method, the mean nipple height was 2.9 mm prior to secondary nipple reconstruction
and 4.7 mm at an average follow-up of 10.9 months. In contrast, for secondary nipple
reconstruction cases using the star-flap method, the mean nipple height was 1.8 mm
prior to secondary nipple reconstruction and 6.0 mm at an average follow-up of 8.4
months. The preoperative projection before secondary reconstruction showed a statistically
significant difference between the two groups, because we considered whether the remaining
nipple projection was more than 2 mm when selecting which method to use. However,
with regard to final nipple height, acceptable projection (more than 5 mm) could be
achieved in both groups ([Table 3]).
Table 3.
Outcomes of secondary nipple reconstruction
|
Outcome
|
Technique
|
P-value
|
|
Star flap
|
Purse-string suture
|
|
Values are presented as the mean±SD.
a) Mann-Whitney U test;
b) Independent t-test;
c) Statistically significant, P<0.05.
|
|
Preoperative projection (mm)
|
1.8 ± 0.5
|
2.9 ± 1.3
|
0.025a),c)
|
|
Final projection (mm)
|
6.0 ± 1.5
|
4.7 ± 1.6
|
0.055b)
|
|
Follow-up time (mo)
|
8.4 ± 2.4
|
10.9 ± 5.4
|
0.252b)
|
Comparison with opposite nipple projection
[Table 4] summarizes the data for the height of the reconstructed nipple and the opposite
nipple measured at the last follow-up. At an average of 12.9 months after secondary
nipple revision, the reconstructed nipple was 5.1 mm high, the opposite nipple was
6.3 mm high, and there was a significant difference between the two values (P = 0.036).
Table 4.
Comparison with opposite nipple projection
|
Patient No.
|
Age (yr)
|
Procedure
|
Final projection (mm)
|
Time from secondary nipple reconstruction (mo)
|
|
Breast reconstruction
|
Secondary nipple reconstruction
|
Reconstructed nipple
|
Opposite nipple
|
|
LD, latissimus dorsi; MS-2 TRAM, muscle sparing-2 transverse rectus myocutaneous;
DIEP, deep inferior epigastric perforator; PS, purse string; SF, star flap.
|
|
1
|
58
|
LD + implant
|
PS
|
5
|
5
|
24
|
|
2
|
50
|
Implant
|
PS
|
6
|
6
|
5
|
|
3
|
34
|
Implant
|
PS
|
6
|
6
|
24
|
|
4
|
50
|
LD + implant
|
PS
|
4
|
3
|
48
|
|
5
|
51
|
Implant
|
PS
|
4
|
10
|
6
|
|
6
|
53
|
MS-2 TRAM
|
SF
|
8
|
10
|
24
|
|
7
|
56
|
MS-2 TRAM
|
PS
|
6
|
6
|
5
|
|
8
|
57
|
LD
|
SF
|
7
|
7
|
12
|
|
9
|
41
|
Implant
|
PS
|
2
|
10
|
24
|
|
10
|
33
|
Implant
|
PS
|
5
|
3
|
6
|
|
11
|
59
|
DIEP
|
PS
|
4
|
5
|
11
|
|
12
|
36
|
LD
|
PS
|
6
|
7
|
4
|
|
13
|
53
|
Implant
|
PS
|
5
|
9
|
4
|
|
14
|
60
|
MS-2 TRAM
|
SF
|
4
|
8
|
12
|
|
15
|
63
|
MS-2 TRAM
|
SF
|
6
|
6
|
8
|
|
16
|
52
|
Implant
|
PS
|
6
|
9
|
3
|
|
17
|
53
|
MS-2 TRAM
|
PS
|
4
|
2
|
7
|
|
18
|
48
|
Implant
|
PS
|
8
|
10
|
3
|
|
19
|
66
|
LD
|
PS
|
6
|
6
|
5
|
|
20
|
50
|
Implant
|
SF
|
5
|
4
|
5
|
|
21
|
52
|
MS-2 TRAM
|
PS
|
2
|
2
|
6
|
|
22
|
34
|
Implant
|
PS
|
3
|
3
|
7
|
|
23
|
58
|
Implant
|
SF
|
7
|
6
|
45
|
|
24
|
42
|
MS-2 TRAM
|
SF
|
4
|
5
|
7
|
|
25
|
48
|
DIEP
|
PS
|
4
|
10
|
6
|
|
26
|
53
|
MS-2 TRAM
|
SF
|
7
|
7
|
24
|
|
27
|
62
|
LD + implant
|
PS
|
3
|
6
|
12
|
|
Mean ± SD
|
|
|
|
5.1 ± 1.6
|
6.3 ± 2.5
|
12.9 ± 12.1
|
Patient satisfaction
Patients were asked to assess the aesthetic outcomes of the reconstructed nipples
overall on a 5-point Likert scale (1 = very poor, 2 = poor, 3 = fair, 4 = good, and
5 = excellent) and a higher score indicated greater satisfaction [15]. The mean satisfaction score was 4.07 (range, 2–5). Most of the patients (73.1%)
were satisfied (scores of 4 or 5) with the nipple reconstruction overall ([Table 5]).
Table 5.
Patients’ satisfaction with the secondarily reconstructed nipple
|
Technique
|
Patients’ satisfaction
|
|
1 (very poor)
|
2 (poor)
|
3 (fair)
|
4 (good)
|
5 (excellent)
|
|
Purse-string suture (n)
|
0
|
2
|
5
|
6
|
6
|
|
Star flap (n)
|
0
|
0
|
1
|
1
|
6
|
DISCUSSION
Reconstructed breasts play a major role in maintaining the femininity of breast cancer
patients, as the nipple completes the naturalness and symmetry of reconstructed breasts.
Nipple reconstruction helps the patient recognize that her body is intact, even if
it is not fully anatomically restored. Breast surgeons might consider nipple reconstruction
to be a minor procedure. However, the result is significant, in that it can change
the outcome of the entire breast reconstruction. No matter how perfectly reconstructed
the breast is, if the nipple is asymmetric or unnatural, it will be unacceptable to
the patient. If reconstruction of the nipple is successful, the overall outcome of
the breast reconstruction can be more natural and satisfactory. Thus, reconstruction
of the nipple is the final step when completing breast reconstruction.
However, reconstructed nipples have a natural tendency to flatten, with the skin surface
returning to its normal contour. Nipple flattening is a multifactorial phenomenon,
with causes including an insufficient amount subcutaneous fat, pressure (both internal
and external pressure), poor flap design, delayed healing, and tissue memory [11]. Wearing a bra may cause external pressure on the breast surface, predisposing it
to nipple flattening. In addition, implants apply internal pressure, resulting in
stretching and flattening of the breast surface over time. Other factors, such as
inadequate subcutaneous fat and poor flap design, can impair circulation in local
flaps, leading to delayed healing and eventual flattening. The natural processes of
contraction inherent to wound healing also cause the projection of the reconstructed
nipple to flatten [6]
[11]. Jabor et al. [16] found that an excessively flattened nipple was the key area of dissatisfaction after
nipple reconstruction in more than 50% of the women whom they surveyed. Therefore,
it is conventional to overcorrect the nipple relative to the opposite nipple projection
considering long-term outcomes.
Several techniques have been devised to resolve the issue of nipple flattening after
nipple reconstruction. However, flattening remains an unsolved problem [12]
[13]
[17]
[18]. Some patients may eventually require secondary nipple reconstruction to regain
projection and to correct flattened reconstructed nipples. Various methods have been
used to rebuild secondary nipples. Nahabedian [11] introduced a technique of secondary nipple reconstruction using local flaps and
acellular dermal grafts. Kim and Ahn [10] reported a nipple revision technique that involves anchoring dermal flaps. However,
it is unknown which method is the most effective in specific cases of secondary nipple
reconstruction.
Of the several local flaps, the star flap can include more tissue than can the C-V
flap, because the central limb is also V-shaped. Unlike the skate flap, primary repair
of the donor site is possible. For this reason, we chose the star flap as a local-flap
method for secondary nipple reconstruction. Implementing star flaps on nipples showing
excessive flattening after primary nipple reconstruction can produce acceptable long-term
results. In our study, among the eight nipples with star flaps, six (75%) demonstrated
acceptable projection.
However, the star flap is not always applicable, such as in patients with severe scarring.
If the flattening was not extreme or the scarring was severe, we performed the purse-string
suture technique for secondary nipple reconstruction instead of a star flap. The purse-string
suture technique is reproducible and does not require a separate skin-graft harvest
for areola creation [19]
[20]
[21]. Of the 19 nipples with purse-string sutures, 10 (53%) demonstrated acceptable projection.
Patient satisfaction is also associated with tattooing. We usually perform tattooing
more than 3 months after the nipple revision, so most patients are not tattooed at
the third month after nipple revision, which is when their satisfaction was evaluated.
Therefore, in our study, patient satisfaction was related to nipple projection rather
than tattooing.
Based on these experiences, we devised an algorithmic approach for secondary nipple
reconstruction ([Fig. 1]). Given the favorable results in this study, we believe that good surgical outcomes
can be achieved by our method of deciding on nipple reconstruction according to the
degree of scarring in tissue and the remaining nipple projection.
Our study has several limitations. First, we did not compare this cohort of patients
with a control group. However, considering that the average nipple height of women
is 5 mm, the final outcomes were satisfactory, with comparable postoperative projections
[14]. Second, the difference in the follow-up period and the remaining height of the
nipple just before nipple revision for each patient might have affected the final
outcomes. However, in most cases, the remaining height of the nipple was less than
2 mm, and the average follow-up period was more than 6 months, which was the period
during which nipple projection would gradually achieve a stable plateau [6]
[7]
[10].
We obtained good results by performing a star flap if the scarring was not severe
and a purse-string suture in severe cases. It is possible to achieve balance with
the opposite nipple by performing secondary nipple reconstruction using a proper method,
thereby achieving aesthetic goals and increasing patient satisfaction. In this regard,
the algorithm proposed herein could be a guide for secondary nipple reconstruction.
NOTES
Ethical approval
The study was approved by the Institutional Review Board of Korea University Anam
Hospital (IRB No. 2020AN0174) and performed in accordance with the principles of the
Declaration of Helsinki. Informed consent was waived because of the retrospective
nature of the study and the analysis used anonymous clinical data.
Patient consent
The patients provided written informed consent for the publication and the use of
their images.
Author contribution
Conceptualization: ES Yoon. Data curation: HD Yeo, SP Jung, SH Park. Formal analysis:
HD Yeo. Methodology: DS Kim. Project administration: DS Kim. Visualization: DS Kim.
Writing - original draft: HD Yeo, DS Kim. Writing - review & editing: JH Chung.
