Twelve-year delay of a nipple-sharing graft: A case report

The present report describes the use of a nipple-sharing technique for nipple areolar reconstruction using a donor nipple that was initially grafted from the contralateral and healthy breast 12 years earlier. There are many different techniques available to reconstruct the nipple. Although nipple sharing is not feasible to use in all patients, when available, it is an ideal approach for matching the contralateral nipple in terms of shape, colour, texture and long-term projection.     

Paget disease of a nipple graft following completion of a breast reconstruction with a nipple-sharing technique

Surgical treatment of breast cancer can have a profound impact on patients both physically and psychologically. Postmastectomy breast reconstruction can significantly decrease the psychologic distress that a breast cancer patient experiences. Whereas breast mound reconstruction was initially thought to be sufficient, surgeons and patients have recognized the importance of nipple-areolar reconstruction. The following is a case report of a patient who developed Paget disease of a left nipple graft after left mastectomy and reconstruction with a TRAM flap and nipple sharing from the right breast. This case report provides a unique 14-year retrospective review of a clinical course and to our knowledge is the first reported case in the English literature of Paget disease developing in a nipple reconstructed from the contralateral nipple using the nipple-sharing technique.     

双重加固法重度乳头内陷矫正术

目的：运用双重加固的方法进行乳头内陷矫正术，以减少术后乳头内陷复发的可能性方法：本组10例重度乳头内陷。将3个真皮皮下组织瓣在乳头下方用4-0尼龙线缝合起支撑作用，然后抽紧预先埋置的4-0尼龙线作荷包，减少真皮皮下组织瓣的张力。结果：10例患者乳头内陷均被纠正，乳头形态良好，瘢痕不明显。随访2周到半年，乳头内陷无复发。结论：双重加固法是治疗重度乳头内陷的良好方法。     

Threshold of Tactile Perception After Nipple-Sharing: a Prospective Study

Reconstruction of the nipple-areola complex is the final procedure of a breast reconstruction. The method of choice in our department for nipple reconstruction is nipple-sharing and tattooing of the areola. Some patients are reluctant to use a part of the healthy nipple, as it is not fully known how the sensibility in the remaining donor nipple is affected by surgery. Twenty patients admitted to the hospital for nipple-sharing were invited to participate in the study. The tactile perception threshold of the donor nipple was assessed using von Frey monofilaments preoperatively, and 1, 6, and 12 months postoperatively. The patients' subjective impressions one year postoperatively were also evaluated. The donor nipple had regained sensibility to touch six months after nipple-sharing. All patients reported that the nipple felt the same as before surgery and could become erect. We therefore recommend the nipple-sharing technique for completion of a breast reconstruction.     

Threshold of tactile perception after nipple-sharing: a prospective study.

Reconstruction of the nipple-areola complex is the final procedure of a breast reconstruction. The method of choice in our department for nipple reconstruction is nipple-sharing and tattooing of the areola. Some patients are reluctant to use a part of the healthy nipple, as it is not fully known how the sensibility in the remaining donor nipple is affected by surgery. Twenty patients admitted to the hospital for nipple-sharing were invited to participate in the study. The tactile perception threshold of the donor nipple was assessed using von Frey monofilaments preoperatively, and 1, 6, and 12 months postoperatively. The patients' subjective impressions one year postoperatively were also evaluated. The donor nipple had regained sensibility to touch six months after nipple-sharing. All patients reported that the nipple felt the same as before surgery and could become erect. We therefore recommend the nipple-sharing technique for completion of a breast reconstruction.     

Microbiologic efficacy of a surgically constructed nipple valve

The efficacy of a surgically constructed nipple valve in preventing reflux of colonic bacteria into the small bowel was evaluated. The nipple valve significantly decreased the number of S. marcescens, a marker bacterium, in the small bowel when compared with plain ileocolic anastomosis. In this study, the nipple valve prevented the reflux of bacteria similar to an intact ileocecal valve which suggests that the nipple valve is an effective bacteriologic barrier and may be used as a substitute for the ileocecal valve in patients with short bowel syndrome.     

Nipple reconstruction using a two-step purse-string suture technique

Formation of an aesthetic nipple areola complex with lasting projection remains a challenging final step in breast reconstruction. Despite the many techniques that have been described, no single approach has emerged as the gold standard. The current study presents a novel technique in nipple areola complex reconstruction. In a two-step fashion, the nipple and areola are reconstructed independently. This aims to create a lasting projection of the nipple while maintaining a natural contour among the nipple, the areola complex and the surrounding breast tissue. With more than 15 years of experience using this technique, the authors believe that it is a straightforward procedure and is reliable in providing satisfactory results to both the surgeon and the patient.     

Effectiveness of a handsewn nipple valve for reflux prevention in bladder reconstruction.

The intussuscepted nipple has proved to be a versatile mechanism to provide continence or prevent reflux in urological reconstructive surgery. Early in its use detussusception of the nipple was recognized as a common complication, which was usually prevented by using several rows of staples to stabilize the nipple. The use of staples has reduced the rate of reoperation for eversion or obstruction but it has led to a higher stone formation rate, ranging from 10 to 18% in recent series. Since 1983 we have used a handsewn intussuscepted ileal nipple stabilized without staples as our antireflux mechanism in bladder augmentations and continent diversions. This technique has been performed in 30 patients with an average followup of greater than 3 years. A small bladder stone developed in only 1 (3%) of the patients, who was completely dependent on intermittent catheterization, while 4 (13%) required reoperation due to eversion of the nipple. This incidence compares well with nipple reoperation rates in recent series, which range from 7 to 28%. We conclude that absorbable sutures are as effective as staples in stabilizing the antireflux nipple, and that they result in a lower incidence of subsequent stone formation.     

Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction

This study was performed to determine the degree of shrinkage over time in nipple projection after reconstruction. Nipple-areolar reconstruction was performed using the modified Anton-Hartrampf technique, and pigmentation was achieved with tattooing. This study looked at 28 consecutive patients with nipple reconstruction performed at The Milton S. Hershey Medical Center of the Penn State Geisinger Health Systems between September 1989 and November 1993. Two patients were lost to follow-up and 3 patients died of breast cancer. Thus, 23 patients and a total of 32 nipples were investigated. Initial measurements of nipple projection were taken 2 weeks postoperatively. Patients were followed an average of 38.7 months (range, 11-66 months). Ten patients (18 nipples) had tissue expansion and implantation for breast mound reconstruction. Thirteen patients (14 nipples) had autologous breast mound reconstruction. The mean decrease in projection of the tissue expansion and implantation group was 76.7+/-9.7%. The mean decrease in projection of the autologous reconstruction group was 64.3+/-12.1%. The mean decrease in projection for the entire group was 71.3+/-21.9%. Comparison between the two groups using a two-sample t-test showed p = 0.0047. The authors concluded that there is a significant reduction in nipple projection over time using the modified Anton-Hartrampf technique regardless of the type of breast mound reconstruction. In addition, their results also indicated that nipple projection on the breast mound reconstructed with an autologous musculocutaneous flap technique achieved a better long-term outcome. This study is potentially helpful in planning the initial size of the reconstructed nipple papule to match the opposite normal nipple. Additional studies need to be performed on other types of nipple-areolar reconstruction.     

Triple-V flap: nipple reconstruction using a modified C-V flap technique for long-lasting improvement of projection

Background

Reconstruction of the nipple–areola complex is the last procedure in breast reconstruction after mastectomy. Various techniques have been described, but the creation of a long-lasting projection represents a challenge in plastic surgery causing frequent nipple projection loss.

Methods

From December 2008 and September 2010, we performed 43 nipple reconstructions using our new technique named “triple-V flap.” This procedure is similar to C-V flap but uses a further V limb area that is de-epithelialized and provides significant support to the new nipple. Clinical assessment was performed with a caliper measuring nipple projection at 1, 6, and 12 months after the surgical procedure.

Results

We evaluated the triple-V nipple reconstruction technique in 43 patients. Reconstructed nipple projection ranged between 3.3 and 6.4 mm (mean 4.8 mm). Mean decrease in nipple projection was 0.2 mm at 1 month, 1.4 mm at 6 months, and 1.6 mm at 1 year. After 1 year, mean nipple projection decrease was 34 %.

Conclusions

Our triple-V technique allows the maintenance of long-lasting projection of the reconstructed nipple at 12 months after surgery. Ease and speed of execution made our technique usable in all patients who need to complete the breast reconstruction process. Level of Evidence: Level IV, therapeutic study.     

The use of a ureteric nipple alone for reflux prevention.

In the re-implantation of a ureter into the bladder, vesico-ureteric reflux can be prevented by a ureteric nipple alone, provided the nipple is at least 1.5 cm long. This eliminates the need for an oblique ureteric entry or a submucosal tunnel. Longer nipples may be used although they may lead to difficulties with catheterisation. Reduction in the length of the nipple frequently occurs later.     

Reconstruction after complete avulsion of the nipple caused by a human bite using an amputated tissue graft in situ

Abstract

Integrated avulsion of the nipple by human bite is not common. We treated a patient whose left nipple had been completely avulsed by modifing the nipple as a free skin graft and reconstructing a pillar-like fascia flap as the core to reshape the configuration of the nipple.     

A seromuscular stripping method to create a nipple valve without metal stapling for continent urinary reservoir

Urinary continence with a Kock or Mainz pouch is achieved by a nipple valve of the invaginated ileum which is usually fixed with metal staples. However, metal staples can cause various complications as a foreign body. The seromuscular stripping method, a new technique to create a nipple valve, was applied to 17 patients with bladder cancer in the construction of a continent urinary reservoir by the ileocolonic pouch (Mainz pouch). Metal staples were not used. The results were satisfactory except for 2 patients who became incontinent because of prolapse of the nipple in one and insufficient valve function due to ischemic change of the nipple valve in the other. Histology of the nipple valve from an autopsy case showed a good double layer nipple valve that functioned well to preserve continence.     

Nipple adenoma in a man: An unusual case report

Adenomatosis (adenoma, papillary adenoma, florid papillomatosis) of the nipple is a rare benign disorder involving the nipple witch can be mistaken clinically for Paget's disease and pathologically can be misinterpreted as an adenocarcinoma. It occurs mostly in middle-aged women and is extremely rare in adolescents and children. We report a 55-year-old man with an adenomatosis of the nipple evolving positively after surgery.     

Secretory Carcinoma of the Breast with a Cystically Dilated Intraductal Component: Report of a Case

A case of secretory carcinoma of the breast in a 61-year-old woman is described. She came to our hospital complaining of a bloody nipple discharge. The physical examination revealed a 2.8 × 2.1-cm, firm, irregular lump with bloody nipple discharge in her left breast. Mammography demonstrated an irregular mass and ultrasonography showed an irregular hypoechoic mass accompanied with a cyst. Ductgraphy was done. It showed a dilated mammary duct leading to the cyst which was partially occupied with carcinoma. A cytologic smear of the nipple discharge and fine-needle aspiration cytology revealed similar findings, and both findings were malignant. A modified radical mastectomy was performed. A pathological examination revealed secretory carcinoma of the breast which had spread inward and outward from the cyst. In addition, the nipple discharge flowed from the cyst through the dilated mammary duct. The patient is presently alive and well 2 years after the operation. Secretory carcinoma is an extremely rare tumor of the breast and 48 cases have been reported in Japan. The present case is the first known case of secretory carcinoma demonstrating a bloody nipple discharge to come from a cyst which has been invaded by carcinoma. Received: December 7, 2000 / Accepted: January 8, 2002 Reprint requests to: J. Izumi, Department of Surgery, Kyouritsu Hospital, 16-5 Chuoh-cho, Kawanishi 666-0016, Japan     

Nipple reconstruction using a modified arrow flap technique

Nipple reconstruction is the perfection of breast reconstruction. Although many reconstruction techniques are available, all come with the risk of projection loss. Most of the commonly used local flap techniques give reliable immediate results, but are associated with a loss in projection of 50 to almost 70% over the first three postoperative years. We herein present a modification of the nipple reconstruction technique as presented by Thomas et al. in 1996. By forming a deepithelialized area when closing the skin donor site, a firm foundation plate for the new nipple is created. The authors observed that this solid foundation plate, as well as the separation of the nipple cavity of the subcutaneous fat, results in less nipple projection loss.     

The use of a combined technique in reduction mammaplasty (inferior pyramidal and superior glandular techniques)

The management of mammary hypertrophy is a developing process. The common surgical options for reduction mammaplasty include amputation with free nipple graft as well as the bipedicled, inferior pedicle and vertical pedicle techniques. All techniques are used widely. Disadvantages of these procedures include nipple areola necrosis, insensitivity, hypopigmentation, and poor breast projection. Even with the standard modifications of the original techniques, the resultant breast and nipple may be wide and flat. The purpose of this study was to assess whether combined inferior pyramidal pedicle and superior glandular pedicle reduction mammaplasty can optimize nipple and breast projection. Attention will focus on the viability and sensation of the nipple areola complex. Nine patients with mammary hypertrophy were studied. The change in nipple position ranged from 7 to 13 cm. The amount of tissue removed from each breast ranged from 500 to 1150 g. Nipple/areola sensation was retained in all cases with the exception of one breast. Nipple/areola necrosis or hypopigmentation were not observed. Optimal central breast projection was maintained in all patients, and postoperative evaluation was carried out at 12 and 22 months. The patient satisfaction was very high.     

Mammaplasty: a technique of comprehensive correction of the ptotic breast

Ptosis of the breast and the optimum position of the nipple in the non-ptotic breast have been defined. A descent of the infra-mammary fold in ptosis is demonstrated: the concept of the nipple infra-mammary distance is introduced and the optimum values are defined. The principle of relocating the infra-mammary fold in any form of mammaplasty where the nipple is elevated is introduced together with a precise method for defining the new level of the infra-mammary fold in relation to the proposed size of the reconstructed breast. Emphasis is placed on the aesthetic significance of avoiding inter- and extra-mammary scarring.     

Segmental resection of secretory carcinoma of the breast in a young woman: 14-year follow-up

A 21-year-old woman with a 5-cm secretory carcinoma of the breast was successfully treated by wide segmental excision, including removal of a portion of the nipple. At presentation, she had a 5-year history of predominantly yellow and occasionally bloody discharge from the nipple. The tumour had classical histological features of secretory carcinoma with surrounding hyaline fibrous tissue predominating, a feature previously associated with a good prognosis. Identification by frozen section of extension near the nipple led to intraoperative excision of a nipple segment. She is healthy with a satisfactory cosmetic result 14 years after excision and has breast fed two children from the affected breast.     

乳头凹陷隆起器临床应用报道附346例

目的　由于手术治疗先天性乳头凹陷常有些严重并发症,故研究利用非手术负压吸引疗法,将凹陷乳头吸出,并维持到正常状态。方法　制作乳头凹陷隆起器,用负压吸引原理,将乳头吸引出并维持到正常状态。操作应仔细并循序渐进,防止乳头缺血坏死。一般30天左右,乳头不再回缩。继续佩带3个月,以巩固疗效。结果　346例均得到随访,随访时间3～12个月,随访期间内观察,除7例外,均获得良好的近期效果达98%。结论　由于乳头凹陷隆起器用于先天性乳头凹陷治疗临床近期效果较好。为目前较佳的非手术治疗方法,但还须进一步观察。