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

Background  This article provides an algorithm for achieving an aesthetically pleasing nipple–areola complex in cases of skin-sparing mastectomy and immediate reconstruction Methods  If the contralateral nipple was big enough and the nipple-sharing technique could be used in the future for reconstruction, we left a round skin paddle at the time of the skin-sparing mastectomy and immediate flap reconstruction. The diameter of the round skin paddle was approximately the same as the contralateral areola. For nipple reconstruction we placed the graft from the contralateral nipple in the middle of the aforementioned skin paddle. If the contralateral nipple was not sufficiently large for use as a donor, then the C-V flap was used for nipple reconstruction. In these cases we deliberately left an oval skin paddle when the skin-sparing mastectomy and immediate flap reconstruction were performed. The short diameter of the oval skin paddle was approximately the same as the diameter of the contralateral areola. The position and the height of the C-V flap were marked in order to transform the oval skin paddle to a round one when the donor site of the C-V flap was closed. Results  Following this algorithm an optical illusion of a nipple–areola complex that is similar to the contralateral normal one is created. Conclusion  From our experience this algorithm can help create an aesthetically pleasing nipple–areola complex and also provides a ready pattern to our tattoing experts for the dermatography of the nipple–areola complex.     

Predictors of Nipple–Areolar Complex Involvement by Breast Carcinoma: Histopathologic Analysis of 787 Consecutive Therapeutic Mastectomy Specimens

Background  

Breast-conserving therapy (BCT) is an accepted therapeutic option for most breast cancer patients. However, mastectomy is still performed in 30–50% of patients undergoing surgeries. There is increasing interest in preservation of the nipple and/or areola in hopes of achieving improved cosmetic and functional outcomes; however, the oncologic safety of nipple–areolar complex (NAC) preservation is a major concern. We sought to identify the predictive factors for NAC involvement in breast cancer patients.     

Nummular Nipple Hypertrophy and Repair as Part of an Aesthetic Nipple-Areola Unit

The author suggests that an aesthetically pleasing ratio between nipple and areola diameter exists which should always be taken in consideration during nipple and areola reconstruction. In a study of 40 nipple–areola complexes of 20 healthy, nulliparous, Caucasian female volunteers with a mean age of 25.5 years, the average nipple diameter measured 28% of the areola diameter, that is, a ratio of 1:3.6. A hitherto undescribed form of macrothelia is presented in which the nipple width rather than the projection (length) is increased. A successful technique for reconstruction is described, based on the new method of assessing the aesthetic relations within the nipple–areola complex and known anatomy.     

A Superior Vertical Dermal Pedicle for the Nipple–Areola: An Alternative for Severe Breast Hypertrophy and Ptosis

Background  

Nipple–areola nourishment and sensation have been the main concern in reduction mammaplasty for severe breast hypertrophy and ptosis. Free grafting for the nipple–areola can cause flatness and loss of sensation. These complications can be improved by pedicle techniques for the nipple–areola, no matter the pedicle orientation. The aesthetic outcomes and complications are similar for the inferior and superior pedicle techniques. The pedicle length has been crucial to nipple–areola viability and sensation.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.     

Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple

A method of repair is described for correction of abnormally enlarged nipple–areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple–areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple–areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.     

Combined superior crescentic total glandular augmentation mastopexy: report of 37 cases

Methods of periareolar, donut, or crescentic patterns for augmentation mastopexy in mild to moderate ptosis cases are minimally invasive (short scar) options. In this article, we report a modified version of the classical crescentic technique of augmentation mastopexy, namely, “superior crescentic total glandular augmentation mastopexy”. Thirty-seven patients with (a) breasts having mild to moderate ptosis (Regnault grades I–II), (b) breasts requiring less than 3 cm of nipple–areola elevation, and (c) mild skin elasticity were included in the study. During surgery, the mean size of 290 cc of silicon gel-filled implants were placed. The mean follow-up was 39 months ranging from 6 and 58 months. None of the patients had disastrous complications such as skin or nipple–areola necrosis. Poor scar healing and areolar asymmetry were the main problems encountered during follow-up. Ptosis recurrence (n = 1), and capsular contracture (n = 1) were the main reasons for revision surgery (5.4%). Five patients were re-operated on due to complications and implant change requirements (13.5% , total revisions). Mean suprasternal notch–nipple distance was recorded as 20.8 cm (19.3–22.4 cm) postoperatively. After an average time of 39 months, this distance was found to be 21.2 cm (20.1–23.2 cm) (the case with the recurrent ptosis was excluded). Superior crescentic total glandular augmentation mastopexy has yielded satisfactory results in patients with mild to moderate breast ptosis; therefore, it seems to be a valuable option in terms of minimally invasive augmentation mastopexy techniques.     

Central Pedicled Breast Reduction Technique in Male Patients After Massive Weight Loss

Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. Techniques with free or pedicled nipple–areola complex (NAC) transposition are widely accepted. The authors present their approach to male breast reduction with preservation of the NAC on a central dermoglandular pedicle and a wide elliptical tissue excision of breast and lateral thorax tissue in combination with liposuction. Male breast reduction was performed on patients after moderate to massive weight loss due to diet or bariatric procedures. Former procedures included free nipple–areola grafts or inferior pedicled techniques for NAC preservation. As a modification, we performed a central pedicled breast reduction on nine male patients with excessive liposuction of the pedicle and a horizontal elliptical skin removal, allowing for sufficient tissue removal at the lateral thorax. From October 2010 until June 2011, nine male patients had central pedicled breast reconstructions after massive weight loss. Mean age was 29.1 years, mean preoperative body mass index was 29.2, and mean preoperative weight loss was 63.9 kg. The chest wall improvement was rated “very good” by eight patients. No major complications occurred in all nine patients. Male chest deformities after massive weight loss can be dealt by several approaches. The optimal scar positioning and the preservation of NAC may be the most challenging aspects of these procedures. Therefore, the preservation of the NAC on a central dermoglandular pedicle with a horizontal submammary scar course may optimize the esthetic outcome.     

Analysis of nipple/areolar involvement with mastectomy: Can the areola be preserved?

Background Skin-sparing mastectomy (SSM), which involves the resection of the nipple/areolar complex with the breast parenchyma, improves the aesthetic outcome for breast cancer patients. Most patients undergoing SSM desire reconstruction of the nipple/areolar complex for symmetry. These data explore the possibility of preserving the areola in selected mastectomy patients. Methods A retrospective analysis of 217 mastectomy patients was conducted to determine the frequency of malignant nipple and/or areola involvement. The association between nipple and/or areola involvement and prognostic factors, including tumor size, stage, nuclear grade, axillary nodal status, and tumor location, was evaluated. Results The overall frequency of malignant nipple involvement was 23 of 217 (10.6%). In a subgroup of patients with tumors <2 cm, peripheral tumors, and with two positive nodes or less, the incidence of nipple involvement was 6.7%. When the nipple and areolar involvement were analyzed separately, only 2 of 217 patients had involvement of the areola (0.9%). All patients with areolar involvement had stage 3 breast cancer and were located centrally in the breast. Conclusions We conclude from these data that nipple preservation is not a reasonable option for mastectomy patients. However, preservation of the areola with mastectomy in selected patients warrants further study. Presented at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

Mammoplasty: Breast Fixation with Dermoglandular Mono Upper Pedicle Flap Under the Pectoralis Muscle

A surgical procedure for breast fixation to avoid secondary ptosis of the lower quadrants and nipple–areola complex bascule and to maintain the breast upper pole projection is described and evaluated after long-term pexy and reduction mammoplasty. A superior monopedicle dermal–adipose–glandular flap with the areola–nipple complex placed in its base is mobilized and its extremity sutured to a ``trapdoor' type of flap dissected in the pectoralis muscle. This procedure determines the permanent areola–nipple complex and the upper breast quadrant position, avoiding the common secondary breast ptosis, when the breast tissue is sutured to the pectoralis muscle. One thousand seven hundred patients have undergone this procedure in the last 15 years.     

Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases

Background The literature reports many variations of Poland’s syndrome. This article describes 18 cases of Poland’s syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques. Methods This study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple–areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case. Results For the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple–areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap. Conclusions This study demonstrated several breast reconstruction options for patients with Poland’s syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.     

Successfully Exploiting Two Opposing Forces: A Rational Explanation for the ��Interlocking Suture��

Background  

Issues of poor circumareolar scars and asymmetry or malposition of the nipple–areola complex (NAC) are frequently associated with those breast reduction or pexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical scar in a circumvertical approach. To prevent such problems, in 2007 Hammond et al. introduced the “interlocking suture.” The objective of this study was to demonstrate the true ability of this suture to reduce the common complications of periareolar surgery simply by managing the existing contrast between NAC centripetal and outer breast tegument centrifugal forces.     

A New Personal Surgical Procedure for Breast Reduction and Lifting

A series of 40 patients operated from 1995 through 1997 is reviewed. The women ranged in age from 18 to 40 and were seen in either a university- or a private-hospital setting. Thirty-eight of the patients underwent reduction mammaplasty, which was performed using an inferior pedicle technique with a straight-line incision; two patients underwent mastopexy only. The reduction procedure depends on the formation of a cap from medial, lateral, and superior flaps. Following resection of breast tissue the cap is joined to a cone—the nipple–areola complex carried on a subcutaneous inferior pedicle. The cone is fixed to the chest wall with simple vertical stitches, minimizing the recurrence of ptosis. This technique is safe and versatile, avoids a submammary scar, and offers an aesthetic and long-lasting result.     

Vertical Mammaplasty Marking Using the Key Hole Pattern

Many modifications of the vertical mammaplasty procedure used to shorten the learning curve have been described. The authors advocate marking the breasts for the vertical mammaplasty operation according to the key hole pattern. They have used inverted T techniques on the upper breast and Lejour’s vertical mammaplasty on the lower breast. A total of 14 patients who had breast hypertrophy and ptosis underwent operations with this marking modification. The amount of removed breast ranged from 285 to 875 g per breast. Hematoma, skin necrosis, skin dehiscence, loss of nipple–areola sensitivity, and distortion were not observed in these cases.     

Mammaplasty with Inferior Pedicle Flap After Massive Weight Loss

Background  

After massive weight loss, one of the stigmas that afflict women is the remaining deformity of the breasts which become flaccid and ptotic, with an absent or flat upper pole. The authors propose the use of a well-established mammaplasty technique to fill the upper pole, reshape the breast cone, and correct ptosis with nipple–areola complex (NAC) repositioning.     

Dermafascial Fixation Suture: A Technique for a More Durable Projection with Short-Scar (Vertical) Reduction Mammaplasty

Background Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. Methods The perimeters of the medial pedicle and the nipple–areola complex are marked, and the medial pedicle is deepithelialized. A 2 × 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. Results Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle’s circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple–areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple–areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. Conclusions The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.     

Aesthetic Quality of the Nipple–Areola Complex in Breast Reconstruction with a New Local Graft Technique

Background  

Reconstruction of the nipple–areola complex (NAC) is the last stage of breast reconstruction and represents the search for symmetry in regard to the contralateral breast. The objective of this study was to present an areola reconstruction technique with local skin graft to improve the texture and aspect of the reconstructed areola, searching for a natural look.     

A Solution to the High-Riding Nipple–Areola Complex

There are limited techniques described in the literature on how to lower the nipple–areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty.     

Nipple-Sparing Mastectomy: Critical Assessment of 51 Procedures and Implications for Selection Criteria

Background  Retrospective studies have shown that occult nipple–areolar complex (NAC) involvement in breast cancer is low, occurring in 6–10% of women undergoing skin-sparing mastectomy (SSM). The cosmetic result and high patient satisfaction of nipple-sparing mastectomy (NSM) has prompted further evaluation of the oncologic safety of this procedure. Methods  We conducted a retrospective chart review of 36 self-selected patients who underwent 51 NSM procedures between 2002 and 2007. Criterion for patient selection was no clinical evidence of nipple–areolar tumor involvement. All patients had the base of the NAC evaluated for occult tumor by permanent histologic section assessment. We also evaluated tumor size, location, axillary node status, recurrence rate, and cosmetic result. Results  Malignant NAC involvement was found in 2 of 34 NSM (5.9%) completed for cancer which prompted subsequent removal of the NAC. Of the 51 NSM, 17 were for prophylaxis, 10 for ductal carcinoma in situ (DCIS), and 24 for invasive cancer. The average tumor size was 2.8 cm for invasive cancer and 2.5 cm for DCIS. Nine patients had positive axillary nodes. Overall, 94% of the tumors were located peripherally in the breast. After mean follow-up of 18 months, only two patients (5.9%) had local recurrence. Conclusion  Using careful patient selection and careful pathological evaluation of the subareolar breast tissue at surgery, NSM can be an oncologically safe procedure in patients where this is important to their quality of life. A prospective study based on focused selection criteria and long-term follow-up is currently in progress.     

Prospective Evaluation of the Nipple–Areola Complex Sparing Mastectomy for Risk Reduction and for Early-Stage Breast Cancer

Background

Psychological effects of mastectomy for women with breast cancer have driven treatments that optimize cosmesis while strictly adhering to oncologic principles. Although skin-sparing mastectomy is oncologically safe, questions remain regarding the use of nipple–areola complex (NAC)-sparing mastectomy (NSM). We prospectively evaluated NSM for patients undergoing mastectomy for early-stage breast cancer or risk reduction.

Methods

We enrolled 33 early-stage breast cancer and high-risk patient; 54 NSMs were performed. NAC viability and surgical complications were evaluated. Intraoperative and postoperative pathologic assessments of the NAC base tissue were performed. NAC sensory, cosmetic and quality of life (QOL) outcomes were also assessed.

Results

Twenty-one bilateral and 12 unilateral NSMs were performed in 33 patients, 37 (68.5%) for prophylaxis and 17 (31.5%) for malignancy. Mean age was 45.4 years. Complications occurred in 16 NACs (29.6%) and 6 skin flaps (11.1%). Operative intervention for necrosis resulted in 4 NAC removals (7.4%). Two (11.8%) of the 17 breasts with cancer had ductal carcinoma-in-situ at the NAC margin, necessitating removal at mastectomy. All evaluable patients had nipple erection at 6 and 12 months postoperatively. Cosmetic outcome, evaluated by two plastic surgeons, was acceptable in 73.0% of breasts and 55.8% of NACs, but lateral displacement occurred in most cases. QOL assessment indicated patient satisfaction.

Conclusions

NSM is technically feasible in select patients, with a low risk for NAC removal resulting from necrosis or intraoperative detection of cancer, and preserves sensation and QOL. Thorough pathologic assessment of the NAC base is critical to ensure disease eradication.