Basal Cell Carcinoma of the Nipple: A Case Report and Review of the Literature

BACKGROUND: The nipple is an extremely unusual location for basal cell carcinoma (BCC). OBJECTIVE: To report a case of BCC originating on the areola and nipple region in a 47-year-old Dominican woman treated with Mohs micrographic surgery (MMS). METHODS: We discuss a case of BCC originating on the areola and nipple region treated with MMS and review the literature regarding treatment of BCC of the nipple. RESULTS: BCCs of the nipple occur rarely, with a total of 19 cases reported in the literature, 6 of which occurred in females. While many of the reported cases were treated with simple excision, several of these required postoperative radiation therapy and/or mastectomy due to their large size and aggressive nature. CONCLUSION: MMS should be considered for treating BCCs at this site as a tissue-sparing measure to minimize deformity of this important anatomic area and to minimize the risk of recurrence.     

Nipple-Sparing Mastectomy: Initial Experience at the Memorial Sloan-Kettering Cancer Center and a Comprehensive Review of Literature

Abstract: Success achieved with skin‐sparing mastectomy has led surgeons to reconsider the necessity of nipple–areola complex removal. This study reports our short‐ and mid‐term postoperative outcomes with nipple‐sparing mastectomy (NSM) and an updated review of reported literature. Data were retrospectively abstracted from medical records at our institution. Patients underwent NSM based on patient preference, oncologic criteria, and cosmesis. A literature review was undertaken through a PUBMED search and selected based on title and abstract relevance. Twenty‐five patients underwent 42 NSMs at our institution from July 2000 to October 2005. Patient mean age was 44 years (29–59 years). Indications for mastectomy were: 34 (81%) for prophylaxis, 5 (12%) for invasive ductal carcinoma, 2 (5%) for ductal carcinoma in situ, and 1 (2%) for a malignant phyllodes tumor. One prophylactic mastectomy specimen showed ductal carcinoma in situ in the retroareolar tissue, and the nipple–areola complex was removed at a second operation. Mean tumor size in cases with invasive carcinoma (n = 5) was 1.9 cm (0.7–2.5 cm). All tumors were peripherally located, and no cases showed occult nipple involvement. The nipple–areola complex was entirely preserved in 39 (93%) mastectomies. One nipple–areola complex was surgically removed, and two (5%) cases had partial loss due to infection or ischemia. Cosmetic result from surgeon’s assessment was excellent in 30 mastectomies, good in 7, acceptable in 3, and poor in 2, with slight nipple asymmetry in 8 cases. At a median follow‐up of 10.5 months (range, 0.4–56.4 months), the 39 nipple–areola complexes were intact and there were no local or systemic recurrences in cases treated for cancer. NSM represented approximately 1% of all mastectomies performed at our institution during the reported period. It was mostly used for prophylaxis and for the treatment of malignant tumors in few selected cases. NSM can be performed with a high success rate of nipple–areola complex preservation. Conclusions about the oncologic safety of this procedure cannot be drawn from our study due to small size series and short follow‐up. However, available published data show that NSM can be safely performed for breast cancer treatment in carefully selected cases. Further studies and longer follow‐up are necessary to refine selection criteria for NSM .     

3D areola dermopigmentation (nipple‐areola complex)

Surgical techniques for reconstructing the nipple‐areola complex (NAC) pose disadvantages such as areola necrosis, loss of nipple projection, depression or local necrosis, temporary leave from professional activities due to convalescence, and operational costs, all of which are factors that may discourage patients from undergoing them. In this context, dermopigmentation stands out as an emerging nonsurgical option. It is an inexpensive outpatient procedure that mimics the nipple‐areola complex by means of defining the areolar contour, Montgomery's tubercles, and a variety of colors that allow for individualization and contralateral symmetry. In this pioneering study, we propose to validate the 3D dermopigmentation technique as a preferential technique in the NAC reconstruction process. We selected 30 women with previous breast cancer who underwent conservative breast surgeries or mastectomy with NAC removal more than 6 months prior to their participating in our study. We employed the dermopigmentation technique, which we evaluated with the aid of questionnaires intended for patients, doctors, and tattooists. Among specialists, results were considered good and excellent with regard to overall esthetics (76.07%) and color (72.5%); whereas among patients, results were considered good and excellent with regard to overall satisfaction (95%) and color (100%); no adverse events were observed. Three‐dimensional dermopigmentation proved to be a promising nonsurgical technique for nipple‐areola complex reconstruction.     

乳头乳晕色素性病变切除的修复

目的探讨去除病变组织同时修复乳头乳晕组织缺损的方法。方法根据乳头缺损的范围，选择乳晕组织瓣。采用逆行设计法对缺损面积准确估计后，皮瓣按常规设计超出缺损面积的10％，使之旋转达乳头缺损区，局部推进皮瓣修复创面。结果本组10例患者，其中6例乳头乳晕均有部分色素痣，4例仅乳晕有色素痣。选用两个皮瓣进行修复。术后两侧对称，功能良好，效果满意。结论本方法可有效切除病变的同时，保持良好的外形，并保留乳头勃起功能。     

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.     

Immediate reconstruction of the nipple/areola complex in oncoplastic surgery after central quadrantectomy

BACKGROUND: Oncoplastic surgery adds valuable techniques for breast-conservation therapy that allows for wide excisions and prevents breast deformities. However, no such technique has addressed loss of the nipple/areola complex (NAC) after central lumpectomy. We present a simple and effective technique for immediate reconstruction of the NAC after such loss due to tumorectomy. METHODS: After central tumorectomy, a local tissue flap is created above the defect to restore the nipple. Then the neonipple is carried on a superior-based, dermoglandular pedicle to its new position, similar to breast reduction surgery. The operation is continued with resection of redundant tissue lateral to the pedicle for optimal breast shape. From the discarded breast tissue, a full-thickness skin graft is harvested and used to reconstruct the areola. The contralateral breast is treated with a usual mammaplasty and tailored to the specific needs of the opposite side. RESULTS: Nine patients with central tumors of the breast were treated in this fashion at our institution. In all patients, the aesthetic result was good to excellent. In 1 patient, there was delayed wound healing of the full-thickness skin graft for the areola, which healed by secondary intention. CONCLUSION: The presented technique is easily achieved and produced excellent results after breast-conservation surgery. It will expand the armamentarium of oncoplastic surgery to meet central defects with loss of the nipple/areola complex.     

Simultaneous Breast Augmentation and Lift

Often, both augmentation and mastopexy are necessary to solve the problems of breast ptosis with hypoplasia. These two procedures can be done simultaneously with no increased risks. Patients who have any degree of ptosis may benefit from some lifting of the nipple areola complex if the nipple is not in the central portion of the general contour of the breast mound when seen in the upright position. A simple crescent or eccentric excision in the upper quadrant may be sufficient to lift the nipple–areola complex 1–2 cm. If the nipple needs to be moved more than a couple of centimeters, or if the distance between the nipple and the inframammary crease is already excessive, an inframammary skin excision and redraping will be necessary. We have been using these combined techniques for 20 years with universal patient satisfaction.     

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.     

Surgical treatment of nevoid hyperkeratosis of the areola by removal of the areola and reconstruction with a skin graft

Hyperkeratosis of the nipple and areola is a rare, sporadic, benign condition characterized by verrucosus thickening and brownish discoloration of the nipple and areola. Approximately 50 cases of hyperkeratosis of the nipple and areola have been reported in the literature. Dermatologists treated most of them conservatively. We have described the case of healthy 19-year-old girl with bilateral nevoid hyperkeratosis of the areola and our treatment by surgical removal of the areola and reconstruction with a skin graft. As far as we know, this is the first report of this kind of treatment. The final result is esthetically excellent and without recurrence during 12 months' follow-up.     

改良双环法乳房缩小术

目的探索一种简单可靠的乳房缩小成形手术。方法用双环形切口，保留乳头乳晕深动脉和乳房下限的组织，对肥大的乳房进行缩小和重新塑形。结果23例惠者的乳头乳晕均无坏死，感觉良好，乳房形态自然。结论本手术设计简单，操作容易，术后瘢痕隐蔽，效果稳定，是修复各种肥大或下垂乳房的较好方法。     

乳腺上蒂瓣法乳房缩小成形术后乳头乳晕区的感觉评价

目的：研究乳腺上蒂瓣法行乳房缩小成形术对乳头乳晕区皮肤感觉的影响。方法：术后定期用棉花轻触法、细针针刺法检查乳头乳晕区的触觉和痛觉并进行比较。结果：术后乳头乳晕区感觉在半年内逐渐恢复，乳头区较乳晕区感觉恢复更早，乳晕的上部区域较下部区域感觉恢复更书。结论：乳头和乳晕的感觉恢复快慢及敏感性与术中切除的乳腺组织数量及乳头提升的高度相关。     

乳腺三角瓣交叉支撑法矫治乳头内陷

目的介绍一种矫治乳头内陷的新方法。方法采用乳头基底部乳腺组织三角瓣,交叉缝合支撑乳头基底,防止乳头内陷,保持乳头外凸形态。结果应用本方法矫治乳头内陷13例24侧,效果满意。随访2-8个月,乳头功能正常,外形、高度均理想,无回缩。结论本方法简单安全,效果持久,均能获得满意的效果。     

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.     

Isolated invasive ductal carcinoma of the nipple‐areolar complex: A rare occurrence yet to be reported in current literature

Invasive ductal carcinoma of the nipple‐areolar complex is exceedingly rare. Patients who present with bloody nipple discharge with or without the presence of Paget's disease constitute one‐third of all symptomatic in situ patients. Only rarely does an invasive cancer cause nipple discharge in the absence of a clinical mass. Even more obscure is the case of the invasive cancer involving solely the nipple‐areolar complex. Sir James Paget first described ‘an eczematous change in the skin of the nipple preceding an underlying mammary cancer’ in 1874, which is now known as Paget's disease, considered to be ductal carcinoma in situ of the nipple‐areolar region. There are two competing theories as to the pathogenesis of Paget's disease of the breast—one suggests that Pagetoid cells are keratinocytes that have undergone malignant transformation. According to this theory, Paget's disease of the breast represents an in situ carcinoma of the skin—and that overlying skin changes and underlying malignancy are discontinuous. The second theory suggests that cells migrate along basement membranes and enter the epidermis and dermis of the nipple‐areola complex. Pagetoid cells and underlying carcinomas demonstrate similar immunohistochemical staining patterns.     

乳腺三角瓣交叉支撑法矫治乳头内陷

目的介绍一种矫治乳头内陷的新方法。方法采用乳头基底部乳腺组织三角瓣,交叉缝合支撑乳头基底,防止乳头内陷,保持乳头外凸形态。结果应用本方法矫治乳头内陷13例24侧,效果满意。随访2~8个月,乳头功能正常,外形、高度均理想,无回缩。结论本方法简单安全,效果持久,均能获得满意的效果。     

双环真皮单蒂缩乳术治疗男性乳房发育症

目的：探讨双环真皮单蒂缩乳术治疗男性乳房发育症的疗效。方法：5年来采用双环形切口,乳头乳晕外上真皮单蒂法治疗男性乳房发育症,共10例,20侧乳房。结果：每侧乳房切除150～500g组织,除1例一侧乳房出现乳晕部分坏死外,余胸部形态美观,感觉恢复,效果满意,随访2～50个月,效果较为满意。结论：双环真皮单蒂缩乳术治疗男性乳房发育症,操作简便,安全,并发症少,术后胸部形态美观,值得推荐。     

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.     

Expanding the transplanted areola in breast reconstruction

Summary A simple single stage method of nipple and areola reconstruction has been used in a number of cases following unilateral breast amputations, removal of nipple and areola for benign tumor and post surgical accidental loss. The combination of areolar sharing and meshing of the graft inables the surgeon to cover the size of a normal areola. The taking of the graft does not alter the shape and the function of the normal side since it is not totally detached from its donor site.     

乳房下垂伴小乳房的综合修复术

目的 探讨针对不同程度乳房下垂伴小乳房综合修复治疗的有效手术方法.方法 根据乳房下垂的轻重进行分度,针对不同的分度进行治疗.Ⅰ度下垂伴小乳房,应用胸大肌后间隙置入假体隆胸;Ⅱ度下垂伴小乳房,在Ⅰ度下垂治疗的基础上应用深层乳腺与胸大肌表面脱套剥离及乳腺组织悬吊固定;Ⅲ度下垂伴小乳房,在Ⅱ度下垂治疗的基础上结合双环法多余皮肤切除、深层乳腺与胸大肌表面脱套剥离及乳腺组织悬吊固定;Ⅳ度下垂伴小乳房,应用直线瘢痕法乳房悬吊结合假体隆乳.结果 综合修复治疗乳房下垂伴小乳房116例,无血肿、无感染、无乳头乳晕坏死等并发症发生.术后随访6～31个月,平均随访时间13.3个月,乳房丰满挺拔,乳房下垂得到矫正,乳头乳晕感觉功能正常.结论 针对乳房下垂伴小乳房的不同情况,应用规范化的手术方案可取得较好的临床治疗效果.     

Bilateral DCIS following gynecomastia surgery. Role of nipple sparing mastectomy. A case report and review of literature

Bilateral ductal carcinoma in situ of breast is a very rare disease in men. Ductal carcinoma in situ (DCIS) is an abnormal proliferation that involves the ductal epithelium and it has the potential of evolving into an invasive tumour. Gynaecomastia (female like breast in men) is a benign condition though it is associated with a reported 3% incidence of unilateral invasive breast cancer.(2) Synchronous bilateral breast cancer in association with gynaecomastia is exceptionally rare. The recommended treatment for DCIS in male is mastectomy. So far only 2 cases of bilateral DCIS in male patients has been reported in the literature treated with skin and nipple sparing mastectomies. We report another case of synchronous bilateral DCIS in a male treated with skin and nipple sparing mastectomies. A 44 year-old man with history of long-standing gynecomastia. He had no identifiable risk factor for the development of cancer. His pre operative assessment of breast including mammograms was normal. He underwent bilateral subcutaneous mastectomies, with subsequent incidental diagnosis of synchronous bilateral ductal carcinoma in situ. The case was discussed in multidisciplinary team meeting and the need for further surgery was felt including excision of nipple areola complex. However considering patient wishes, cosmetic outcome and recent literature it was decided to preserve nipple areola complex (NAC) with regular follow up evaluation. Our patient at completion of 18 months of treatment is doing well with no signs of local recurrence.