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.     

乳晕放射状切开松解合并双环形荷包缝合治疗乳头内陷

目的：介绍一种有效治疗乳头内陷的手术方法。方法：采用乳晕放射状切口切开乳晕皮肤,离断松解短缩的纤维结缔组织及平滑肌,松解后应用双环形荷包缝合形成乳头颈部和根部并防止回缩。结果：应用该方法矫正治疗乳头内陷11例,术后回访1～6个月,其中10例效果良好,1例一侧乳头重新回缩。结论：乳晕放射状切开松解合并双环形荷包缝合法对于矫正乳头内陷是一种良好的手术方法,对Ⅰ型和Ⅱ型乳头内陷有其良好的应用效果。     

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。     

An Analysis of Complication Risk Factors in 641 Nipple Reconstructions

Nipple‐areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB‐approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15‐year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy‐two patients with 641 nipple reconstructions were included with an average follow‐up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant‐based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant‐based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.     

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.     

Spread to the nipple and areola in carcinoma of the breast.

In 40 breasts with primary carcinoma, the nipple and areola were cut horizontally in order to investigate the frequency of intraductal and invasive cancer. In 20 of these breasts the nipple and/or areola were found to be involved at a depth of 1 cm (50%; 95% confidence limits: 33.8-66.2%). Eleven neoplasms were purely intraductal, eight intraductal as well as stromal, and only one purely stromal. By means of clinical or physical findings, it was not possible to select the breasts in which the nipple and/or areola were not involved. It is concluded that the general use of surgical methods preserving the nipple and areola in treating breast cancer leaves a focus of invasive or intraductal carcinoma in about half the patients. The implications of this are not known.     

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 .     

楔形真皮乳腺瓣法矫正重度乳头内陷

目的：探讨矫正女性重度乳头内陷的手术治疗新方法。方法：设计乳晕去表皮楔形真皮乳腺瓣,双侧楔形瓣翻转180°交叉重叠置于乳头基部,以支撑乳头和缩小乳头颈部直径。应用不可吸收的缝线分层严密缝合创口,消除新乳头可能回缩的空间,缩窄乳头颈部皮肤。结果：2002年7月-2008年12月采用该方法共治疗35例先天性或复发性重度乳头内陷的患者,全部病例术后伤口均愈合良好,无血肿、感染等并发症。术后随访3个月～3年,切口瘢痕不明显,乳头高度及外形满意,无复发。结论：楔形真皮乳腺瓣法是矫正重度乳头内陷和术后复发的一种较好手术治疗方法,对防止乳头内陷的术后复发有良好效果。     

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.     

乳晕内下缘弧形切口皮内缝合治疗男性乳房肥大症

目的:探讨通过乳晕内下缘弧形切口切除增生乳腺组织,并采用皮内缝合治疗男性乳房肥大症的手术方法和临床效果。方法:回顾性分析5年来采用局部浸润麻醉或基础麻醉+局部浸润麻醉,在乳晕内下缘取弧形切口切除肥大增生乳腺组织,保留乳头下方的部分乳腺组织垫,治疗59例,76侧男性乳房肥大症的临床资料。结果:59例,76侧男性乳房肥大症患者,经治疗后手术效果确切,血运障碍发生少,术后患者胸部平坦,无凹陷,乳头无异常感觉,外形满意,切口隐蔽,切口痕迹不明显。结论:采用乳晕内下缘弧形切口皮内缝合治疗男性乳房肥大症能有效去除多余的腺体和脂肪组织,创伤小,恢复快,减少了术后乳头乳晕血运障碍的发生,无感觉障碍,而且切口隐蔽,瘢痕细小,是治疗男性乳房肥大症的良好手术方法。     

Post-treatment sequelae after breast cancer conservative surgery

Thanks to the earlier detection of breast cancer, the advent of neoadjuvant therapy and the development of more effective surgical procedures reducing treatment sequelae, conservative treatment has dramatically expanded over the past 15 years. Several factors have recognized negative aesthetic consequences for breast cancer patients: being overweight, having voluminous or on the contrary, very small breasts, having a tumor located in the lower quadrant, having high breast-tumor: breast-volume ratio. Tissue injuries induced by radiotherapy and chemotherapy, such as shrinking, fibrosis or induration, maximize the deleterious impact of surgery. The results of conservative treatment also deteriorate with time: weight gain is common and may result in increased breast asymmetry. Patients undergoing conservative treatment may experience sequelae including various degrees of the following dimorphisms, all possibly responsible for minor or even major breast deformity: breast asymmetry, loss of the nipple/areola complex, scar shrinkage and skin impairment, irregular shape and position of the nipple and areola. Various sensory symptoms have also been reported following conservative treatment, with patients complaining of hypo- or dysesthesia or even suffering actual pain. Breast lymphedema is also a common incapacitating after-effect that is believed to be largely underdiagnosed in clinical practice. Finally, like mastectomy, conservative breast surgery may induce serious psychological distress in patients who suffer the loss of physical integrity, womanhood or sexual arousal. Clinicians must be aware of the radiological changes indicative of late cancer recurrence. There are four types of modifications as follows: increased breast density, architectural distortion at the surgical site and formation of scar, mammary fat necrosis, and occurrence of microcalcifications. The management of sequelae of conservative breast treatment must therefore involve a multidisciplinary approach; patients not only expect better cosmetic appearance, but also a focus on other treatment advances such as improvement of psychological and sensory outcome. The interpretation of radiological images is also an integral part of the management of these patients at significant risk of recurrence.     

Immediate nipple reconstruction utilizing the DIEP flap in areola‐sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin‐sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46–59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost‐effective and feasible technique for recreating a natural‐appearing and aesthetic nipple in select patients. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

双新月形乳晕瓣结合乳腺组织瓣矫治重度乳头内陷

目的：探索一种效果持久且美容效果良好的矫治重度乳头内陷的方法。方法：彻底松解乳头下引起乳头内陷的纤维束和部分缩短的乳腺导管,移植乳腺组织瓣填充乳头下的空隙。设计上下两个新月形乳晕瓣旋转缝合至乳头颈部,增加乳头颈高度并使乳头挺立、饱满。结果：2001年3月至2008年5月共矫治43例72侧重度乳头内陷患者,经随访6个月～2年,效果持久,无一例复发,远期乳头感觉及勃起功能正常,乳头外形良好,切口痕迹不显。结论：双新月形乳晕瓣加强乳头颈部结合乳腺组织瓣填充原乳头下空隙是矫治重度乳头内陷的较为理想的方法,值得临床推广。     

Paget's disease of the breast areola mimicking cutaneous melanoma

Paget's disease of the breast nipple and areola complex represents a cutaneous manifestation of an underlying breast malignancy. The typical skin changes characteristic of breast Paget's disease are usually easily distinguished from those found of malignant melanoma. The rare finding of a pigmented cutaneous breast lesion mimicking melanoma presents a diagnostic dilemma. This case presentation describes a pigmented mammary lesion involving the areola that had undergone changes in diameter and pigmentation. The lesion was not associated with nipple drainage, nipple excoriation, dermal ulceration, or a palpable breast mass. The areola lesion was highly suggestive of a dermatologic malignancy such as malignant melanoma. As such, a biopsy was performed with initial findings suggestive of cutaneous melanoma. Upon more detailed analysis of a larger excision specimen, immunohistochemical staining was highly supportive of the diagnosis of breast Paget's disease. A total mastectomy with sentinel lymph node evaluation was performed along with immediate reconstruction. The final pathology revealed a small focus of ductal carcinoma in situ of the breast associated with the areola changes. Histologic and immunohistochemical analysis of a biopsy specimen were paramount in differentiating these two lesions.     

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.     

楔形真皮瓣塑形矫正乳头内陷21例

目的：探讨Ⅱ、Ⅲ型乳头内陷合并近乳晕区包块的手术治疗方法。方法2010年8月至2013年1月对21例Ⅱ、Ⅲ型乳头内陷合并近乳晕区包块患者行包块切除术的同时行楔形真皮瓣乳头内陷矫正术。根据乳腺包块位置与乳头连线方向设计一个以乳晕侧为蒂的去表皮楔形真皮瓣,包块切除后皮瓣卷起内翻旋转固定于乳头基部以支撑乳头,并作荷包缝合塑形乳头颈部防止乳头回缩。结果用该矫正术治疗21例、21个乳头,术后乳头血运良好,外形满意。随诊6个月,感觉、勃起正常,瘢痕不明显。其中2例Ⅲ型乳头内陷术后出现轻度回缩,但比术前明显改善,患者未要求二次修复。结论该术式操作简单有效,同时解决了乳腺包块、乳头内陷,以及乳头内陷引发包块再发的隐患,针对乳头内陷合并乳腺包块人群值得推广。     

乳房外上真皮乳腺单蒂瓣巨乳和垂乳缩小整复术

目的　探讨乳房缩小美容术保持乳头乳晕血运感觉的方法。方法　采用宋氏巨乳缩小术方法设计切口,以乳头乳晕上方及外侧真皮乳腺单蒂供应乳头乳晕血运和神经支配,完成乳腺整形。１９９６ 年１ 月～１９９８ 年１２ 月对１８ 例３０ 侧巨乳和１２ 例２２ 侧垂乳进行手术。结果　新乳房外形满意,乳头乳晕血运感觉保留好。结论　该法切口瘢痕小、乳头乳晕血运感觉良好,适合于不同轻重程度的巨乳垂乳,可作为乳房肥大或松垂的重要手术方法     

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.     

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.     

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.