CHAPTER 63 NIPPLE RECONSTRUCTION
MICHAEL S. BECKENSTEIN
Nipple reconstruction is an essential component in the creation of an attractive breast. When viewing breasts, the eyes are drawn to the nipple–areola complexes. A surgeon can create aesthetically pleasing breast mounds, but the improper placement of the nipple–areola complexes will compromise the final result. In addition, errors in nipple–areolar placement are challenging to correct. Nipple reconstruction techniques may seem minor in the overall scheme of breast reconstruction; they are a major factor in the final result and demand meticulous attention to achieve good aesthetic results.
The goal of nipple–areolar reconstruction is to create nipples that are appropriately located on the breast mound and are of appropriate size, shape, color, and texture. Projection is another key aspect of nipple reconstruction which can be varied to attain a patient’s goal. There are many techniques of nipple–areolar reconstruction that can be employed to suit the goals of both the patient and the surgeon. Some techniques are better suited for autologous breast reconstruction where there is more subcutaneous adipose tissue and others might be best applied to prosthetic breast mounds with thinner subcutaneous tissue.
When performing unilateral breast reconstruction, simply triangulating the distances from the contralateral nipple onto the reconstructed breast mound may not result in an appropriate placement. Because there are usually breast mound asymmetries, the surgeon uses aesthetic judgment to position the nipple. One way to approximate the nipple–areola position is to cover the contralateral breast and carefully study the reconstructed breast mound and place a mark where the nipple location appears appropriate. The contralateral breast is then uncovered and a careful comparison is made. Adjustments are made as deemed necessary. The patient is allowed to have input into the nipple–areola location as well. A round adhesive bandage is placed on this location. The patient can relocate the bandage to what she feels is an appropriate location.
In bilateral reconstructions, there is more latitude in nipple location yet the marking methods are similar. Initially, each breast is assessed separately. Careful inspection of both breasts is then performed and adjustments/compromises made as necessary.
Ideally, the surgeon is familiar with a variety of techniques and will choose one based on the goals of the patients and the amount of tissue available on the breast mound. The more common reconstruction methods consist of local flaps, grafts, or a combination of both. Acellular dermal matrices (ACMs) used alone or in conjunction with local flaps are being utilized as well as injectable materials. Tattooing can also serve as the sole form of nipple–areola construction in select patients.
Local flaps are the most frequently performed methods of nipple reconstruction today. A central dermal fat pedicle is wrapped by full- or partial-thickness skin flaps, creating a nipple. These procedures employ skin grafts or primary closure to close the donor defects. Examples of the commonly used pedicle flaps are the skate flap, modified skate flap, star flap, cervical visor (CV) flap, wrap flap, and fishtail flap. To be successful in creating nipples of sufficient projection and dimension, the breast mound must provide well-vascularized soft tissue of sufficient thickness. One must keep in mind that these are second-generation flaps; that is, they are created from flaps of tissue that were themselves either mastectomy flaps or autologous transferred flaps! These methods may not be suitable for reconstructions in patients with thin skin or irradiated tissue. Local flaps are best suited for breast mounds composed of autologous tissue where these soft-tissue requirements are met.These local flaps often lose volume and contract substantially over time. Consequently, an initial overcorrection is warranted. In unilateral reconstruction, the local flap is made 50% to 75% larger than the contralateral nipple size in anticipation of atrophy. If the final result is substantially larger than desired, a reduction is readily performed as an office procedure. It is easier to reduce the size than to perform a secondary procedure to increase the size of a volume-depleted, contracted nipple.
Technique. All local flap procedures begin by designing the flaps so that the base of the flap is located at the marked position of the nipple. The flap dimensions are drawn within the confines of a 38-, 42-, or 45-mm “cookie cutter.” The skin incisions are then made; the lateral flaps are raised as full- or partial-thickness skin grafts. The dermal fat pedicle is incised into the subcutaneous adipose layer, raising the dermal-fat pedicle 90° to the plane of the breast mound. Care is taken to preserve the delicate blood vessels in the adipose tissue to minimize tissue atrophy postoperatively. The dermal fat pedicle must be of sufficient thickness to provide the necessary bulk for the nipple. The donor site is closed in layers, approximating the deep dermis with an absorbable 4-0 suture. The skin is closed with 5-0 absorbable simple mattress sutures. The lateral skin flaps are then rotated around the dermal fat pedicle and sutured with simple mattress sutures. All remaining skin edges are closed in a similar manner. Figure 63.1A–C demonstrates these tenets, using Hartrampf’s Penny flap as the example. A dressing is applied, consisting of the base of a 20-mL syringe, cushioned by an eye pad with the center cut out. A 1-in. Xeroform strip is placed into the barrel of the syringe after it is placed over the newly reconstructed nipple and a Tegaderm dressing is applied. An alternative dressing consists of an arterial line protector, which is then injected with antibiotic ointment, after it is placed over the nipple. The dressings are removed 1 week postoperatively. The patient wears the plastic nipple shields for an additional week, placing them through the center of an adhesive bandage. These dressings are changed twice daily, applying antibiotic ointment to the nipple.
The use of grafts is another effective method of nipple–areola reconstruction. Grafts are particularly useful in prosthetic reconstructions as there is often a paucity of soft tissue to create nipples with sufficient projection using the local flap techniques. The disadvantage of autografts is that they require a donor site. Grafts of tongue, earlobe, toe, and labia have been used, but these donor sites are undesirable and are of mostly historical significance.
FIGURE 63.1. The “penny flap” demonstrates the basic tenets of dermal fat pedicle reconstruction of the nipple. A central dermal fat pedicle is elevated from the breast mound with partial- or full-thickness lateral “wings” elevated in continuity. The lateral “wings” are wrapped around the dermal fat pedicle and sutured into place. The base of the flap is sutured to the breast mound. The donor defect can be closed primarily or reconstructed with a small skin graft. A. Flap design. B. Flap elevation. C. Formation of the nipple.
One of the best methods in unilateral breast reconstruction is a composite nipple graft from the contralateral nipple. If the patient has sufficient projection in the contralateral nipple and is willing to use it as a donor site, excellent nipple symmetry can be attained. This is an easy technique to perform and can readily be accomplished in the office. The patient must be informed that the donor nipple may suffer loss of sensibility and erectile and ductile function. The graft can be harvested in several ways, depending on the nipple size and projection. If there is sufficient donor nipple projection, a simple transection of the distal 30% to 50% of the nipple can be performed. The donor nipple can be closed primarily with 4-0 chromic, interrupted, vertical mattress sutures. Alternatively, a central vertical wedge can be excised closing the defect in a similar fashion. If the donor nipple does not have a significant projection to accommodate simple transection, a wedge can be excised along the horizontal axis (analogous to a piece of pie), closing the defect primarily. This will diminish the diameter of the donor nipple but will not alter the projection. The appropriate diameter of skin is excised to prepare the recipient site. The graft is then placed duct side down and sutured to the skin with 4-0 chromic mattress sutures. Another method, which increases both the nipple size and projection, raises a small, local skin flap 90° from the plane of the recipient breast mound. The nipple graft is sutured to the base of the recipient site and to the local flap edges creating a hybrid, local flap–composite graft nipple reconstruction. Dressings, similar to those used for local flaps, are employed. The donor site is dressed with antibiotic ointment and a bandage. The graft dressings are changed 1 week postoperatively, and are dressed every other day with Xeroform for an additional week. Although the graft may appear dark and dusky after 1 week, it is usually pink and viable within 2 to 3 weeks. Over the next 2 to 3 months, the graft may grow approximately 20% to 30% larger, attaining the appearance of the contralateral nipple.
Skin Grafts. Skin grafts can be used to create the nipple–areola complex, often using an ellipse of medial thigh skin. The graft is placed over the de-epithelialized, circular, donor site and sutured with a tie-over dressing that is removed 1 week postoperatively. A separate, central graft is placed to simulate the nipple. Alternately, the skin graft is placed around a local flap or composite graft. Although skin grafting alone may not create significant projection, it may provide a more three-dimensional areola than areolar tattooing. These grafts, however, are poor color matches to “normal” areolae and they do not take up the tattooed pigments readily. The medial thigh donor site is also undesirable to most patients.
Donated (Homograft) Cartilage
The use of cartilage is an excellent method of nipple reconstruction, particularly in prosthetic reconstruction where there might be a soft-tissue deficiency (Figure 63.2). The surgeon has complete control over the dimensions of the nipple. The procedure is applicable to both unilateral and bilateral nipple reconstruction, is an easy procedure to perform, does not involve a donor site, and maintains long-lasting projection. A disadvantage of donated cartilage is that the resulting nipple is firm with an unnatural feel. If the grafts are placed too superficially and do not have a smooth contour, they can extrude through the skin, necessitating revision and/or removal. Thin skin flaps or irradiated tissue also make extrusion more likely and extreme caution should be exercised in these patients. The use of simple nipple–areola tattooing may be the best option for these patients. The patient must be aware, during the informed consent, that the cartilage is from an organ donor and there is a theoretical risk of infectious diseases.
Technique. A pocket is created to accommodate the nipple graft, which is performed by making an incision approximately 2 cm from the position of the nipple. After the skin is incised, a double-hook retractor is placed and the subcutaneous tissue is carefully dissected down to the pectoralis major muscle or capsule. Gentle dissection is performed to the location of the nipple position and then spread for an additional 0.5 cm around the marked dimensions of the nipple. Extreme care must be taken not to perforate the capsule, as this structure is essential in providing the vascularized tissue for the base of the graft. If the skin flaps are of sufficient thickness, the dissection can proceed into the subcutaneous tissue avoiding the muscle or capsule, provided there is enough soft tissue for the underlying to overlying skin to “cushion” the graft. Hemostasis is achieved with a needle-tip cautery and the wound is irrigated with antibiotic solution.
FIGURE 63.2. Nipple reconstruction using costal cartilage. A. The grafts are shaped into the patient-specific dimensions of diameter and projection. B. The graft is made smooth with a rasp. C. After the skin incision is made, the pocket to accommodate the graft is created with the gentle spreading of a tenotomy scissor in the plane between the skin and pectoralis major muscle. D. A horizontal mattress suture is placed from the center of the nipple position, through the graft, and back through the same skin location. E. The graft is inserted into the pocket employing traction on the suture to guide the graft into position. F. The incision is closed.
The graft is carved carefully with a no. 10 scalpel to create a nipple of the appropriate dimensions. The anterior aspect (or tip) must be completely rounded and devoid of any sharp edges. A no. 5 rhinoplasty rasp can be used to soften and smooth the anterior surface to prevent potential areas of pressure necrosis leading to graft extrusion. The base of the graft should be slightly wider than the tip to create a more natural shape and 4-0 absorbable suture is placed at the center point of the nipple location, through the skin, and into the pocket. The suture is then placed through the tip of the graft, back through the pocket, and out through the center point of the nipple location (essentially a horizontal mattress suture). It is useful to place a forceps into the pocket to prevent inadvertent puncture of the implant. Using the suture as a guide, gentle traction is placed on it while the opposite hand pushes the graft into the pocket and to the appropriate location. Traction on the suture will assure the graft is upright and the suture is then gently tied. The skin incision is then sutured with 4-0 chromic horizontal mattress sutures. Four or five 5-0 chromic, quilting sutures can be placed around the circumference of the graft to define the base of the reconstructed nipple. The avoidance of overly tight sutures is essential as these can constrict the dermal blood supply, leading to graft extrusion. An eye pad and adhesive are placed over the graft and left in place for 3 to 5 days. The central guide structure is removed 1 week postoperatively.
Acellular Dermal Matrices. Processed dermis can be used as an adjunct to local flap reconstruction or as the primary material for the nipple. A cylindrical roll of ACM can be created and placed in front of the dermal fat pedicle of any local flap. This creates a more rigid “strut” which is then wrapped by the lateral skin flaps. The dimensions of this strut can be precisely controlled to achieve the desired dimensions of the nipple. The surgeon must pay careful attention when designing the dimensions of the lateral flaps in order to accommodate the added volume of the ACM strut.
A rectangular sheet of ACM, measuring 4 cm × 2 cm, can be fashioned into a form of a nipple similar to what is created from cartilage. It is placed just as was described with the cartilage grafts. A cylindrical shape can be created, which usually creates adequate projection. The 4 cm × 2 cm sheet is rolled along the long axis where the edges are secured with absorbable sutures. The length is then bisected creating congruent halves. There are cases where more projection is desired or the mammary skin flaps are “tight” requiring a larger ACM graft. In these cases, the cylinder tends to collapse on itself losing projection. A longer rolled graft is made that is sutured end to end to create a donut shape. This form is more resistant to the compressive forces, yielding a larger, more projecting nipple. A disadvantage to ACM is the cost which dramatically increases the overhead of a procedure that is currently not highly reimbursed.
Nipple–areola tattooing is an excellent adjuvant treatment (Figures 63.3 and 63.4). Because color choice is unlimited, excellent symmetry is attainable in both unilateral and bilateral reconstructions. With attention to detail, excellent three-dimensional appearance can be created with the use of basic light and shading principles. The Montgomery glands can also be added to achieve a more natural appearance. A nipple–areola tattoo is a two-dimensional entity and results in a flat areola, when compared with a natural areola. This method will not achieve the true, three-dimensional appearance of a skin-grafted areola, but can create the illusion with good artwork! Tattooing should be performed approximately 6 to 8 weeks after nipple reconstruction, to allow for wounds to heal. While this is an easy office procedure, insurance carriers no longer reimburse for this procedure, as it is included into the global CPT (Current Procedural Terminology) code for the nipple–areola reconstruction. As a result, surgeons are now delegating this procedure to outside sources, including cosmetologists, salons, and other venues.
For selected patients, the entire nipple–areola complex can be created with tattooing. Using basic principles of light and shadowing, a three-dimensional illusion can be created. This is particularly useful in patients with prosthetic reconstructions who have thin, tenuous skin that would not support a local flap or graft. Some patients do not wish to undergo additional surgical procedures and may simply opt for tattooing alone. A nipple can be reconstructed at any time thereafter if the patient desires. Tattoos often fade and approximately 60% of patients may require a secondary tattoo session.
In cases where a reconstructed nipple has insufficient dimensions and there is disparity with the contralateral nipple, secondary procedures can be performed. Small asymmetries can be rectified with the insertion of a small dermal graft, ACM, or cartilage into the base of a local flap. A skin or composite graft can be placed on top or around a portion of the flap or graft. Autologous fat can be injected into the base of a local flap as well. For more significant disparities involving local flaps, a second flap can be raised using the base of the previous flap as the new nipple location. A CV or fishtail flap is particularly useful in this situation. The use of long-term injectable fillers can be used to supplement smaller nipple deficits.
FIGURE 63.3. A 2-year follow-up of a Penny flap with areolar tattooing in a transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction.
FIGURE 63.4. A. Bilateral nipple reconstruction with acellular dermal matrix and tattooing. B. Right nipple reconstruction with cartilage and left nipple reconstruction 10 months after injection with hydroxyapatite (a series of three injections over 9 months utilized).
ON THE HORIZON
The use of injectable fillers can be used to create a new nipple as well as augment or improve the contours of an established nipple (Figure 63.5). Dermal substitutes can also be utilized for this as well. However, the costs of these methods may exceed third-party reimbursement, thus limiting their use. Fillers are easily injected in the office. We raise a wheal in the skin using the base of a 3 cc syringe that is spilt on the side to accommodate the needle. The syringe helps contain the filler within the confines of the nipple location. We inject 0.3 to 0.5 cc per session and repeat it every 3 to 6 months to build sufficient projection. Long-term results greater than 1 year are not yet available and this is off-label use of the product. Further evaluation is warranted.
Although the techniques of nipple reconstruction seem simplistic compared with those employed in creation of the breast mound, nipple reconstruction is extremely important. Inappropriate position of the nipple–areola complexes on the breast mound leads to an unacceptable result. Careful planning is required and the procedure relies on the aesthetic judgment of the surgeon. Patient input is also useful.
Several methods are available for nipple–areola reconstruction. It is important for the surgeon to become familiar with several techniques to meet the various challenges of breast reconstruction. Local flaps, with or without skin grafts, are best suited for autologous reconstruction as there is adequate subcutaneous fatty tissue to provide sufficient volume and projection. These methods may not be suited for prosthetic reconstructions where the mammary flaps are thin. In these situations, the grafting techniques are indicated. The use of tattooing alone may be an acceptable alternative in select patients. The use of injectable materials is being evaluated with ongoing trials and studies.
FIGURE 63.5. A. The technique of injecting a dermal filler for nipple reconstruction; the base of a 3 cc syringe, with a slit cut into the side, accommodates the needle. This device assists in the containment of the material within the confines of the base. This allows for more precise filling as it diminishes wider dispersion of the material. B. The immediate appearance following injection of 0.3 cc of filler.
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