Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy

doi:10.4236/mps.2012.24021

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Modern Plastic Surgery, 2012, 2, 87-90

http://dx.doi.org/10.4236/mps.2012.24021 Published Online October 2012 (http://www.SciRP.org/journal/mps) 87

Usefulness of Free Nipple-Areola Complex Graft for

Nipple Malposition after Nipple Sparing Mastectomy

Kyoichi Matsuzaki1,2

1Department of Plastic and Reconstructive Surgery, Kawasaki Municipal Tama Hospital, Kawasaki, Japan; 2Department of Plastic

and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.

Email: [email protected]

Received July 9th, 2012; revised August 6th, 2012; accepted September 7th, 2012

ABSTRACT

Purpose: This article identifies the advantage and disadvantage of a free nipple areola complex graft (FNACG) for nip-

ple malposition which resulted from tissue-expander insertion and subsequently replaced with an implant after nipple

sparing mastectomy (NSM). Methods: The subjects were three such patients treated using FNACG and who were fol-

lowed up for at least one year postoperatively. The surgical outcome was assessed for symmetry of nipple-areola posi-

tion, graft take, depigmentation, and shrinkage. Results: In all patients, the graft was accurately transferred to a po sition

to achiev e symmetry with the unaffected breast, and there was complete graft take in the areola by simple surgical de-

sign and techniques. No depigmentation of the areola was observed. The size of the areola was almost unchanged after

grafting in two patien ts, but areolar shrinkage occu rred in one other patient. There was complete graft take in th e nipple

in one patient and no depigmentation of the nipple was observed. Necrosis occurred at the tip of the nipple in two other

patients. These patients had depigmentation, and the height of nipples decreased in proportion to the level of necrosis.

Conclusion: FNACG can be a useful method if its advantages and disadvantages are well considered.

Keywords: High-Riding Nipple; Nipple Areola Complex Graft; Nipple Sparing Mastectomy; Nipple Malpositio n;

Nipple Transposition

1. Introduction

Many women who undergo breast cancer surgery not

only face anxiety and fear toward cancer but also are

affected by the sense of loss of their breasts. Thus, nipple

sparing mastectomy (NSM) tends to be selected in pa-

tients who want to preserve their nipples and areolas and

for whom this treatment is indicated [1]. In NSM, the re-

sected breast tissue needs to be replaced with autologous

tissue in a single-stage surgery. Otherwise, nipple-areola

complex malposition occurs due to contraction of the

skin and changes to the breast volume.

Patients are placed in an unexpected situation of facing

breast cancer, and some of them are unprepared to decide

at the stage of breast cancer surgery whether they want to

use autologous tissue to recon struct their breasts. Thus, a

tissue expander is often inserted at the site of the breast

tissue resection in NSM. Postoperatively, the patients can

take their time to decide on breast reconstruction when

they are in a state of mind to make such a decision.

There have been many reports on surgical methods to

correct nipple-areola complex malposition. This article

identifies the adv antage and disadvantage of a free nipple

areola complex graft (FNACG) [2].

2. Patients and Methods

2.1. Patients

The subjects were selected among patients in whom a

tissue expander (Integra® Tissue Expander Model 3612-

06, PMT® Corporation, USA) was inserted after NSM

and it was subsequently replaced with an implant (Mc-

Ghan Style 410, INAMED Corporation, Ireland). The

subjects were three such patients whose nipple sensation

was lost, nipple-areola complex malposition was cor-

rected using FNACG, and who were followed up for at

least one year postoperatively (Table 1).

2.2. Operative Procedures

The tissue expander inserted after NSM was inflated so

that the affected breast was approximately 20% more

than the volume of the unaffected breast (Figures 1(a)

and (b)). One year after NSM, the tissue expander was re-

placed with an implant (Figure 1(c)). After replacement

with an implant and six months postoperatively, FNACG

was performed with local anesthesia. The nipple-areola

complex was resected in a spindle shape. The resection

was performed in the same drection as the laxity of sk in i

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy

(a) (b) (c)

(d) (e)

(f) (g) (h)

Figure 1. (a) Case 1: A 39-year-old female. Nipple sparing mastectomy (NSM) with axillary dissection was performed for the

left breast cancer. A tissue expander was inserted; (b) One year after NSM. A tissue expander was inflated so that the af-

fected breast was approximately 20% more than the volume of the unaffected breast; (c) Replacement with an implant at six

months postoperatively; (d) The nipple-areola complex was resected in a spindle shape. The size of the new areola was estab-

lished to be the same as the unaffected areola; (e) The immediate postoperative result; (f) One month after free nipple areola

complex graft (FNACG); (g) One year after FNACG. Frontal view; (h) One year after FNACG. Oblique view.

Table 1. Cases treated with a free nipple areola complex

graft.

Case Age Type of Implant Follow-Up

1 39 Cohesive Gel 27-FL 1 2 0 - 250 19 months

2 55 Soft Touch Gel ST-LM 130 - 320 18 months

3 49 Soft Touch Gel ST-FL 100 - 140 17 months

which was less susceptible to deformation of the breast

mound, and then suturing was performed. At this stage,

the patients came off of the operating table and were in a

standing position. The design was established so that

nipple transposition would result in the same distance

between the sternal notch and the new nipple on the af-

fected breast as between the notch and the unaffected

nipple. The size of the new areola was established to be

the same as the unaffected areola (Figure 1(d)). Epider-

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy 89

mal resection was performed in the area where the areola

was to be created. A full-thickness graft was used to re-

construct the nipple-areola complex and fixed with a

tie-over dressing (Figure 1(e)). Seven days postopera-

tively, the tie-over dressing was removed. Subsequently,

petroleum jelly was applied followed by a dressing until

complete epithelialization occurred in the nipple-areola

area. In the six-month postoperative period, the nipple

was protected by a sponge with the center cut out to cre-

ate a doughnut shape. This sponge was used to prevent

pressure on the nipple by underwear or while sleeping.

2.3. Assessment of Surgical Outcome

At least one year postoperatively, the results were as-

sessed for symmetry of nipple-areola p osition, graft tak e,

depigmentation, and shrinkage.

3. Results

In all patients, the graft was accurately transferred to a

position to achieve symmetry with the unaffected breast,

and there was complete graft take in the areola. No de-

pigmentation of the areola was observed. The size of the

areola was almost unchanged after grafting in two pa-

tients, but areolar shrinkage occurred in one other patient

(Figures 1( f) -(h)).

There was complete graft take in the nipple in one pa-

tient. No depigmentation of the nipple was observed

(Figure 2). Necrosis occurred at the tip of the nipple in

two other patients. These patients had depigmentation,

and the height of their nipples decreased in proportion to

the level of necrosis (Figures 1(f)-(h)). In one patient

without necrosis, there was slight flattening of the nipple

(Figure 2 and Table 2).

4. Discussion

There have been many reports on surgical methods to

correct nipple-areola complex malposition (Table 3).

There is a method in which a tissue expander is inserted

and the skin on the cranial aspect is inflated to lower the

high-riding nipple-areola complex [3]. The advantage of

this method is that no new breast scar is created if the

(a) (b) (c)

Figure 2. (a) Case 2: A 55-year-old female. Before free nip-

ple areola complex graft (FNACG); (b) The immediate

postoperative result; (c) One and a half years after FNACG.

Table 2. Results of a free nipple areola complex graft for 3

cases.

No. of Areolae No. of Nipples

Symmetry of nipple-areola

position 3 3

Complete graft take 3 1

Depigmentation 0 2

Shrinkage 1 Not applicable

Table 3. Transposition of the nipple areola complex.

Tissue expander

Periareolar skin excision

Myocutaneous flap

Skin flap (Z-plasty flap technique)

Island flap (Subcutaneous pedicle)

Free nipple areola complex graft

tissue expander is inserted from the preexisting scar from

NSM. However, its procedure can become complicated,

the treatment period can be prolonged, and the stretched

skin can revert back to its original state. The method of

periareolar skin resection [4] has the advantage of a

camouflaged breast scar because the areolar margin ob-

scures the scar. If there is insufficient skin laxity of the

breast, it is difficult to su ccessfully achieve nipple-areola

complex transposition. A defect resulting from the trans-

position can be treated using a myocutaneous flap [5,6].

This method enables successful nipple-areola complex

transposition. However, there is morbid ity of the myocu-

taneous flap donor site and prominent patchworklike

scars of flaps. A method using a Z-plasty flap technique

[7] can result in prominent geometric scars with an un-

natural appearance. Another method involves an island

flap in which the nipple-areola complex is transferred as

a subcutaneous pedicle flap [8]. In this method, the

transfer can be achieved without the interruption of the

blood flow. Therefore, compared with the FNACG me-

thod, this method is less susceptible to problems such as

areolar shrinkage, necrosis of the tip of the nipple, and

depigmentation. However, the skin of the breast is thin,

and caution is required due to potential flap necrosis if

blood flow of the subcutaneous pedicle is unstable. In

addition, sufficient breast skin laxity is important to pre-

vent impeded blood flow due to pressure on the subcuta-

neous pedicle in the subcutaneous tunnel in the breast. In

FNACG, suturing also cannot be performed at the donor

site of the nipple-areola complex if there is insufficient

skin laxity of the breast. Thus, a tissue expander is in-

serted after NSM to adequately stretch the skin of the

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy

breast. The disadvantages of FNACG are that areolar sh-

rinkage can occur, the height of the nipple can decrease

due to necrosis if the nipple is high, and depigmentation

can occur.

Ahmed et al. [9] reported on temporary banking of the

nipple-areola complex in cases of skin sparing mastec-

tomy. The complex was temporarily banked in areas such

as the groin region. The banked nipple-areola complex

was replanted onto the reconstructed breast mound in a

second surgery. Their results of the first transplantation

showed that 88% of the cases had nipple-areola complex

graft survival rates of at least 80%, and that 51% of the

cases maintained at least 50% nipple projection. In their

study, the color change was graded at 3 levels of good,

moderate, and poor. Pig mentation was defined as good if

the color of the nipple areola complex had not changed.

Loss of pigment was considered a moderate result in

cases where the nipple-areola complex was still clearly

darker than the surrounding skin of the breast mound.

The result was poor if there was no distinction between

the color of the nipple areola complex and surrounding

skin. Their results of the first transplantation were good

in 48% of the cases, moderate in 51% of the cases, and

poor in 1% of the cases. In this study, there was areolar

shrinkage in one patient. Since areolar shrinkage was not

included as an item examined by Ahmed et al., there

could be racial differences in the results of the FNACG

just as there are racial differences in scar contracture and

keloid formation. Further studies will be necessary to

examine the usefulness of this method in Asians, who are

more susceptible to conspicuous scar formation than

Caucasians [10,11].

The advantage of FNACG is that a graft can be trans-

ferred to a site far from the donor site. Treatment using

flaps can result in th e position o f a nipp le-areola co mplex

that might be slightly different from the preoperatively

planned position because of the state of the subcutaneous

scar and the thickness and texture of the skin of the

breast. In FNACG, the position of the nipple-areo la com-

plex is determined after the donor site of the complex is

sutured. Th erefo r e, th e graf t can be accurately transferred

to a position to achieve symmetry with the unaffected

breast. The method of FNACG involves simple surgical

design and techniques, and is not greatly affected by the

technical skills of surgeons. Thus, the method should be

considered as one surgical treatment option.

In conclusion, the disadvantages of FNACG are that

areolar shrinkage can occur, the height of the nipple can

decrease due to necrosis of the tip if the nipple is high,

and depigmentation can occur. The advantage of FN-

ACG is that a graft can be transferred to a site far from

the donor site. It involves simple surgical design and

techniques and is not greatly affected by the technical

skills of surgeons. Therefore, the method can be useful if

its advantages and disadvantages are well considered.

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