Reconstruction of the Nipple-Areola ComplexDr,Ramprabhu 2 may 2015

BackgroundBreast reconstruction can provide significant psychosocial benefits for women

NAC is an aesthetically important part of the breast

NAC reconstruction is the final step in long and traumatic process of breast reconstruction.

Increases subjective satisfaction and acceptance of post-operative body image

Multitude of techniques developed alongside breast mound reconstruction.

Anatomy

AnatomySignificant variation is seen in size, projection, shape, texture, colour between individualsImportant features are:Pigmented area in the most anterior part of breast.Central elevated structure within this area-nippleNipple is ideally just above inframammary fold.

Nipple projection results from the primary location of the mammary ducts in the central portion of the nipple complex. This arrangement produces a semi-rigid structure --significantly more fibrotic element than the soft and pliable surrounding areola.

The contractile properties of the areola also contribute to the gradual change in nipple projection obtained with direct or neural stimuli.

The nipple is supplied by branches of the 4th lateral intercostal nerve(cutaneous nerve).

One branch of this nerve travels through the breast to the nipple.

Another traverses medially on the chest wall before ascending vertically towards the nipple.

AnatomyFor ideal aestheticsSternal notch to NAC distance ~21-23 cm~5-7cm from inframammary foldNAC diameter ~4.2-5cmNipple projection + diameter ~1/3-1/4 areolar diameter

Note: normal nipple projection varies!

More important to match contra lateral side!

Goals of nippleareola reconstruction Position Symmetry Pigmentation Color Texture Size Projection

TimingReconstruction of the NAC is usually performed at least 3 months after breast reconstruction.This is because it is difficult to correctly site the NAC at the time of breast reconstruction.

OptionsNon-SurgicalNAC tattooingProsthesisSurgicalGraftNipple sharingSkinAutologous dermo-fat / AllodermCartilageLocal flap

ProsthesisStock prostheses availableCan be made to match other sideStick onFall off!Much dissatisfaction on long term use.

Surgical optionsMore realistic in terms of nipple shape, size, contour.Not yet able to reconstruct functional nipple!Challenge in creating 3 dimensional structure from 2 dimensional surfaceLoss of projection often occurs, may require 2nd procedure

Pre-op planningIf good symmetry match contra lateral NAC positionOtherwiseCover contra lateral breast, mark nipple position where appears best. Compare to other side and adjust if appropriate.Note patients wishes.

Nipple SharingUses contralateral nipple as donor.

If enough projection, transection of distal/inferior 30-50% of donor nipple sufficient.

Wedge excision (with small local flap).

Reduces/obliterates function of contra lateral normal nipple.

Difficult to justify given other methods available.

GraftingSkin graft for nipple with filler injectionPoor projection unless used with local flap, cartilage or AllodermMore diffuse nippleCartilage Autologous costal cartilageFirm textureMay erode through skinMay be painful

Costal Cartilage graft

Post-op cartilage graft + tattooing

Local flaps

May lose projection over time so should be planned 50-75% larger than contra lateral nipple.Donor sites may be closed primarily or grafted.Scars from donor site should be within future areola reconstruction (4.2-5cm diameter)Many techniques surgeon/patient preference. Best orientation for scar.

Skate Flap(Little in 1987 )Nipple reconstruction by the skate flap. 1: Area beyond tangent to nipple disk A denuded; lines from 3- and 9-oclock of nipple disk to 6-oclock of areolar pattern outline body of skate; 2: wings of skate elevated deep split-thickness up to body; 3: dissection changes from horizontal to vertical as dermis and fat are cut through to form composite body; 4: body dissected centrally and elevated; deep trough remains in dermal bed. 5:Areolar bed closed; areolar pattern distorts and wings of skate brought around body to each other; 6: completed nipple cone; areolar pattern revised, areolar doughnut graft added.

Skate Flap

Skate Flap

Skate Flap

Bell Flap(Eng 1996)Diameter 15-20% larger than other nipple

Handle ~ diameter of circle

Bell Flap

Elongated C Flap

Elongated C Flap

Elongated C Flap

Cervical-visor (C-V) flap

Jones and Bostwick

CV Flap

Star flapBase 3x diameter of contra lateral nippleAnton, Eskenazi, and Hartrampf in 1991.

Star Flap

Double Opposing Tab Flap(Kroll)

Areola reconstruction

Methods for recreating the areola range from simple tattooing to the more complex grafting techniques, which are performed approximately 2 to 3 months after the nipple reconstruction. Non hairy skin lateral to Labia majora

Post operative careAfter nipple reconstruction, an ointment is placed over the nipple, and 2 2 gauze squares, with central holes the size of the diameter of the new nipple, are placed over the breast in layers. The dressing is taped to the breast skin and should remain in place for 5 to 7 days.

The tattoo is usually delayed for 4 to 6 weeks, and pressure to the nipple reconstruction site is avoided. With techniques that involve the use of a graft, the bolster dressing is removed in 3 to 5 days.

ComplicationsUncommonNecrosis (partial/total)Unsatisfactory positioning.Loss of projection(most common)Secondary procedures/revision

Necrosis

Postmastectomy reconstruction patients can be subdivided into three groups in regard to nipple-areola reconstruction:

(1) patients who have no interest in further surgery, (external silicone ectoprosthesis)

(2) patients who have unstable central mound skin or present with irradiation injury to the central breast mound,(delayed reconstruction of the NAC) and

(3) patients with a stable skin envelope or flap at the central breast mound.(, immediate or delayed nipple-areola reconstruction)