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Reelevating the Mastectomy Flap: A Safe Technique for Improving Nipple-Areolar Complex Malposition after Nipple-Sparing Mastectomy

  • July 2017
DOI:10.1097/GOX.0000000000001426
Authors:
Zhang Shuhao at Nanjing University
Zhang Shuhao
Nadia P. Blanchet
Nadia P. Blanchet
Nadia P. Blanchet
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Abstract and Figures

Nipple-areolar complex (NAC) malposition is one of the most common complications following nipple-sparing mastectomy with implant-based reconstruction. To maximize perfusion to the NAC, traditional methods of correcting NAC malposition limit undermining below the NAC. We demonstrate a series of cases in which improvement of NAC malposition was safely performed by reelevating the NAC and mastectomy flap to allow redraping of the soft tissue envelope over the implant and the overlying capsule. Thirty-four patients were identified in a span over 4 years where 44 NACs were repositioned using this method. There was zero incidence of postoperative ischemia or necrosis of the NAC or mastectomy flaps. There was noticeable improvement in the NAC position on the breast mound. Reelevation of the mastectomy skin flap to correct malposition of the NAC after nipple-sparing mastectomy is a safe and effective option, avoids additional scars, and can be performed more than once to further improve positioning of the NAC.
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Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
www.PRSGlobalOpen.com 1
INTRODUCTION
Over the past decade, nipple-sparing mastectomy
(NSM) has become increasingly popular.1 Patients who
undergo NSM and breast reconstruction report superior
aesthetic results, improved psychosocial well-being, self-
image, and sexual function.2 Nonetheless, NSM is not
without risks and a common complication related to NSM
with reconstruction is malposition of the nipple-areolar
complex (NAC). This disfiguring complication is present
in up to 75% of NSM with implant-based reconstruction.3
The NAC is most commonly displaced laterally and supe-
riorly due to relative skin excess of the medial and infe-
rior breast. A number of operative strategies to manage
NAC malposition after implant-based reconstruction have
been published,3–8 all of which involve making additional
breast scars. We propose a simple method to reposition
the displaced NAC after implant-based reconstruction by
reelevating and redraping the entire mastectomy flap.
This avoids a new visible breast incision and is safe and
effective for mild-to-moderate malposition.
PATIENTS AND METHODS
This study was conducted in adherence with the
guiding principles of the Declaration of Helsinki. A ret-
rospective chart review of all patients undergoing NAC
relocation in the senior author’s practice from January
2012 through June 2016 was performed. All patients who
had partial submuscular, acellular dermal matrix (ADM)–
assisted implant-based reconstruction were included. All
patients had signed informed consent for nipple reposi-
tioning as part of staged implant-based breast reconstruc-
tion. Patient demographics, breast/NAC characteristics,
surgical outcomes, and complications were recorded.
Operative Technique
NAC reposition is performed simultaneously with tissue
expander or implant exchange. After prosthetic exchange
is completed and the capsule is closed, the subcutaneous
plane is infiltrated with tumescent solution of dilute lido-
caine with epinephrine. A variable area of mastectomy flap
is elevated away from the underlying pectoralis muscle/
Received for publication February 16, 2017; accepted June 9,
2017.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This is
an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000001426
From the Division of Plastic Surgery, Virginia Commonwealth
University, Richmond, Virginia.
Summary: Nipple-areolar complex (NAC) malposition is one of the most common
complications following nipple-sparing mastectomy with implant-based reconstruc-
tion. To maximize perfusion to the NAC, traditional methods of correcting NAC
malposition limit undermining below the NAC. We demonstrate a series of cases in
which improvement of NAC malposition was safely performed by reelevating the
NAC and mastectomy flap to allow redraping of the soft tissue envelope over the
implant and the overlying capsule. Thirty-four patients were identified in a span
over 4 years where 44 NACs were repositioned using this method. There was zero
incidence of postoperative ischemia or necrosis of the NAC or mastectomy flaps.
There was noticeable improvement in the NAC position on the breast mound.
Reelevation of the mastectomy skin flap to correct malposition of the NAC after
nipple-sparing mastectomy is a safe and effective option, avoids additional scars,
and can be performed more than once to further improve positioning of the NAC.
(Plast Reconstr Surg Glob Open 2017;5:e1426; doi: 10.1097/GOX.0000000000001426;
Published online 24 July 2017.)
Shuhao Zhang, MD
Nadia P. Blanchet, MD
Reelevating the Mastectomy Flap: A Safe Technique
for Improving Nipple-Areolar Complex Malposition
after Nipple-Sparing Mastectomy
Disclosure: The authors have no financial interest to declare
in relation to the content of this article. The Article Processing
Charge was paid for by the authors.
Reelevating the Mastectomy Flap
Zhang and Blanchet
xxx
xxx
8
Sudharshini
Plastic & Reconstructive Surgery-Global Open
2017
5
Ideas and Innovations
10.1097/GOX.0000000000001426
9June2017
16February2017
© 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society
of Plastic Surgeons.
24July2017
Breast
Supplemental digital content is available for this
article. Clickable URL citations appear in the text.
2017
IDEAS AND INNOVATIONS
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
PRS Global Open • 2017
2
ADM (see video, Supplemental Digital Content 1, which
demonstrates reelevation of the mastectomy flap to allow
mobilization of the NAC over the breast mound. This video
is available in the “Related Videos” section of the Full-Text
article on PRSGlobalOpen. com or available at http://links.
lww.com/PRSGO/A489). The previous mastectomy incision
or a new inframammary fold incision is used (Fig. 1). Pa-
tients early in the series underwent limited undermining,
but as the safety of the technique became evident, under-
mining became more extensive. Currently, we prefer to
reelevate the entire mastectomy flap as greater mobility is
gained with more undermining. The deep surface of the
mastectomy flap and NAC are then sutured to the pectora-
lis muscle or ADM at the desired location with multiple 2-O
absorbable quilting sutures at 2–3 cm intervals. The skin in-
cision is closed without drains. In the last 15 patients, NAC
position change was measured preoperatively and intraop-
eratively with the patient in the sitting position.
RESULTS
Thirty-four patients were identified, undergoing re-
position of 44 NACs (Table 1). Except for 1 patient who
underwent direct to implant reconstruction, all patients
underwent 2-stage tissue expander to implant reconstruc-
tion. All patients were nonsmokers. Average time between
nipple reposition and previous surgery was 115 days.
Thirty-three breasts used inframammary fold incisions for
nipple reposition and 37 had the entire flap undermined.
Nineteen breasts had undergone a nipple delay proce-
dure 2–3 weeks before mastectomy, as described by Jensen
et al.9 and others.10
Mean follow-up was 421 days. There was no incidence
of postoperative ischemia, necrosis, or seroma formation.
No implants required explantation. In cases where NAC
movement was measured, NAC could be reliably moved
up to 3 cm. Two patients underwent this procedure twice,
1 year apart, to readvance 2 NACs. The aesthetic outcome
was significantly improved in most patients (Figs. 2, 3),
except in breasts with severe malposition or inelastic skin
due to radiation.
DISCUSSION
NAC malposition can be a disappointing complication
following NSM. Nonetheless, accurate nipple placement is
sometimes elusive. The NAC position is dependent on the
interaction between the skin envelope and the underlying
breast mound and often migrates unpredictably during
healing and the expansion process.
Other authors have described treatment of NAC mal-
position using crescentic mastopexy, transposition flaps,
and free nipple grafts, all of which involve additional vis-
ible incisions.3–8 Our method treats the skin envelope as a
Video Graphic 1. Reelevation of the mastectomy flap to allow mo-
bilization of the NAC over the breast mound. This video is available
in the “Related Videos” section of the Full-Text article on PRSGlobalO-
pen.com or available at http://links.lww.com/PRSGO/A489.
Fig. 1. Elevation of the mastectomy ap from underlying muscle
and ADM. A new IMF incision is used to allow wider undermining.
Table 1. Patient and Mastectomy Flap/NAC Characteristics
Patient Characteristics (N = 34) Value (%)
Age (y)
Mean 46.3
Range 27–65
BMI (kg/m2)
< 25 21
25–30 10
> 30 3
ASA class
1 31
2 3
Comorbidities
Hypertension 5
Smoker 0
Mastectomy flap/NAC characteristics (N = 44)
Incision type for flap elevation
IMF 33 (75)
Other (Periareolar, lateral radial, supra areolar) 11 (25)
Number of NAC with prior delay procedure 19 (43.2)
Reconstructive surgery before NAC reposition
Immediate tissue expander placement 40
Delayed tissue expander placement 3
Immediate direct to implant placement 1
Time between initial reconstruction and NAC reposi-
tion (d)
114.9
Final implant volume (cc)
Mean 451
Range 255–650
Previous radiation 1
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
Zhang and Blanchet • Reelevating the Mastectomy Flap
3
distinct, mobile entity and moves the NAC by redraping
the mastectomy flap over the breast mound. This is typi-
cally performed during the second stage of a prosthesis-
based reconstruction. In our experience, the NAC could
be reliably moved up to 3 cm when the entire mastectomy
flap was undermined. Repeating this procedure to gain
more mobilization of the mastectomy flap is safe. Not all
patients will obtain satisfactory results from this proce-
dure. Those who have severe malposition or inelastic skin
will need other alternative procedures. In mild-to-moder-
ate cases of NAC malposition, this is a reasonable first-line
procedure, since ‘‘no bridges are burned.”
Previous authors may have avoided undermining the
NAC due to concerns regarding perfusion.6 We reason
that a surgical “delay” is performed during the initial
mastectomy, essentially creating a well-vascularized flap.
The senior author works with 5 different oncologic breast
surgeons with variable mastectomy skin flap thickness, so
we believe this is universally safe. Reelevating the skin en-
velope several months postmastectomy does not result in
further ischemic insult. None of the breasts in our series
developed ischemia or necrosis after undergoing NAC
and mastectomy flap reelevation. A formal nipple delay
procedure had been performed 2–3 weeks before the mas-
tectomy in 19 breasts. Although the rate of initial mastec-
tomy flap necrosis postmastectomy was lower in the delay
group, NAC repositioning did not cause ischemia in any
of the breasts that did not initially undergo a nipple delay.
This study’s shortcomings are its retrospective, non-
randomized nature and the variable degree of mastec-
tomy flap elevation. Although this technique has not yet
been performed in prepectoral implant reconstructions,
we believe it is applicable as well.
CONCLUSIONS
Reelevating the mastectomy skin flap to correct malpo-
sition of the NAC after NSM is a safe and effective option
and avoids additional scars. It allows redraping of the skin
envelope over the implant and does not threaten perfu-
sion of the nipple areolar complex. Its utility is limited by
Fig. 2. A, A 41-year-old woman 2 months after left NSM with immediate tissue expander and ADM placement, with moderate (2 cm)
superolateral displacement of the left NAC. B, Twelve (12) months after undergoing left tissue expander exchange for permanent gel
implants with repositioning of left NAC by elevation of entire mastectomy ap. Note the left implant now sits lower in the breast, which
typically raises the NAC position. By reelevating and redraping the left mastectomy ap, an improved NAC position can be achieved.
Fig. 3. A, A 65-year-old woman 3 months after bilateral NSM with immediate tissue expander and ADM placement, with severe (3 cm)
lateral displacement of the right NAC. B, Twelve (12) months after undergoing left tissue expander exchange for permanent gel implants
with repositioning of right NAC by elevation of entire mastectomy ap.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
PRS Global Open • 2017
4
the elasticity and availability of the skin envelope in the
opposite vector of desired NAC movement. This tech-
nique can reliably move the NAC up to 3 cm and can be
repeated to further improve NAC position.
Nadia P. Blanchet, MD
9210 Forest Hill Ave
Richmond
VA 23235
E-mail: nadia@nadiablanchet.com
REFERENCES
1. Sisco M, Kyrillos AM, Lapin BR, et al. Trends and variation in the
use of nipple-sparing mastectomy for breast cancer in the United
States. Breast Cancer Res Treat. 2016;160:111–120.
2. Metcalfe KA, Cil TD, Semple JL, et al. Long-term psychosocial
functioning in women with bilateral prophylactic mastectomy:
does preservation of the nipple-areolar complex make a differ-
ence? Ann Surg Oncol. 2015;22:3324–3330.
3. Spear SL, Albino FP, Al-Attar A. Repairing the high-riding
nipple with reciprocal transposition flaps. Plast Reconstr Surg.
2013;131:687–689.
4. Spear SL, Albino FP, Al-Attar A. Classification and management
of the postoperative, high-riding nipple. Plast Reconstr Surg.
2013;131:1413–1421.
5. Takayanagi S. Transposition of the malpositioned nipple-areola
complex in breast reconstruction with implants. Aesthetic Plast
Surg. 2010;34:52–58.
6. Small K, Kelly KM, Swistel A, et al. Surgical treatment of nipple
malposition in nipple-sparing mastectomy device-based recon-
struction. Plast Reconstr Surg. 2014;133:1053–1062.
7. Mohmand H, Naasan A. Double U-plasty for correction of geo-
metric malposition of the nipple-areola complex. Plast Reconstr
Surg. 2002;109:2019–2022.
8. Frenkiel BA, Pacifico MD, Ritz M, et al. A solution to the high-
riding nipple-areola complex. Aesthetic Plast Surg. 2010;34:525–
527.
9. Jensen JA, Lin JH, Kapoor N, et al. Surgical delay of the nip-
ple-areolar complex: a powerful technique to maximize nipple
viability following nipple-sparing mastectomy. Ann Surg Oncol.
2012;19:3171–3176.
10. Martinovic ME, Pellicane JV, Blanchet NP. Surgical delay of the
nipple-areolar complex in high-risk nipple-sparing mastectomy
reconstruction. Plast Reconstr Surg Glob Open. 2016;4:e760.
Revising Prepectoral Breast Reconstruction
Article
Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis’ unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author’s (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.
Breast Splint for Prevention of Nipple–areolar Complex Malposition after Direct-to-implant Breast Reconstruction
Article
  • Jan 2022
Breast reconstruction with immediate placement of breast implants (direct-to-implant methods) following nipple-sparing mastectomy has increased because of the low burden on the patient and good aesthetic results. However, nipple–areolar complex (NAC) malposition after this surgery remains a common complication that has yet to be entirely resolved. Here, we introduce an approach using Duoactive CGF to prevent postoperative NAC malposition. Immediate postoperative fixation of Duoactive CGF cranially to the NAC of the operated breast was applied for 2–4 weeks. This is referred to as a breast splint. In the study, nine patients who received breast splints and 15 patients who did not were enrolled. The NAC position on the splint-treated breast was compared with that on the healthy side within 6 months after surgery. A case with little visual malposition was defined as having a good outcome, based on the deviation in the cranial direction not exceeding the position of the contralateral NAC. Our preliminary data demonstrated that the rate of good outcomes was significantly higher (P = 0.028) in cases in which a breast splint was used, compared with those that were not treated with a breast splint (7/9, 78.8% versus 4/15, 26.7%). Postoperative application of a breast splint using Duoactive CGF is a simple and useful method to prevent NAC malposition after breast reconstruction, using a direct-to-implant method.
Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope
Article
  • Apr 2020
Background: Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction. Methods: A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-areolar complex necrosis and malposition following stage 2. Results: Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. Conclusion: Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. Clinical question/level of evidence: Therapeutic, IV.
Accurate Nipple Areolar Positioning in Nipple-sparing Mastectomy Reconstruction
Article
Full-text available
  • Jan 2019
Nipple-sparing mastectomy continues to grow in popularity as oncologic indications for preserving the nipple areolar complex have become less stringent and more patients with genetic predispositions to breast cancer seek aesthetically superior prophylactic mastectomy reconstructions. Nonetheless, nipple malposition remains a common and disturbing complication. This article proposes several anatomic variations that predispose to nipple malposition and a strategy to avoid it through a reliable, easily reproducible method of preoperative marking and intraoperative stabilization.
Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States
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Full-text available
PurposeFor many women, nipple-sparing mastectomy (NSM) provides aesthetic and quality-of-life outcomes superior to skin-sparing mastectomy. Accumulating data suggest that NSM provides similar oncologic outcomes in select breast cancer patients. This study sought to determine national trends in NSM use. Methods Using the National Cancer Data Base, 6254 women with breast cancer who underwent NSM between 2010 and 2013 were identified. NSM rates were determined relative to the number of patients who received a mastectomy with reconstruction (n = 114,849). Associations between patient, tumor, and facility characteristics and NSM were assessed using logistic regression. ResultsThe rate of NSM increased from 2.9 to 8.0 % between 2010 and 2013. NSM was most commonly performed in academic (adjusted odds ratio [OR] 1.43, p < 0.001) and high-volume (OR 1.59, p < 0.001) breast centers. There was up to a 5.8-fold variation in its delivery between geographic census regions (p < 0.001). Of 1231 hospitals, only 491 (39.9 %) reported performing at least one NSM during the study period. Half of all NSMs were performed by the top 6 % (n = 30) of NSM-performing centers. NSM was associated with small tumor size (p < 0.001), lower tumor grades (p < 0.05), and negative nodal status (p < 0.001). However, half of NSM patients had at least one tumor characteristic that diverged from current (2016) NCCN recommendations for the procedure. Conclusions The use of therapeutic NSM is increasing dramatically in the United States, despite recommendations that the procedure be used with caution. As NSM becomes increasingly common, efforts are needed to monitor its long-term oncologic outcomes and to ensure equitable access to it.
Surgical Delay of the Nipple–Areolar Complex in High-risk Nipple-sparing Mastectomy Reconstruction
Article
Full-text available
  • Jun 2016
As nipple-sparing mastectomy gains increasing popularity, minimizing the risk of nipple necrosis continues to be of critical importance to patients and surgeons. Patients with large or ptotic breasts, scars from previous cosmetic and/or oncologic breast surgery, or previous irradiation have often been denied nipple-sparing mastectomy (NSM) because of increased risk of nipple necrosis. A variety of interventions have been suggested to minimize the ischemic insult to the nipple-areolar complex (NAC). This article presents our experience in 26 high-risk patients with surgical delay of the NAC. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Long-Term Psychosocial Functioning in Women with Bilateral Prophylactic Mastectomy: Does Preservation of the Nipple-Areolar Complex Make a Difference?
Article
Full-text available
Nipple-sparing prophylactic mastectomy (PM) is an option for women at high-risk for breast cancer, and may offer better cosmetic results than a skin-sparing PM where the nipple-areolar complex (NAC) is removed. However, there may be residual breast cancer risk due to the maintained NAC. It is unclear if sparing the NAC with PM impacts on psychosocial functioning, including cancer-related distress and body image after PM. This was a cross-sectional survey study of women who had undergone bilateral PM (no previous breast cancer) recruited through surgical or cancer genetics clinics. All women completed standardized questionnaires assessing cancer-related distress, anxiety, depression, satisfaction with decision, decision regret, and health-related quality of life related to breast surgery. Outcomes were compared between women with nipple-areola-sparing PM (NAC-PM) and skin-sparing PM (SS-PM). Overall, 137 women completed the study; 53 (39 %) had NAC-PM and 84 (61 %) had SS-PM. The mean age of the study population was 41.5 years [standard deviation (SD) 8.8] and the mean time between PM and questionnaire completion was 50 months (SD 31). On the BREAST-Q, we found that women with NAC-PM had significantly higher levels of satisfaction with breasts (p = 0.01), satisfaction with outcome (p = 0.02), and sexual well-being (p < 0.001) compared with SS-PM. No statistically significant differences in total cancer-related distress (p = 0.89), anxiety (p = 0.86), or depression (p = 0.93) were observed between the two groups. Overall, women with NAC-PM had better body image and sexual functioning compared with women with SS-PM, while both groups had comparable levels of cancer-related distress and perception of breast cancer risk.
Abstract 47: Surgical Treatment of Nipple Malposition in Nipple Sparing Mastectomy Device-Based Reconstruction.
Article
  • Jan 2014
We report our senior author's experience with nipple-areolar complex (NAC) malposition following nipple sparing mastectomy (NSM), surgical options for treatment, and an analysis of risk factors. A retrospective review was conducted on a prospectively-collected IRB-approved database of NSM cases with immediate device-based reconstruction performed between July 2006 and October 2012. Malposition was graded as mild displacement (1cm), moderate (2cm), or severe (>3cm). 319 NSMs were reviewed. Malposition occurred in 13.79% (n=44). Significant factors were age (p<0.0001), diabetes mellitus (p=0.0025), body mass index (p=0.0093), preoperative sternal notch to nipple distance (p=0.015), preoperative breast base width (p=0.0001), peri-areolar mastectomy incision with lateral extension (p <0.0001), prior radiation therapy (p=0.0004), prior ipsilateral lumpectomy (p=0.0125), unilateral NSM (p=0.0004), and postoperative NAC ischemia (p=0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant.19/44 malposition cases were satisfied. 8/44 cases were not offered surgical correction because of an inadequate skin envelope. 8/44 cases had crescent mastopexy, 3/44 had implant exchange and pocket revision, 4/44 had free nipple grafts, and 2/44 had pedicled nipple transposition. 2/44 had nipple excision and reconstruction secondary to recurrence. There were no incidences of necrosis or malposition after surgical correction. NSM followed by immediate device-based reconstruction has an identifiable risk of nipple malposition. We found several risk factors to be significantly associated with nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in a well-selected population.Level of Evidence: II / III.
Repairing the High-Riding Nipple with Reciprocal Transposition Flaps
Article
  • Apr 2013
The high-riding nipple-areola complex is a clinical problem that can be encountered following cosmetic and reconstructive breast surgery. Because of the desire to avoid scars on the superior aspect of the breast and the limited availability of superior breast skin, it can be technically challenging to place the nipple-areola complex in a lower position. Multiple surgical strategies have attempted to lower it, and each has its advantages and disadvantages. Reciprocal rotation flaps have been used by the authors with success. They describe the surgical technique and outcomes in five breasts. The medical records of all patients who had reciprocal rotation flaps for high-riding nipple-areola complexes performed by the senior author (S.L.S.) were reviewed. The institutional review board-approved review included preoperative history and examination, surgical findings, surgical technique, and postoperative course. Five reciprocal rotation flap procedures were performed on four patients between 2005 and 2012 for high-riding nipple-areola complexes. The high-riding nipple-areola complexes were all iatrogenic, following reconstruction for nipple-sparing mastectomy or mastopexy. All nipple-areola complexes were successfully lowered with an average follow-up duration of 2.1 years. One breast that had undergone previous radiation therapy had a nipple-areola complex flap that appeared ischemic; the patient underwent hyperbaric oxygen therapy and the flap fully survived. Reciprocal rotation flaps are an effective strategy for management of the high-riding nipple-areola complex and can be safely performed with thoughtful planning and careful surgical technique. This technique is riskier in the irradiated breast but may be facilitated with hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.
Classification and Management of the Post-Operative, High-Riding Nipple.
Article
  • Feb 2013
Background: Postoperative nipple malposition can be an aesthetically devastating problem for patients and a formidable challenge for surgeons. The authors' aim was to identify the common antecedent events leading to high-riding nipples, provide a classification system for these problems, and discuss management. Methods: A retrospective review of medical records was conducted for patients who presented to the senior surgeon (S.L.S.) for management of a postoperative, excessively high nipple-areola complex over an 8-year period from January of 2004 to March of 2012. Demographic information, medical histories, operative details, and office records were reviewed for each patient. The high nipple-areola complex was classified as mild, moderate, or severe depending on the distance from the superior breast border to the top of the nipple-areola complex in relation to the vertical breast height. Results: Twenty-five women met study criteria, with 41 breasts determined to have an excessively high nipple-areola complex. The average patient was aged 44.3 years and had undergone 2.5±1.3 operations before the development of a notably high nipple-areola complex, including nipple-sparing mastectomy (32 percent), augmentation/mastopexy (29 percent), augmentation (27 percent), mastopexy (10 percent), and skin-sparing mastectomy with nipple reconstruction (2 percent). Patients were classified as having mild (27 percent), moderate (56 percent), or severe (17 percent) nipple-areola complex displacement; surgical correction was attempted in 54 percent of cases. Conclusions: A high-riding nipple-areola complex can develop following aesthetic or reconstructive surgery. Although many patients may not need or choose correction, there are surgical options that may be helpful in improving the nipple-areola complex position.
Surgical Delay of the Nipple-Areolar Complex: A Powerful Technique to Maximize Nipple Viability Following Nipple-Sparing Mastectomy
Article
Nipple-sparing mastectomy (NSM) improves cosmetic outcome of mastectomy, but many patients are not candidates for this procedure because of concerns about nipple-areolar viability. Surgical delay is a technique that has been used for more than 400 years to improve survival of skin flaps. We used a surgical delay procedure to improve nipple viability in patients who were identified to be at high risk for nipple necrosis following NSM. Patients at high risk for nipple necrosis following NSM underwent a surgical delay procedure 7-21 days prior to mastectomy. Subareolar biopsy and sentinel node biopsy, if indicated, were performed at the time of the delay procedure. Nipple viability was assessed before and after NSM. If the subareolar biopsy revealed malignancy, the NAC was removed at the time of mastectomy. 31 NAC in 20 patients underwent surgical delay. All of the NAC subjected to a surgical delay survived following the delay procedure. In 2 patients, the subareolar biopsy was positive and 3 NAC were removed at the time of mastectomy (1 for purposes of symmetry). Of the 28 delayed NAC left at the time of NSM, all survived the post-mastectomy course. A procedure to surgically delay the NAC 7-21 days prior to NSM is demonstrated to ensure viability of NAC in patients previously thought to be at high risk for nipple loss.
A Solution to the High-Riding Nipple-Areola Complex
Article
There are limited techniques described in the literature on how to lower the nipple-areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty. © 2010 Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery.
Transposition of the Malpositioned Nipple-Areola Complex in Breast Reconstruction with Implants
Article
The goal of breast reconstruction after breast cancer is to obtain symmetrical breasts, including the nipple-areola complex. However, in some cases the nipple-areola complex may not be symmetrical even though a symmetrical breast shape has been created. In such cases the nipple-areola complex has been transpositioned, leaving a scar to close the wound or skin graft in the original position. To treat this problem, skin surrounding the areola is removed and two pedicles are created to bear the nipple-areola complex. The nipple-areola complex is then moved to the proposed position and the surrounding circular edge of the skin is closed using a purse-string suture. The author performed this technique in three nipple-areolae of two patients. All the nipple-areolae were transposed to the proposed position to create symmetrical breasts without any complications. This technique can be used when the malpositioned nipple-areola complex is not too far from the proposed position. The nipple-areola complex can be moved without leaving any scar at the original position of the complex.
Double U-Plasty for Correction of Geometric Malposition of the Nipple-Areola Complex
Article
A simple, permanent, and accurate technique of repositioning the nipple-areola complex is presented here derived from the principle of Z-plasty. This method allows correction of a malpositioned nipple-areola complex in all axes with acceptable results. It can also potentially preserve better cutaneous sensation and the function of the ductal system of nipples in younger patients, provided a careful dissection is performed.