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

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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.
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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
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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
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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.