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It is well known that nipples reconstructed using local tissue flaps slowly flatten. Furthermore, patients with implant reconstruction show the highest amount of nipple projection loss.
This article describes some modifications to the technique proposed by Thomas et al in order to maintain flap projection.
We undertook a prospective study to evaluate the effectiveness of our technique, named ‘arrow flap’. We compared a series of patients with unilateral breast reconstruction (16 implants, 16 TRAM flaps) who underwent nipple reconstruction using either the ‘modified star flap’ or the ‘arrow flap’. The statistical significance of the results was determined by Student's t test.
The arrow flap proved to have a higher residual projection and these results were statistically significant. Furthermore, it has been equally useful on implant and autologous reconstructions. This technique is easy to learn and to perform. The procedure is reliable and patient satisfaction and compliance are very good.
Nipple/areola reconstruction is a minor surgical procedure representing the final surgical act of breast reconstruction.
Various techniques are used to reconstruct the nipple. Local flaps seem to give better results, in terms of morphologic results, scars and patient acceptance, than grafts. Drawbacks of these procedures are excessive nipple flattening and difficulty of nipple reconstruction in implant-reconstructed breasts due to the low amount of subcutaneous fat. The modified star flap
is an easy and reliable method to reconstruct the nipple, although the technique itself gives poorly predictable long-term nipple projection. Thomas et al
proposed a technique that has seemed to be easier to plan and master, shortening the surgical learning curve.
This article describes some modifications to the Thomas technique, intended to decrease nipple flattening and improve flap stabilisation, even in implant-reconstructed patients.
In a prospective study, we compared a series of patients who underwent nipple reconstruction using either the ‘modified star flap’
They noted that nipple projection gradually decreases over time, but it stabilises after approximately one year.
2. Patients and methods
Over the study period, 32 patients with unilateral breast reconstruction (16 implants, 16 TRAM flaps) were followed prospectively. Patients ranged from 23 to 64 years of age. Thirty-two nipple reconstructions were performed between January 2000 and March 2001, 5–7 months after breast reconstruction. Implant reconstructions were randomly assigned to subgroups A1 and B1, whereas TRAM flap reconstructions to subgroups A2 and B2. Thus, groups A and B were formed by summing up patients of subgroup A1 and A2, and those of subgroup B1 and B2, respectively.
The modified star flap was used to reconstruct nipples of group A patients, and the arrow flap was used in group B.
Areola reconstruction was performed either immediately (25 cases) or in a second stage (7 cases), and either with graft from the upper inner thigh (27 cases) or with tattooing (5 cases), as preferred by the patient.
Nipple localisation and size were based on the contralateral nipple and patients' desire. The position was then confirmed by standard measurements.
Surgical techniques: Procedures are performed by using local anaesthetic with 1: 200.000 epinephrine.
In group A patients, the modified star flap was performed as described by Eskenanzi.
It consists of two wings, a central cap and a base. Wings and body of the flap may be elevated with a variable amount of fat, depending on the desired final volume.
In group B patients, preoperative marking was performed following the Thomas principles.
The nipple can be considered as a cylinder that is a three-dimensional structure. It can be broken down geometrically by unfolding it in to a two-dimensional structure. Acting in this fashion, we will obtain a rectangle and a circle attached to a rectangle mid-portion. The circle has a diameter equal to D(2r). Its circumference is equal to 2πr(=πD). The rectangle has a width equal to πD, and a height equal to that of the cylinder (equal to nipple projection). This pattern represents the basis for nipple reconstruction.
Our modifications include (Figure 1, Figure 2) : (1) marking a triangular area above the circle that does not overstep the proposed areola site. This area will be deepithelised, and then elevated, united to the circle area (flap cup); (2) one side of the rectangle will be marked as an arrow point, while the other side as an arrow tail; (3) the arrow tail will be deepithelised, leaving the dermis united to the rectangle; (4) when elevating the flap, just a little superficial subcutaneous fat will be left under the flap components (cup, triangular dermal area and wings) to preserve sub-dermal blood supply; any excess fat will be trimmed off.
Figure 1(A) Flap design. (B) Lateral view and dimensions of contralateral nipple. (C) Lateral three-dimensional aspect of the reconstructed nipple.
The rectangle height is 150% of the final required nipple projection.
The flap pedicle is centrally located, on the opposite side of the rectangle–circle juncture, with a width almost equal to D. Care must be taken not to incise it.
The flap donor site is closed subcutaneously using 5/0 interrupted polyglactin 910.
After elevation, the dermal triangular flap is folded under the cup and covered by flap wings. Then, the point and the tail of the arrow flap are fixed together by three 6/0 nylon sutures: one central with a three-corner stitch, two lateral with interrupted stitches (Fig. 1(C)). Finally, the cup is fixed to the wings and the flap base to the surrounding skin by using interrupted 6/0 nylon sutures.
Either flap can be based in any direction as local scarring dictates to increase flap reliability.
Finally, the flap donor site is covered by a full-thickness skin graft from the upper inner thigh, or it is closed using 5/0 external interrupted nylon and is grafted or tattooed during a second procedure after healing is complete.
The same observer measured projection of reconstructed nipples after 1 week, and after 1, 3, 6 and 12 months.
The percentage of residual projection of each nipple was calculated based on its initial and final projections. Then, the mean percentage of residual projection of each group and of each subgroup was calculated.
Thus, we compared mean percentages of groups A and B, of subgroups A1 and A2, and of subgroups B1 and B2, and the statistical significance of differences was determined by Student's t test.
3. Results
In group A, the mean percentage calculated from the residual projection percentage of each nipple was 34.3%, and the mean nipple projection was 3.25 mm. In group B, the mean percentage was 49.1%, and the mean nipple projection was 4.75 mm. The difference between mean percentages of groups A and B was statistically significant (p<0.001, Table 1A) .
Table 1The statistical significance of differences between mean residual projection percentages of groups and subgroups was determined by Student's t test
Group (technique)
No.
Mean residual projection (%)
SD
SE
1A. Residual projection of reconstructed nipple after 12 months (p=5.34215E−08, assuming unequal variances)
A (modified star flap)
16
34.3
6.1
1.5
B (arrow flap)
16
49.1
5.5
1.4
Subgroup
1B. Residual projection of group A reconstructed by the modified star flap after 12 months (p=0.002400742, assuming unequal variances)
A1 (implant)
8
30.1
3.4
1.2
A2 (TRAM)
8
38.5
5.2
1.8
1C. Residual projection of group B reconstructed by the arrow flap after 12 months (p=0.962190436, assuming unequal variances)
When comparing nipples created on breasts reconstructed with different methods (implant vs. TRAM), the difference between mean percentages of subgroups was significant in group A (p<0.01, Table 1B), but it was not in group B (p>0.05, Table 1C).
To date, there have been no complications or need for revision.
4. Discussion
In the literature, many techniques are used to recreate the nipple. They should both restore projection and pigmentation of the contralateral nipple, and obtain patient satisfaction and compliance. Nipples reconstructed with local flaps slowly flatten. This phenomenon is due to different forces, in particular to skin surface tension, to the retracting action of scar tissue, to soft tissue absorption and necrosis, and to the compression by clothing or firm-fitting bra.
At the present day, many surgical procedures are in use.
Most options are some variant of local tissue flaps. The skate flap
is similar to the skate flap. They differ because, in the former, the flap design is similar to a star and wings flap are raised full-thickness, including skin and subcutaneous tissue instead of only the dermis. The C–V flap technique
uses two V flaps as wings and a C flap as cup. Both the star flap and the C–V flap do not need skin grafting to the donor site, unlike the skate flap. Thomas simplified flap planning on the basis of a geometrical analysis. His technique is easier to master, shortening the learning curve.
All these techniques include subcutaneous tissue to obtain volume and projection, and to increase pedicle reliability. The drawback is that fat is absorbed with time, causing flap flattening. Furthermore, patients with a tightly expanded breast mound have thinner subcutaneous fat, due to tissue expansion and compression. These patients show the greatest amount of nipple projection loss.
Moreover, the presence of a vertical scar along the reconstructed nipple tends to retract it with projection loss.
Final nipple projection is influenced by local tissue characteristics, in particular by the amount of flap dermis and fat. The former, formed by collagen fibres, hyaluronic acid, and fibrocytes, is more stable with time. The latter, formed essentially by fat cells, tends to necrotise and to be reabsorbed with time. On the basis of this analysis, we elevate the arrow flap on a sub-dermal plane. To obtain volume and projection, we increase the amount of dermis of the flap without enclosing in it any excess subcutaneous fat. This procedure has proved to be reliable because the blood supply to the nipple flap is primarily sub-dermal.
Our results show that nipples reconstructed by the arrow flap, compared to those reconstructed by the modified star flap, maintain a better projection after one year (Table 1A, Figure 3, Figure 4, Figure 5) .
Figure 3Preoperative marking (left) and one year follow-up views of left nipple reconstruction of patient of Figure 2 with pedicle TRAM flap breast reconstruction.
of 28.7% with the modified Anton-Hartrampf technique (mean follow-up time 38.7 months).
These improvements are probably due to modifications made to the Thomas technique. In particular, the dermal prominence of the flap is not resorbed and it remains more stable, whereas the amount of fat necrotised and reabsorbed is minimal. Furthermore, a ‘V’ interrupts the scar, preventing nipple retraction.
Moreover, the difference is not statistically significant when comparing residual projection of nipples on implant and on TRAM flaps reconstructions (Table 1C). Banducci et al
noted that the difference in degree of shrinkage between nipple reconstructed on implant and autologous tissue was significant. Other authors did not see a statistically significant difference in projection of nipples created on breast reconstructed with different methods.
No one has explained this phenomenon. We have noted that projection loss occurs in reconstructed nipples of small size. Those created on breasts with implants are often small, because subcutaneous tissue is very thin. We have obtained nipples as big as required using the arrow flap even on breasts with implants, and this could explain why there is no difference in residual projection if compared to nipples reconstructed on autologous tissue.
Our modifications to the Thomas technique seem to improve flap stabilisation and evolution. Incorporating these technical modifications, we do not need to plan wider flaps to achieve volume and projection. Thus, less distortion will be created on the breast mound.
Acknowledgements
The authors would like to thank Ms N. Sale for her technical support in drawing the illustrations of the technique.
References
Eskenanzi L
A one-stage nipple reconstruction with the ‘Modified Star’ flap and immediate tattoo: a review of 100 cases.
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