Long-term Result of Nipple Reconstruction Using Skate Flap after Breast Reconstruction
Deok Yeol Kim, M.D.1, Eun Sang Dhong, M.D., Ph.D.1, Eul Sik Yoon, M.D., Ph.D.1, Gil Su Son, M.D., Ph.D.2 Departments of 1Plastic and Reconstructive Surgery, 2General Surgery, Korea University College of Medicine, Seoul, Korea Purpose: A number of flap for nipple reconstruction have been well described in the literature. However, most of these techniques do not permit the reconstruction of a projecting nipple and all are hampered to some extent by long-term loss of nipple projection. The objective of this study is to evaluate the long-term result and clinical efficacy of nipple reconstruction using skate flap technique after breast reconstruction.
Methods: A retrospective chart review was carried out on 23 patients who underwent 25 nipple reconstructions. In those patients with greater than 10 mm nipple projection, reconstruction with skate flap and full-thickness skin graft and/or tattooing was performed. Maintenance of nipple projection was then carefully assessed over one-year follow-up. The following factors were analyzed: type of breast reconstruction, type of areola reconstruction, follow- up period, decrease in nipple projection, complication, and whether secondary nipple reconstruction was necessary and/or performed.
Results: Breast reconstructions were performed in 17 patients with free transverse rectus abdominis musculo- cutaneous flap, 3 patients with extended latissimus dorsi musculocutaneous flap, and 3 patients with expander and implant. The mean follow-up after nipple reconstruction was 17 months. Mean loss of projection were 17.0 ± 13.99%, 25.0 ± 12.70%, 30.0 ± 12.57% and 30.8 ± 12.49% at 3, 6, 9 months and over one year, respectively. The greatest decrease in projection was noted in the first 3 months
following surgery.
Conclusion: These results indicated that nipple recon- struction with skate flap showed about 70 percent of the projection achieved over one year postoperation. There- fore, the skate flap may be a reliable method of nipple reconstruction in those patients with greater than 10 mm nipple projection.
Key Words: Nipple reconstruction, Skate flap, Breast reconstruction
I. INTRODUCTION
Reconstructing the nipple-areola complex is pivotal in breast reconstruction for psychological and cosmetic satisfaction. Numerous literatures stated that the presence of the nipple and areola considerably affected patient’s satisfaction of the breast reconstruction and played a key role in patient’s self image and quality of life after the surgery.
Many techniques have been introduced for the nipple reconstruction in the past 30 years. The most commonly used techniques consist of local flaps without damage to the contralateral nipple. Various “pull-out” flaps from the breast tissue such as CV, bell, and star flaps have been recently reported. Projection of the nipple, however, was decreased after the surgery as time elapses in most cases. Approximately 30~50% of resorption depending on surgical methods was reported.1-4For this reason, nipples are recreated bigger than desired size. To achieve this, more severe defect is created in the donor site and the reconstructed breast is deformed. Consequently, results of the breast and nipple reconstruction are somewhat disappointing.
A skate flap was introduced to overcome the draw- backs of the local flaps.5 Primary closure is possible and sufficient nipple size can be maintained with the skate flap. However, Long-term follow-up study of the nipple reconstruction with the skate flap after the breast reconstruction is scarce. This study aimed to evaluate outcomes of the nipple reconstruction by the skate flap after breast reconstruction for 1 year or more.
Received November 26, 2010 Revised May 20, 2011 Accepted May 23, 2011
Address Correspondence : Eul Sik Yoon, M.D., Ph.D., Depart- ment of Plastic and Reconstructive Surgery, Ansan Hospital, Korea University Medical Center, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do 425-707, Korea. Tel: 031) 412-5070/
Fax: 031) 475-5074/E-mail: yesanam2@korea.ac.kr
유방재건 후 Skate 피판을 이용한 유두재건술의 장기추적결과
김덕열1 동은상1 윤을식1 손길수2
고려대학교 의과대학 성형외과학교실1, 외과학교실2
II. MATERIALS AND METHODS
A. PatientsThis study retrospectively investigated 23 patients whose nipples were recreated with the skate flap after the breast reconstruction with free transverse rectus abdominis musculocutaneous flap, extended latissimus dorsi musculocutaneous flap, or tissue expander and implant between October 2002 and February 2009. Subject selection criteria were as follows: patients treated with mastectomy for breast cancer; 1 year or longer follow- up; and 10 mm or more projection of the contralateral nipple irrespective of the areola projection.
B. Operative Technique
The position of the nipple was determined by the distance from the sternal notch to the contralateral nipple in the upright or standing position for the symmetry of right and left nipples. Flap was designed to reconstruct the nipple slightly bigger than contralateral side (Fig. 1, 2). The nipple-areola complex was reconstructed in two ways: in early cases, nipple reconstruction by the skate flap and areola reconstruction with full-thickness skin graft from groin area were simultaneously performed (Fig. 3); in latter cases with the introduction of micro- tattooing, donor site was primarily closed after the nipple reconstruction with the skate flap (Fig. 4) and the areola
was reconstructed with the micro-tattooing at 8 weeks after the nipple reconstruction (Fig. 5). Darker shade of the areola was reproduced considering post-operative discoloration when compared with the shade of the contralateral areola. Micro-tattooing was conducted with a tattooing machine (Fig. 6; MediUm-TECH; MT.DERM GmbH, Berlin, Germany).
Local anesthesia was administered during the surgery except in micro-tattooing. Sutures were taken out 10 to 14 days after full-thickness skin graft was completely healed. Antibiotic ointment was applied after micro-tat- tooing for 5 to 7 days.
C. Data Collection
Method of the breast reconstruction, follow-up period after the nipple reconstruction, change of height and width of nipple, method of areola reconstruction, com- plications, and presence or absence of additional surgery were reviewed. For standardization of the result, two plastic surgeons trained for the measurement of nipple projection recorded the data at room temperature when patients were standing. The projection of both nipple were measured with a caliper immediately after surgery, at 3, 6, 9 months, and followed by every 6-month exami- nation. The reduction rate of nipple was calculated and represented as the mean ± standard deviation.
III. RESULTS
25 nipple reconstruction cases by the skate flap in 23 patients were retrospectively investigated using medical record. Patients’ age at the time of surgery ranged from 30 to 62 years with mean age of 44 years.
Follow-up period ranged from 16 months to 28 months (mean, 17 months). The nipple reconstructions were Fig. 1. Schematic illustrations of the skate flap.
Fig. 2. Intraoperative design of the skate flap.
performed between 3 months to 6 months (mean, 4.5 months) after the breast reconstruction. Breast reconstruc- tion was carried out by free transverse rectus abdominis musculocutaneous flap in 17 patients, by extended latissimus dorsi musculocutaneous flap in 3 patients, and by expander and implant in 3 patients (Table I).
The nipple-areola reconstruction was performed on single side in 21 patients and both sides in 2 patients.
Average diameter of the reconstructed areola was 35
mm. Projection of reconstructed nipple was slightly greater than the contralateral side with an average of 16 mm. Decrement rate of the nipple projection was 17.0 ± 13.99% at 3 months, 25.0 ± 12.70% at 6 months, 30.0 ± 12.57% at 9 months, and 30.8 ± 12.49% over one-year follow up with the biggest value found at 3 months (Table II). Projection of the nipple was main- tained after 9 months (Fig. 7). Additional surgery of the nipple-areola reconstruction was conducted in 3 Fig. 3. (Above) A 35-year-old female with left breast cancer. After skin sparing mastectomy, breast reconstruction using free transverse rectus abdominis musculocutaneous flap was performed. (Center) After 4 months later, nipple-areola complex was reconstructed with skate flap and full thickness skin graft. (Below) Photographs at 15 months after breast reconstruction.
patients for the following reasons: wound dehiscence;
partial flap necrosis; and partial necrosis of skin graft.
The wounds were conservatively healed after local debridement in all of these cases.
With respect to the method of the breast reconstruc- tion, the mean height of nipple over one year after the reconstruction were 11.2 mm, 11.0 mm, and 10.6 mm when free transverse rectus abdominis musculocutane- ous flap, extended latissimus dorsi musculocutaneous flap, and expander and implant were used for breast reconstruction, respectively, and the mean height of nipple was 10.7 mm when complications were noted.
IV. DISCUSSION
Reconstruction of nipple-areola complex is psycholo- gically and cosmetically as crucial as breast reconstruc- tion to breast cancer patients. Patient satisfaction of the breast reconstruction was greater when nipple-areola complex was recreated. Presence of the nipple-areola
Variable No.
No. of skate flap 25
Mean age of surgery, years 44
Mean interval after breast reconstruction, months 4.5
Mean follow-up period. months 17
Methods of breast reconstruction
Free TRAM* flap 17
Extended LD flap 3
Expander/implant 3
*: TRAM, transverse rectus abdominis musculocutaneous, : LD, latissimus dorsi musculocutaneous.
Table I. Patients of Nipple Reconstruction Using Skate Flap
Fig. 4. Immediate postoperative photographs. (Left) Front view demonstrates a primary closure of the donor site was done.
(Right) Lateral view. The skate flap makes a favorable height of the nipple.
Fig. 5. (Left) A 41-year-old woman with right breast cancer. After skin sparing mastectomy, breast reconstruction using free transverse rectus abdominis musculocutaneous flap was performed. After 4 months later, nipple was reconstructed with skate flap. And then, after 2 months later, tattooing was performed. (Right) Photograph at 18 months after breast reconstruction.
complex assures patients to recognize that their recon- structed breast as an actual part of their body and not just mimicked form of the breast.6,7Successful reconstruc- tion of nipple-areola complex leads to more natural appearance and more patient satisfaction. Therefore, reconstruction of nipple-areola complex completes the breast reconstruction.
Success of nipple-areola complex reconstruction
depends on the position, exterior form, size, and projec- tion. Reconstruction is regarded as successful when recreated nipple and areola is natural and located symmetrical to the contralateral side with similar size and texture. Unfortunately, although the shape, texture, color, and sensory of nipple were considered during reconstruction, perfect reconstruction of the nipple is almost impossible.
Patient Immediate postoperative projection (mm)
3 mo postoperative 6 mo postoperative 9 mo postoperative Over 1 yr postoperative Projection
(mm) Reduction
(%) Projection
(mm) Reduction
(%) Projection
(mm) Reduction
(%) Projection
(mm) Reduction (%)
1 15.8 10.4 34.2 9.5 39.9 9.0 43.0 8.9 43.7
2 15.6 9.8 37.2 9.4 39.7 8.9 42.9 8.8 43.6
3 15.4 15.0 2.6 14.1 8.4 13.1 14.9 13.1 14.9
4 15.5 14.3 7.7 11.8 23.9 9.8 36.8 9.8 36.8
5 15.2 10.2 32.9 9.1 40.1 8.7 42.8 8.6 43.4
6 15.6 13.8 11.5 10.9 30.1 9.9 36.5 9.7 37.8
7 16.5 10.6 35.8 9.9 40.0 9.4 43.0 9.3 43.6
8 15.8 15.4 2.5 14.9 5.7 14.4 8.9 14.4 8.9
16.2 11.0 32.1 10.2 37.0 9.8 39.5 9.6 40.7
9 16.1 15.4 4.3 14.6 9.3 14.3 11.2 14.2 11.8
10 16.1 15.2 5.6 13.2 18.0 10.3 36.0 10.2 36.6
11 16.1 11.9 26.1 11.2 30.4 9.9 38.5 9.8 39.1
12 16.4 10.7 34.8 10.3 37.2 9.9 39.6 9.7 40.9
13 15.4 14.3 7.1 13.1 14.9 12.6 18.2 12.5 18.8
14 16.1 15.7 2.5 14.5 9.9 13.2 18.0 13.1 18.6
15 16.2 11.2 30.9 10.1 37.7 9.8 39.5 9.6 40.7
16 15.6 14.8 5.1 13.2 15.4 12.3 21.2 12.1 22.4
17 15.6 11.1 28.8 9.9 36.5 9.4 39.7 9.3 40.4
18 16.5 16.2 1.8 14.0 15.2 13.5 18.2 13.3 19.4
19 16.8 16.3 3.0 14.7 12.5 13.8 17.9 13.5 19.6
20 16.2 13.6 16.0 10.9 32.7 10.3 36.4 10.1 37.7
21 17.0 10.3 39.4 10.3 39.4 9.1 46.5 9.1 46.5
15.9 15.5 2.5 14.1 11.3 13.5 15.1 13.3 16.4
22 16.3 15.9 2.5 15.3 6.1 14.9 8.6 14.6 10.4
23 16.4 13.4 18.3 10.9 33.5 10.4 36.6 10.3 37.2
Mean 16 (mm) 17.0 (%) 25.0 (%) 30.0 (%) 30.8 (%)
SD* 13.99 12.70 12.57 12.49
*: SD, standard deviation
Table II. Results of Nipple Reconstruction Using Skate Flap
In addition, reconstructed nipples are resolved as time passes due to lack of supporting anatomical structure and scar contracture. So various local flaps such as star, bell, double opposing tab, CV, T, S, quadrapod flap are introduced to overcome shrinkage and decrease of the nipple projection.1-4,8-10 However, surgical protocol to reconstruct naturally looking nipple and areola similar to the contralateral side is not established yet.10
For nipple reconstruction, the authors used the CV flap when less than 10 mm of nipple height was desired, and the skate flap in case of that greater than 10 mm of the nipple height was required. The nipple-areola complex was initially designed symmetrical to the contralateral side with an average areola diameter of 40 mm and an average nipple height of 15 mm, that was bigger than Korean women’s average nipple size considering the post-operative shrinkage of the reconstructed nipple.
According to Lee et al, Korean women’s average areola diameter and nipple height were 30.9 mm and 6.5 mm, respectively.11Previous literatures reported of the post- operative shrinkage after the nipple reconstruction with various local flaps. Lee et al. reported that the nipple height was decreased to 50% of the original height.1 Nahabedian et al. reported of decrease to 52% of the original height.2Loss of nipple was observed in 32.5%
of cases performed with CV flap according to Ahn et al.3In this study, nipple reconstruction using skate flap technique showed about 30% of shrinkage, which is clinically tolerable and may be effective as other recon- struction methods.
Causes of the postoperative nipple projection decrease include inadequate subcutaneous tissue, pressure from inside and outside, improper flap design, and necrosis of the flap. Because relatively thin skin flap is elevated in the traditional CV flap, the CV flap is advantageous if 10 mm or less nipple projection is required. But blood supply is impaired potentially and it is hard to obtain sufficient amount of nipple tissue with the CV flap than other local flaps.12Consequently, when 10 mm or more nipple projection is to be reconstructed, the skate flap is a better option. The skate flap maintains adequate size and volume using sufficient amount of skin and sub- cutaneous tissue.13And blood supply is also facilitated because more dermal arterial network is present. Although the nipple projection was decreased, it was maintained stable after 9 months postoperation. It means that the skate flap is reliable for the nipple reconstruction in terms of maintaining the stable outcome.
To minimize loss of the nipple projection, base of the nipple should be reconstructed to be wider. And also, it is important to prevent deformation of the reconstructed breast by minimizing scar formation with primary Fig. 6. Photographs of micro-tattooing device.
Fig. 7. Mean decrease in projection of reconstructed nipple at 3 months, 6 months, 9 months and over one year post- operation. The greatest decrease in projection was noted in the first 3 months after surgery. Although the nipple projection was decreased, it was maintained stable after 9 months postoperation.
closure of the donor site. Loss of the nipple from exces- sive tension of suture should be avoided. Scar tissue should be excluded in the flap to enhance blood supply.
Especially if breast is reconstructed with expander and implant, it should be dealt with great care because of thinner skin flap and insufficient blood supply on the contrary to the free transverse rectus abdominis muscu- locutaneous flap technique. Patient should be advised of possible reduction in the nipple projection due to scars and interference of blood supply when complications arise after breast and nipple reconstruction.
Nipple reconstruction is usually performed 3 to 6 months after the surgery when the size and shape of the breast is completely settled and flap is stabilized. This time-schedule is advantageous because patient and doctor can actively participate in the ideal form of the nipple after breast reconstruction and secondary breast reconstruction surgery can be simultaneously conducted.
If it is conducted earlier, shape of the breast or nipple can be deformed due to the interference with blood supply of the flap maturation and scar contracture. Color of the areola can now be reproduced similar to the contralateral areola using micro-tattooing. Micro-tattooing has several advantages: it does not involve donor site;
procedure time is shorter than full-thickness skin graft technique; it does not require compressive dressing, so blood supply to the nipple is facilitated; and it is essen- tially tension-free because suture is not necessary.
Therefore micro-tattooing is relatively simple and effective method.14 Although discoloration after the procedure is mentioned as a drawback, desirable color can be reproduced with one grade darker shade than the final one.15
V. CONCLUSION
When more than 10 mm of nipple projection was required, nipple reconstruction with the skate flap showed about 70 percent of the projection achieved over one year after surgery. In conclusion, the skate flap may be a reliable method of nipple reconstruction
in those patients with greater than 10 mm nipple projection.
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