Nipple-Areola Complex Reconstruction after Postmastectomy Breast Reconstruction in Taiwanese Females

J Med Sci 2005;25(3):125-130 http://jms.ndmctsgh.edu.tw/2503125.pdf Copyright 2005 JMS Shyi-Gen Chen, et al. Nipple-Areola Complex Reconstruction after Postmastectomy Breast Reconstruction in Taiwanese Females Shyi-Gen Chen 1*, Jyh-Cherng Yu 2, Tim-Mo Chen 1, and Hsian-Jenn Wang 1 1 Division of Plastic and Reconstructive Surgery, 2 Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China Background: Breast reconstruction plays an important role to regain a semblance of lost breast due to mastectomy, rebuild body image, restore femininity, and to provide psychosocial benefits. Nipple-areola reconstruction is an integral part of breast reconstruction and has important symbolic and aesthetic implications. This study evaluated the results and patient's satisfaction of nipple-areola reconstruction using a badge flap and intradermal tattoo in Taiwanese females. Methods: This was a prospective study based on 3-year experience of 16 nipple-areola reconstructions in 15 patients with autologous breast reconstruction. The diameter of the new nipple was equal to the opposite native nipple or in accordance with the patient s wishes, the badge flap was trapezoid in shape and its length was calculated mathematically (L=2πr) while its width formed the height of the future nipple. Tattooing after the new nipple properly healed completed the areola. Results: All flaps survived well with good contour and symmetry. There was no partial necrosis or other complications. The new nipple kept 67.3% projection within 25.7 months follow-up (range 12-39 months). The pigmentation was determined by patients questionnaire with a rating 8.4/10. The overall satisfaction rate was 91.5%. Conclusions: This novel badge flap with intradermal tattoo is a simple and reliable flap for nipple areola reconstruction; it gives patient good psychological support and a very good aesthetic result with inconspicuous donor scar. Key words: badge flap, breast cancer, breast reconstruction, mastectomy, nipple reconstruction, tattoo INTRODUCTION Breast cancer is the leading type of cancer in women in western countries 1. The incidence of breast cancer is also increasing rapidly in Taiwan 2. Breast reconstruction has increased in popularity, not only for regaining body image, restoring femininity, but also because of its psychosocial benefits 3. Nipple-areola complex reconstruction is often the final stage of breast reconstruction and has important symbolic and aesthetic implications. Nipple-areola reconstruction visually transforms the breast mound into an appearance more closely resembling the original breast. Patient s satisfaction with breast reconstruction correlates highly with the presence of a nipple and areola 4. Received: January 13, 2005; Revised: February 14, 2005; Accepted: February 17, 2005. * Corresponding author: Shyi-Gen Chen, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri- Service General Hospital, 325, Cheng-Gong Road Section 2, Taipei 114, Taiwan, Republic of China. Tel: +886-2- 87927195; Fax: +886-2-87927194; E-mail: shyigen@ms26. hinet.net The major goals of nipple-areola reconstruction are (1) symmetry with the opposite nipple, (2) similar size and maintenance of projection, and (3) good pigmentationcolor match. Numerous reconstructive methods have been developed for this purpose, including intradermal tattooing, reconstruction with skin grafts, local tissue flaps, cartilage grafts, tissue-engineered structures, and nipple-sharing techniques 5-12. Each of these has its own unique advantages, but loss of long term projection and reliability are major concerns 13,14. Aside from this, most of the literature is based on the experience of the western population. There are few reports with regard to nipple-areola reconstruction in Asians. We have devised a reliable badge flap technique combined with intradermal tattooing for creating a new nipple-areola for Taiwanese females. The aim of this report is to describe the surgical technique of the badge flap and report the 29 months follow-up results focusing on projection, size, and pigmentation of the nipple-areola and also patients satisfaction with the final result. METHODS AND TECHNIQUES Included in this study were 15 patients undergoing 125

NAC reconstruction in Taiwanese females a b Fig.1 Diagrammatic presentation of badge flap design. p: width of the pedicle of the badge dermo-fat flap; r: radius of newly created nipple; h: height of newly created nipple; l: length of the badge flap; L= a-a = b-b 2πr. c d postmastectomy breast reconstruction between August 2000 and August 2003. A total of 16 nipple-areola reconstruction procedures were performed on these 15 patients at the Tri-Service General Hospital. The nipple reconstructions were usually performed when the reconstructed breast attaining near-final form with a stable vascularity. Tattooing as the new nipple healed well completed the areola. All patients received a standardized, 3-month postoperative care regimen. Nipple diameter and projection were measured with a caliper by a single observer at the time of completion and at each subsequent follow-up examination. Every patient was also asked to complete a questionnaire that focused on pigmentation existence using a rating scale from 0 to 10, and overall satisfaction with the nipple reconstruction process using a satisfaction percentage on a scale from 0 to 100 percent. Operative Technique Patients were asked to stand in front of a mirror. A pediatric ECG lead is a useful tool that serves as a temporary nipple-areola in choosing a new nipple position. The location of the new nipple was determined after careful evaluation by both the patient and doctor. The flap is then designed, based on the site of the new nipple, symmetry, the diameter, and the projection desired. The diameter of the new nipple is usually equal to the opposite native nipple unless there had been a bilateral mastectomy or the patient requests nipple reduction. The badge flap technique uses two trapezoid flaps and a circle flap to create the nipple (Figs. 1,2b). The circle flap determines the diameter and formats the top of new nipple. The flap s length (L=a-a =bb ) is slightly longer then calculated nipple circumference (>2πr, where r is the radius) while its width forms the height of the future nipple. The width is higher than Fig. 2 A 49-year-old woman presented 7 months after skin sparing mastectomy and immediate pedicled TRAM flap breast reconstruction with good shape and contour (a). Badge flap design for nipple reconstruction (b). Early results after badge flap before tattooing (c). Postoperative results, the nipple-areola showed good shape and projection. The pigmentation was rated 9/10 (d). opposite nipple to allow for loss of projection. C (c=2r) serves as the pedicle of the badge flap, which should be well preserved. This flap usually placed on horizontal, but it can be based on a different direction depending on the scaring of and circulation in the reconstructed breast. The procedure is usually performed under local anesthesia or under general anesthesia while combing it with other revision procedures. Two trapezoid flaps are elevated and thinned subcutaneously to allow wound closure and to form fullness of the nipple. Then two wings are wrapped around to format nipple projection, and the circle flap is used as a lid (Fig. 1). The donor sites are closed uniformly using 4-0 Vicryl subcutaneous suture and 5-0 interrupted nylon. Protective dressing was left in place for 1 week, with a soft nipple stent in place for 3 months to avoid undue pressure. To achieve the best color match with the opposite nipple-areola, we preferred using an intradermal tattoo as the new nipple healed completely (Figs. 2c,d). The nipple was tattooed darker than areola, usually with mixed colors including brown, orange, or ruby red. The areola was tattooed lighter with ambiguity in the peripheral and interlacing with some white spots to resemble the Montgomery glands in a natural areola. (ST1-soft touch machine, Superior Tattoo Equipment Co. Phoenix, Arizona) 126

Shyi-Gen Chen, et al. c a Fig. 3 A 45-year-old woman presented immediate after skin sparing mastectomy and 4 months after immediate free TRAM flap breast reconstruction with good shape and contour (a, b). Oblique view 2 years postoperatively. The nipple areola showed good symmetry, size, and shape (3S) and position, projection, and pigmentation (3P). The patient was 100% satisfied (c, d). RESULTS In these 16 reconstructed nipples, 9 nipple reconstructions were performed following pedicle transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, and 7 were performed following free TRAM flap breast reconstruction. One of these patients had bilateral pedicle TRAM flap for bilateral breast cancers. The mean age was 45.3 years (range 31-55 years). The procedure is simple and fast, and can be performed under local anesthesia within 30 minutes, or performed under general anesthesia while combined with other refining procedures. The average timing for nipple reconstruction was 7.5 months (range 4-31 months) after breast mound formation. All flaps survived well with good contour and symmetry (Figs. 2,3). There was no partial necrosis or other complications. There was no local recurrence or distant metastasis in these patients. The new nipple kept 67.3% projection as compared with opposite nipple in a 25.7- month (range 12-39 months) follow-up. There was no difference in projection between pedicle TRAM and free TRAM. The satisfaction with pigmentation was determined by a patients questionnaire with a rating 8.4/10. The overall satisfaction rate was 91.5%. All patients survived well without evidence of local recurrence or distant metastasis. b d DISCUSSION Management of breast cancer requires teamwork. The goal of treatment is not only early diagnosis and early treatment, but also ensuring psychosocial recovery and quality of life for the patients. A modified radical mastectomy is the most commonly performed surgical procedure to eradicate this type of cancer 15. However, breast ablative surgery usually results in breast disfiguring or cicatrized chest wall deformity that can create a perceived physical distortion and/or emotional disturbance in the affected women. Breast reconstruction plays an important role to regain a semblance of lost breast, rebuild body image, restore femininity, and for psychosocial benefits 16,17. Reconstruction of the breast after mastectomy can be achieved by using implants 18 or autologous tissues 19. Nipple-areola reconstruction is often the final stage of breast reconstruction and has important symbolic and aesthetic implications. The goals of nipple-areola reconstruction comprise the 3Ps (good position, appropriate projection, and pigmentation match) and 3Ss (similar size, shape, and symmetry with the opposite nipple). The most challenging aspect of nipple reconstruction is the creation of a 3-dimensional projecting structure with texture, dimensions, and contour similar to the contralateral nipple. Nipple-areola anatomy is remarkably variable in dimension, texture, and color across ethnic groups. Although there is no published documentation of average nipple projection in Taiwanese women, the opposite nipple in this series is not very high with averaged projection of 9 mm (6-11 mm). This makes it easy for a reconstructed nipple to maintain a similar projection. Numerous reconstructive methods have been developed for nipple-areola reconstruction, including nipple- sharing techniques, intradermal tattooing, skin grafts, local tissue flaps, cartilage grafts, and tissue-engineered structures 5-12. Most of the literature is based on experience of the western population. There are few reports with regard to the nipple-areola reconstruction in Asian females. Nipple-areola saving or banking at the time of mastectomy for later replacement on the reconstructed breast carries the potential risk of auto-transplanting cancer cells to the breast and poor cosmetic results 20. Using a local flap to create a new nipple is the most common and acceptable method nowadays. However, we have been disappointed with the results and unpredictability of various methods of nipple reconstruction. The main problem encountered is the gradual absorption and flattening of the nipple. The new nipple projection will achieve 127

NAC reconstruction in Taiwanese females stabilization 9-12 months after reconstruction 13. Our badge flap method, inspired by the concepts underlying the dermalfat flap of Hartrampf and the C-V flap of Bostwick 7,21, can produce a mathematically calculated desired nipple size and projection. The procedure has several advantages, including predictable size, freedom in designing the length and width of the flap, reliable, simple and fast, can be performed under local anesthesia within 30 minutes. The long-term projection and pigmentation are much better than ever published 21. Reconstruction of the new areola originally involved skin grafts from the contralateral areola, various local or distant sites selected on the basis of pigmentation 21. In our views, grafting method is a more involved procedure with multiple surgical wounds and increased discomfort. Besides, the degree and direction of skin contraction is unpredictable and has the possibility of depigmentation. The use of tattooing in reconstruction of the nippleareola was first reported by Becker 22 in 1986. It can be performed either before or after the nipple reconstruction 23-24. For the best color match with the opposite nippleareola, we preferred delayed tattooing until the new nipple healed well. Tatooing can be done by the surgeon themselves or by a tattoo artist. Many tattoo pigments are available, allowing precise color matching with the contralateral areola. Choosing a shade just darker than the desired color will allow for some fading due to phagocytosis by macrophages. The areola was tattooed lighter with ambiguity in the peripheral and interlacing with some white spots to resemble the Montgomery glands in a natural areola. One or more applications may be necessary to obtain the desired result. The badge flap technique presented here achieves all of the goals of nipple-areola reconstruction, including appropriate nipple projection, areola contour, and nipple-areola color match, without the need for harvesting of a distant skin graft. The major drawback of this technique is loss of the firmness of the new nipple despite its maintenance of a reasonable projection. The badge flap is composed of only dermal fat tissue without the lactatory duct and fibrous tissue support. Adding the ear or rib cartilage could be considered if the patient requests a firm and erect nipple 25. In conclusion, this novel badge flap with intradermal tattoo is a simple and reliable method for nipple areola reconstruction. It created a new nipple-areola with good position, keeping a reasonable projection, and providing good pigmentation. The shape, size and symmetry are also good with high level of patient satisfaction. REFERENCES 1. Weir HK, Thun MJ, Hankey BF, Ries LA, Howe HL, Wingo PA, Jemal A, Ward E, Anderson RN, Edwards BK. Annual report to the nation on the status of cancer, 1975-2000, featuring the uses of surveillance data for cancer prevention and control. J Natl Cancer Inst 2003; 95:1276-1299. 2. Chie WC, Chang SH, Huang CS, Tzeng SJ, Chen JH, Fan BY, Chang KJ. Prognostic factors for the survival of Taiwanese breast cancer patients. J Formos Med Assoc 2002;101:98-103. 3. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000;106:769-776. 4. Wellisch DK, Schain WS, Noone RB, Little JW III. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987;80: 699-704. 5. Little JW, Munasifi T, McCulloch DT. One stage reconstruction of a projecting nipple: the quadripod flap. Plast Reconstr Surg 1983;71:126-133. 6. Little JW. Nipple-areola reconstruction. Adv Plast Reconstr Surg 1987;3:43. 7. Hartrampf CR, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg 1984;73: 982-986. 8. Millard DR Jr. Nipple and areola reconstruction by split-skin graft from the normal side. Plast Reconstr Surg 1972;50:350-353. 9. Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: the S flap. Plast Reconstr Surg 1988; 81:783-787. 10. Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing tab-flap. Plast Reconstr Surg 1989; 84:520-525. 11. Weiss J, Herman O, Rosenberg L, Shafir R. The S nipple-areolar reconstruction. Plast Reconstr Surg 1989; 83:904-906. 12. Cao YL, Lach E, Kim TH, Rodriguez A, Arevalo CA, Vacanti CA. Tissue-engineered nipple reconstruction. Plast Reconstr Surg 1998;102:2293-2298. 13. Few JW, Markus JR, Casa LA, Aitken ME, Redding J. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg 1999;104:1321-1324. 14. Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg 128

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