Areola and nipple reconstruction

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

BACKGROUND

Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction.

METHODS

MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars.

CONCLUSIONS

The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nipple-areola complex reconstruction techniques: A literature review

Many techniques for nipple-areola complex (NAC) reconstruction are described. Clarity is required on the currently available options. Since a complete list of all the techniques described until now is not available, a possibly comprehensive literature overview was carried out from 75 papers (years 1946-2015). The local flap was the most frequently described technique for the nipple reconstruction with no significant difference in complications' rate among the various types of techniques. Complications in nipple reconstruction were 46.9% after graft, 7.9% after local flap, and 5.3% in case of flaps with autologous graft/alloplastic/allograft augmentation, while complications in areola reconstruction were 10.1% after graft, and 1.6% after areola tattoo. Flaps appear to be more reliable than grafts in nipple reconstruction, while tattoo is thought to be safer than graft in areola reconstruction. The loss of projection, although considerable (45%-75%), had not significant impact on patients' satisfaction. Due to contraction, overcorrection of 25-50% of the desired result is advisory when adopting local flaps, in order to prevent loss of projection. The use of flaps with autologous graft/alloplastic/allograft augmentation (cartilage, fat, calcium hydroxylapatite, acellular dermal matrix, polymethylmethacrylate, biologic collagen) showed a minor loss of nipple projection but may expose to a relative increased number of postoperative flap necrosis.

Patient satisfaction following nipple reconstruction incorporating autologous costal cartilage

BACKGROUND

Nipple-areolar reconstruction completes post-mastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time.

OBJECTIVES

To determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction.

METHODS

Sixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction.

RESULTS

Of 26 respondents (mean +/- SEM follow-up period 3.7+/-3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstructions. While both groups would opt for nipple reconstruction again, patients with cartilage grafts incorporated into their reconstructions had overall satisfaction ratings 1.92 grades higher on average (not significant, P=0.12) than those without. This difference increased to 3.2 grades when the satisfaction of the patient's partner was taken into account (P<0.05). Improved satisfaction corresponded to higher scores for volume, consistency, texture, and particularly for projection and contour of the nipple (P<0.05). Although nipple morphology changed over time, there was a trend toward improved stability in the cartilage group.

CONCLUSIONS

Patient satisfaction with nipple reconstruction can be improved by incorporating costal cartilage beneath the skin flaps. Superior contour and projection are sustained over time.

[Nipple-areola complex reconstruction with full-thickness skin graft and subcutaneous pedicled island flap]

We are reporting on an easy, reliable and reproducible nipple-areola complex reconstruction. The main feature is to perform a full-thickness skin graft to rebuild the areola and a subcutaneous pedicled island flap for the reconstruction of the nipple in the middle of the graft. Each step is described. This technique remains easily practical and allows to keep an appropriate nipple projection. Moreover, it fits to all kind of breast reconstruction.

Reconstruction of the nipple-areola complex: an update

Along with continuing progress in reconstructive surgery of the breast numerous techniques of nipple-areola reconstruction have been developed. With time and experience some methods have been discredited to historical significance only while others have evolved to widely accepted concepts used by surgeons all over the world, which in turn contributed new ideas and modifications. In addition to those favourite techniques others are reserved as second-line alternatives in specific situations. The principle criterion for a pleasing nipple-areola complex is symmetry regarding several parameters: colour, texture, size, and projection. The purpose of this manuscript is to review and discuss the concepts and techniques of nipple-areola reconstruction that have evolved over the past decades. Furthermore, those principles and techniques are pointed out that fulfil best the criteria of an ideal nipple-areola complex with emphasis on different techniques of breast reconstruction and individual conditions of the patient.

Breast reconstruction following mastectomy for cancer

Breast reconstruction following mastectomy for cancer is a feasible procedure. The selection of the proper type of mastectomy should be the decision of the cancer surgeon. However, with the advent of modified mastectomies, the use of fewer primary skin grafts, and the preservation of all or part of the pectoralis major muscle, breast reconstruction has become more satisfactory. Since many women adjust poorly to mastectomy, the chance for reconstruction offers hope for a fuller life. Reconstruction of the postmastectomy cancer patient can be accomplished in three basic steps: 1) An adequate breast mound can be constructed with a prosthesis. A flap may be used if the skin cover is inadequate. 2) The size and shape of the remaining breast can be adjusted to obtain symmetry. 3) The nipple-areola complex can be reconstructed if the patient desires. Correction of the infraclavicular and axillary defects may be required. The techniques employed in 14 patients are presented.