Nipple Reconstruction with C-V Flap using Dermofat Graft
SuRak Eo, MD, PhD, SangHun Cho, MD, PhD, Steve S. Kim, MD, PhD, and Andrew L. Da Lio, MD
INTRODUCTION:Aesthetically satisfying nipple restoration plays an important role in post-mastectomy breast reconstruction. Many techniques; such as the skate flap(1), star flap(1), C-V flap(2), S-flap(3),and double opposing tab flaps(4) are currently employed in nipple reconstruction. Despite the plethora of techniques available, a simple and reliable method that maintains nipple projection remains elusive. In this paper, we outline a simple technique that maintains long-term nipple projection. To this end, we have performed local C-V flaps augmented with autologous dermofat grafts harvested from excised breast tissues during breast mound revision.
METHOD:All patients had history of breast cancer ablation and were reconstructed with either transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), or latissimus dorsi (LD) musculocutaneous flaps. Secondary breast mound revisions were needed for the correction of asymmetry and partial fat necrosis. These were corrected simply by excision and scar revision under general anesthesia. The nipples were reconstructed with excised autologous tissues simultaneously.
The position of the new nipple-areola complex was determined with the patient standing in front of a mirror. The diameter of the nipple was designed 15% to 20% larger than that of the desired one using C-V flaps. The projection of the nipple was determined by the width of the V flap and the diameter of the nipple depends based on the diameter of the C flap.In our design, we overcorrected nipple height (made 12 to 18 mm) to compensate for 25 to 50% decrease over time.The final nipple height was calculated to be 6 to 12 mm in height.The C-V flap could be oriented in any direction and was elevated to the thickness of the dermal fat to preserve the subdermal plexuses.
A dermofat graft with dimensions of 1 x 1 x 2 cm was harvested from the excised breast tissues. This was then immediately placed at the center of the newly formed nipple with the dermal tissue laying in the deep aspect. The C-V flap was sutured loosely with 4-0 chromic catguts and donor site was closed primarily without tension in two layers using 4-0 monocryl inverted dermal interrupted sutures and 4-0 monocryl running subcuticular sutures. Doughnut-shaped stent dressing made of cotton patches were maintained for 48 hours to avoid direct pressure on the reconstructed nipple using folded cotton patches with central cutouts for the nipple. The areola was later tattooed in a separate office procedure.
RESULTS: All procedures were performed during the second stage (mound revisions) for breast reconstruction. The patient population consisted of 20 patients of which 22 breasts were operated on. No significant flap loss was encountered in any of the patients. The unfavorable length to width ratios of the CV flaps ( 7 cm X 1.5 cm ) did not adversely effect the flaps. Projection of the reconstructed nipple was well maintained, and the nipple qualitatively had a better shape and height with the dermofat graft as a sustaining strut. Our patients have not only been satisfied but delighted with the three-dimensional projection of the nipple.
CONCLUSION:Nipple reconstructions on the majority are undertaken during breast mound revision, 3-6 months after breast reconstruction. The goals of nipple reconstruction are adequate nipple projection and symmetry (5). The erect and protuberant nipple core seen immediately postoperatively falls victim to shrinkage and contraction, thus rendering a flattened nipple.Dermofat grafts harvested from excised tissue during mound revision were successfully utilized as internal struts for nipple papule projection. This technique is simple and permits greater freedom in choosing the final height of the nipple. Use of the C-V flap augmented with a dermofat graft results in an esthetically pleasing nipple that maintains long-term projection without any donor site morbidity.
REFERENCES
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