The Double-Breasted Dermal Flap in Nipple Reconstruction

Consistent reports of up to 70% nipple projection loss with some local flap techniques[1] correlate with no emergence of any single reconstructive method. A comparison of a modified star, bell,[2] and skate flaps showed the star and skate maintenance of projection to be superior with no significant difference between the two.[1] It is hypothesized that the gradual loss of nipple projection seen may result from reliance on subcutaneous fat for support in the nipple construct or at best a dermal platform. Mori and Hata extended this by providing a dermal platform for the nipple construct and de-epithelialized flap tips in an attempt to preserve projection;[3] however, maintenance of projection has yet to be proven.

We present a method of nipple reconstruction that modifies current concepts in an attempt to provide stronger support to the reconstructed nipple. We use this method predominantly in patients who undergo skin-sparing mastectomy (SSM) and immediate reconstruction with a pedicled latissimus dorsi (LD) flap.

We site our nipple areolar complex (NAC) reconstructions within the periareolar defect produced in SSMs as previously described.[4] An oval line is drawn on the skin paddle as in [Fig. 1]. This template is not circular because the central portion requires an additional 1 to 1.5 cm to allow for the flap width. The nipple cap is also 1 cm in width. Generally, we aim to symmetrize the NAC so dimensions are not standardized.

Fig. 1 Markings on a latissimus dorsi flap. Flap A de-epithelialized. Flap B will form the outer flap of nipple construct. The cross-hatched region represents the 1 to 2 mm of free end excised. Flap A is wrapped under the nipple cap (NC) and flap B is double-breasted around flap A. Arrow shows the central construct packed with dermis.

Full-thickness incisions are made along the lateral flap margins except for the central 1 to 1.5 cm pedicle. The lateral limbs of the flap (A and B) are raised subdermally to the level of the pedicle ([Fig. 1]). Flap limb A is de-epithelialized and trimmed by 1 to 2 mm at the free edge ([Fig. 1]).

The de-epithelialized portion is mobilized centrally and sutured to the base of the contralateral limb base using a 5.0 braided absorbable suture ([Fig. 1]). The shortening allows the contralateral flap to safely wrap around without constriction. The opposing cutaneous lateral flap is wrapped around the dermal flap and sutured to its base. The nipple “cap” is subsequently sutured on top also using 5.0 braided absorbable suture ([Fig. 2]). This provides complete dermal packing of the nipple scaffold.

Fig. 2 Postoperative appearance at 2 and 24 months with comparison to contralateral nipple projection from anterior views.

The remainder of the skin paddle outside the areolar marking is de-epithelialized and the new NAC sutured to the SSM skin defect using a 4.0 absorbable monofilament in a purse string fashion. The nipple is protected from compressive forces in a bra for 1 month postoperatively. [Fig. 2] shows appearance at 2 and 24 months postoperatively.

Although not directly compared, in vivo dermis has more robust physical properties than subcutaneous fat. A recent in vitro study on mouse skin components consistently showed dermis to be more resistant to compression and stretch compared with epidermis.[5] Hence we postulate that the physical properties of a dermal support for the nipple construct ultimately provides better maintenance of projection than comparable methods that rely on subcutaneous fat housed by skin flaps. We have found this method particularly useful in patients undergoing LD reconstructions owing to the thicker dermis of the posterior trunk.

• References

• 1 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 2002; 110 (3) 780-786
• 2 Eng JS. Bell flap nipple reconstruction—a new wrinkle. Ann Plast Surg 1996; 36 (5) 485-488
• 3 Mori H, Hata Y. Modified C-V flap in nipple reconstruction. J Plast Reconstr Aesthet Surg 2008; 61 (9) 1109-1110
• 4 Shestak KC, Nguyen TD. The double opposing periareola flap: a novel concept for nipple-areola reconstruction. Plast Reconstr Surg 2007; 119 (2) 473-480
• 5 Crichton ML, Donose BC, Chen X, Raphael AP, Huang H, Kendall MA. The viscoelastic, hyperelastic and scale dependent behaviour of freshly excised individual skin layers. Biomaterials 2011; 32 (20) 4670-4681