Background: Nipple-areola complex reconstruction aims to be the last step in the postmastectomy treatment procedure. Different techniques have been developed with the purpose of achieving optimal symmetry in position, size, shape, pigmentation, and permanent projection of the reconstructed nipple, but to date, there is no gold standard technique. The five-flap technique provides an easy, simple nipple-areola complex reconstruction method, effectively maintaining longer nipple projection, with a negligible rate of complications. Methods: From November 2018 to April 2021, a total of 21 female patients with an absent unilateral nipple-areolar complex due to postoncological mastectomy were subjected to our technique consisting of a combination of local flaps and a fullthickness skin graft. Patients were observed for 6 months to estimate the percentage of the nipple projection loss. Overall satisfaction was evaluated by the patients themselves and by an external medical observer at the end of the follow-up period. Results: None of the reconstructed nipples experienced either total or partial necrosis. Two minor complications were observed. Nipple projection loss was negligible with an average reduction of 12% from the initial projection. The nippleareolar complex shape remained excellent in all cases, with minimal alteration of the immediate postoperative results. The total average satisfaction score was 8.0 for patients and 9.0 for external observers. Conclusion:The five-flap technique represents a simple, safe, and efficacious procedure in patients with implant-based reconstruction requiring moderate to very projected nipples.

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Summary: Implant-based breast reconstruction represents the most popular procedure for the treatment of women undergoing skin-sparing mastectomy. In selected patients, it allows for obtaining an excellent appearance of the reconstructed breast with great satisfaction to the patient. However, aesthetic and functional results can be affected by complications requiring reoperation. Among them, rippling is an undesired occurrence associated with implant-based reconstruction. It consists of a cutaneous manifestation, visible and/or palpable, of the implant wrinkles and edge which appear mostly when the patient leans forward. To treat this contour deformity, several techniques have been described such as acellular dermal matrices and autologous tissues. In this study, we intend to add the serratus anterior fascial flap within the autologous options in the treatment of implant rippling, reporting our experience.