Surgical Outcomes and Nipple Projection Using the Modified Skate Flap for Nipple-Areolar Reconstruction in a Series of 422 Implant Reconstructions

Abstract

Numerous techniques have been used in an attempt to achieve long-term nipple projection following nipple-areolar reconstruction (NAR). A common setback, however, is the diminution of projection over time; this phenomenon is particularly evident following implant based breast reconstruction. The purpose of this report was thus to evaluate surgical outcomes and long-term nipple projection with the use of "modified skate flap" technique in exclusively implant based postmastectomy reconstructions. A retrospective review was performed for the period between 1993 and 2007. All consecutive patients with 2-staged tissue expander/implant reconstructions followed by NAR using the modified skate flap technique performed by the senior author (P.C.) were identified in a prospectively maintained breast reconstruction database. Only patients with a minimum of 1-year follow-up were included in the study. Patients with a history of irradiation to the breast were excluded from nipple projection assessment. Clinical outcome measurements included long-term nipple projection as well as incidence of complications from the NAR procedure using the modified skate flap technique. Over the 15-year study period, 475 patients underwent 2-staged tissue expander/implant reconstruction followed by NAR using the modified skate flap technique. Of these, there was a total of 292 patients with the minimum requirement of 1-year follow-up post NAR (61% follow-up rate). The total number of reconstructed nipple areolar complexes evaluated in this series was 422 (130 bilateral and 162 unilateral NAR). Forty patients (28 unilateral and 12 bilateral NAR) who received radiation to their breasts were excluded from nipple projection assessment. At a median follow-up of 44 months (range: 12-84 months), mean nipple projection was 2.5 mm (range: 1-4 mm). Minor complications occurred in 7.2% of the patients (n = 292). Skin graft donor site dehiscence was the most common complication (3.1%) followed by partial skin graft nontake of the areola (2.1%). This report documents the largest series of NAR using a single technique in the setting of postmastectomy reconstructions. This technique can be safely performed over breast implants with acceptably low rates of complications and predictable results. Long-term nipple projection over implant reconstructions using this technique is modest and this must be forewarned to patients completing the final stage of their implant reconstruction.

The angel flap for nipple reconstruction

“…The resulting appearance of the reconstructed nipple can significantly contribute to a patient's overall satisfaction with the entire breast reconstruction (9). Although many techniques have adequate results, none produce a truly prominent nipple with lasting projection (20).…”

“…Paramount among these limitations is the loss of projection seen with all local flap techniques. Objective measures assessing long-term nipple projection in the literature are sparse; however, studies that have evaluated long-term follow-up cite a loss of projection of 40% or more (Table 1) (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). This problem has led many to advocate creating overprojection of the nipple to at least 150% of the contralateral side to allow for loss of projection.…”

Oncological Considerations for Breast Reconstruction

“…Nipple sparing mastectomy (NSM) is growing in popularity because of its perceived aesthetic benefits (Figure 2). Patient satisfaction with nipple-areolar reconstruction following SSM can be disappointing [10]. Data regarding the oncological safety of NSM is hampered by small sample size, varying indications and surgical techniques, and short follow-up (Table 2).…”

Smoking as a risk factor for wound dehiscence in nipple reconstruction: An analysis of 1683 cases

“…5 Lasting projection is difficult to achieve and techniques have emerged to overcome this issue. [6][7][8] Studies on complications after nipple reconstruction are scarce 9,10 -only one study has explicitly described risk factors for postoperative complications after NAC reconstruction. 10 Momeni et al focused on the following parameters: age, final implant volume, time from final implant placement to nipple reconstruction, and history of radiotherapy.…”