The angel flap for nipple reconstruction

Abstract

A s more women undergo breast reconstruction following mastectomy, the necessity of excellent nipple-areola reconstruction becomes increasingly relevant. The creation of a pleasing nipple-areola complex is the final stage in breast reconstruction following the recreation of the breast mound. This is an important procedure in recreating a 'breast' that is visually analogous to the preoperative breast. Often, breast reconstruction is an important facet of both physical and psychological healing for women who have been diagnosed with breast cancer. As the final stage in the reconstructive process, it is imperative that the procedure provide a pleasing aesthetic outcome with consistent projection, minimal adjacent tissue distortion and excellent symmetry.In practice and in the literature, the use of local tissue flaps has become the primary contemporary technique. Local flaps preclude the creation of an additional donor site, minimizing perioperative discomfort and additional comorbidities. While each local flap exhibits its own advantages, certain common limitations are ubiquitous. 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. This technique is less than ideal, however, because it increases the necessary local tissue required, creates more potential distortion of the breast mound, places a larger demand on the vascular pedicle that is already susceptible to necrosis and provides an inconsistent result. With regard to projection, reliability and a range of application, a simple and reliable method appropriate for all scenarios remains elusive.The ideal formula for nipple reconstruction would maintain longterm nipple projection, texture and shape, and have minimal donor site morbidity. To enhance reproducibility of the technique and results, the design should be relatively simple and with a short learning curve. When using local tissue, an adequately wide base should be formed to avoid vascular compromise and necrosis, while limiting the length of incisions and local tissue use to minimize alterations in breast shape. Ideally, long-term results should demonstrate adequate projection, an overall aesthetically pleasing appearance and, in appropriate cases, satisfactory symmetry with the contralateral nipple. The surgical technique we present for nipple reconstruction uses local tissues to form an 'angel flap' -a modification of the skate flap. We believe that this technique fulfills the ideal formula for nipple reconstruction. Surgical TechniqueWith the patient in a standing position, the areolar location was determined with consideration of symmetry with the o...

Repair and prevention of nipple inversion following central duct resection utilizing a subcutaneous adipose flap from mammary preglandular tissue

“…An extensive release (surgical or with needle) of the fibrous tissue beneath the nipple, thereby damaging the lactiferous ducts, has often been suggested to repair the higher degree of nipple inversion categorized as II‐III grade in the Han and Hog classification . Fat has been the major component and structural support for nipple reshaping, but it demonstrates to give rise a pervasive loss of projection due to the lacking in dense connective tissue that supports native nipples . Projection of the nipple can be created through various (flap) transposition techniques, a purse string suture, or by suturing the internal sidewalls of the nipple, even if the majority of the studies report techniques using (deepithelialized) flaps to provide bulk under the nipple .…”

“…Fat has been the major component and structural support for nipple reshaping, but it demonstrates to give rise a pervasive loss of projection due to the lacking in dense connective tissue that supports native nipples . Projection of the nipple can be created through various (flap) transposition techniques, a purse string suture, or by suturing the internal sidewalls of the nipple, even if the majority of the studies report techniques using (deepithelialized) flaps to provide bulk under the nipple . However, when the underlying support of the nipple remains the fat an additional support for that fat becomes inconsequential to maintain long‐term nipple projection …”

“…The major problem with local flaps that rely primarily on fat as both the foundation and major structural support of the recreated nipple is flattening due to the lacking in dense connective tissue that supports native nipples . The SCAF‐technique seems to more easily counteract the loss of projection if the base of the nipple is wider than 1 cm; the shape of the nipple could contribute to keep consistency and stability, too.…”

“…This concept was utilized by Filobbos et al who confirmed that free nipple grafts can develop pigmentation irregularities and donor site morbidities together with loss in projection, which can be either avoided or at least mitigated by using a local flap. Novel procedures as the angel flap and the skate flap technique attain for the lowering of centrifugal forces responsible for loss in nipple projection by decreasing the stress placed on the small dermal lining . Moreover, especially the floppy stich at the bottom of the nipple used for keeping the nipple in place, and to pull it (Figure D), seems to ensure the initial stability of the nipple and the achievement of its projection.…”

“…Moreover, especially the floppy stich at the bottom of the nipple used for keeping the nipple in place, and to pull it (Figure D), seems to ensure the initial stability of the nipple and the achievement of its projection. This approach attempts to soften what is proposed by the suturing and traction techniques, together with dressings, also to avoid to woman for special clothing. Finally, the tenuous blood supply to the supporting elements of the new nipple is a determinant factor for achieving nipple shape, cutaneous trophism, and projection.…”