Cosmetic and Reconstructive Breast Surgery

Cosmetic and Reconstructive Breast Surgery
202
A
B
C
D
Case 2 A 48-year-old man with palpable breast tissue and
adiposity who underwent direct excision via a lower peri-
areolar approach (left 100 g, right 80 g) and tumescent
liposuction (225 mL total). This is his 5-month follow-up
(Fig. 14.3).

Gynecomastia
203
A
B
C
D
Case 3 A 15-year-old male with palpable breast tissue and
some skin excess with an enlarged areola. He underwent
periareolar skin excision, direct excision of breast tissue (left
70 g, right 90 g), and chest tumescent liposuction (200 mL
total). This is his 4-month follow-up (Fig. 14.4).

Cosmetic and Reconstructive Breast Surgery
204
A
B
C
D
E
Case 4 A 50-year-old man who underwent previous gyne-
comastia repair via an inframammary incision. He continued
to have skin and volume excess and just wanted to be fl at.
He underwent a direct excision of skin to incorporate the
inframammary scar (512 g on right, 446 g on left) and free
nipple grafting. This is his 9-month follow-up. (Fig. 14.5).
Nipple hypopigmentation has nearly resolved and usually
does so by 1 year postoperatively.

Gynecomastia
205
CONCLUSIONS
Gynecomastia repair incorporates basic plastic surgery
principles to achieve successful results. Unlike female
breast reduction, the goal of gynecomastia repair is a fl at
chest which is in proportion to the patient’s overall body
habitus. A gynecomastia patient must be willing to accept
the possibility of noticeable skin irregularity in the simplest
cases, to noticeable scars, nipple insensitivity, and asym-
metry in more complex cases. Despite this, with proper
patient selection and preoperative counseling, a successful
result can be achieved.
REFERENCES
1. Braunstein GD. Gynecomastia. N Engl J Med 1993; 328:
490–495.
2. Bostwick J. Gynecomastia. In: Bostwick J III (ed) Plastic and
reconstructive breast surgery. St Louis: Quality Medical Publishing,
2000.
3. Daniels IR, Layer GT. Gynaecomastia. Eur J Surg 2001; 167:
885–892.
4. Rohrich RJ, Ha RY, Kenkel JM, Adams WP. Classifi cation and
management of gynecomastia: defi ning the role of ultrasound-
assisted liposuction. Plast Reconstruct Surg 2003; 111: 909–923.
5. Rosenberg GJ. Gynecomastia. In: Spear SL (ed) Surgery of the
breast: principles and art. Philadelphia: Lippincott Williams &
Wilkins, 2006.
6. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary
solution. Plast Reconstruct Surg 1987; 80: 379–386.
7. Hodgson ELB, Fruhstorfer BH, Malata CM. Ultrasonic liposuction
in the treatment of gynecomastia. Plast Reconstruct Surg 116:
646–653.
8. Mladick RA. Gynecomastia. Clin Plast Surg 1991; 18: 815–822.
9. Smoot EC. Eccentric skin resection and purse-string closure for
skin reduction with mastectomy for gynecomastia. Ann Plast Surg
1998; 41: 378–383.
10. Persichette P, Berloco M. Gynecomastia and the
complete circumareolar approach in the surgical management
of skin redundancy. Plast Reconstruct Surg 2001; 107:
948–954.
11. Colic MM, Colic MM. Circumareolar mastectomy in the female-
to-male transsexuals and large gynecomastias: a personal approach.
Aesthet Plast Surg 2000; 24: 450–454.
12. Webster JP. Mastectomy for gynecomastia through a semi-circular
intra-areolar incision. Ann Surg 1946; 124: 557.
13. Barsky AJ, Kahn S, Simon BE. Principles and practice of surgery.
New York: McGraw Hill, 1964.
14. Pitanguy I. Transareolar incision for gynecomastia. Plast
Reconstruct Surg 1966; 38: 414–419.
15. Letterman G, Schurter M. The surgical correction of gynecomastia.
Am Surg 1969; 35: 322–325.
16. Letterman G, Schurter M. Surgical correction of massive
gynecomastia. Plast Reconstruct Surg 1972; 49: 259–262.
17. Pers M, Bretteville-Jensen G. Reduction mammaplasty based on
the vertical vascular bipedicle and ‘tennis ball’ assembly. Scand J
Plast Reconstruct Surg 1972; 6: 61.
18. Peters HM, Vastine V, Knox L, Morgan RF. Treatment of
adolescent gynecomastia using a bipedicle technique. Ann Plast
Surg 1998; 40: 241.
19. Wray RC, Hoopes JE, Davis GM. Correction of exreme
gynaecomastia. Br J Plast Surg 1974; 27: 39–41.
20. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in
surgical management of gynecomastia. Plast Reconstruct Surg
1982; 69: 35–40.
21. Murphy TP, Ehrlichman RJ, Seckel BR. Nipple placement in
simple mastectomy with free nipple grafting for severe
gynecomastia. Plast Reconstruct Surg 1994; 94: 818–823.
22. Beckstein MS, Windle BH, Stroup RT. Anatomical parameters for
nipple position and areolar diameter in males. Ann Plast Surg
1996; 36: 33–36.
23. Shulman O, Badani E, Wolf Y, Hauben DJ. Appropriate location of
the nipple–areola complex in males. Plast Reconstruct Surg 2001;
108: 348–351.
24. Beer GM, Budi S, Seifert B, et al. Confi guration and localization of
the nipple–areolar complex in men. Plast Reconstruct Surg 2001;
108: 1947–1952.

207
C H A P T E R
15
Nipple–Areola Reconstruction
Kenneth C. Shestak
The nipple is an essential aesthetic feature of the breast
and is the visual center around which the rest of the gland
emanates. The nipple is surrounded by areolar tissue, which
is a darkly pigmented epithelium that has a small number
of ducts opening into it. The areolar skin is visually darker
than the surrounding breast skin but slightly lighter in
pigmentation than the nipple1 (Fig. 15.1).
The nipple is most aesthetically positioned at the point
of maximal projection on the breast mound.1,2 It can be
located by the transposition of the inframammary fold
(done routinely when planning a breast reduction) or by
measurements from fi xed points of reference on the ante-
rior chest (done in most nipple reconstructions following a
previous breast reconstruction). The distance from the
nipple to the suprasternal notch and the inframammary
fold varies from patient to patient (Fig. 15.2B). In the
absence of previous surgery or an obvious developmental
asymmetry, the nipple positions are most often roughly
symmetric.
GUIDELINES FOR NIPPLE RECONSTRUCTION
When performing nipple–areola reconstruction the optimal
visual appearance of the reconstructed nipple is achieved by
simulating the best possible position, projection, and pig-
mentation relative to the nipple features on the opposite
breast. The author has come to recognize that perhaps the
most important feature is the color patch symmetry of the
areola with the opposite areola. Visual symmetry between
the color and location of the nipple–areola complex on the
opposite breast and its position on the reconstructed breast
mound is paramount for the optimal visual appearance of
the reconstructed nipple. In the past this was accomplished
by the transplantation of a darkly pigmented full-thickness
skin graft (vulva or proximal medial thigh skin). Currently,
however, it is best done with an intradermal tattoo, which
can produce the most predictable symmetry with the oppo-
site areola over a wide variety of colors.1,2 This characteris-
tic of the color of the areola around the reconstructed nipple
is more important than either position or projection. Indeed,
good color patch symmetry can often compensate for partial
or even signifi cant loss of nipple projection or slight abnor-
malities in position. This is illustrated in the patient in
Figure 15.3 (A–D), who sustained a signifi cant loss of
nipple projection marring what was otherwise a good left
breast reconstruction with a transverse rectus abdominis
musculocutaneous (TRAM) fl ap. This situation was
‘rescued’ by a well-done intradermal tattoo2 which produced
an excellent aesthetic outcome.
In terms of timing, the author believes that nipple–
areola reconstruction is best done at a second stage rather
than at the primary breast reconstruction. This allows the
breast mound to evolve in terms of shape and gravitational
settling. In my practice, nipple reconstruction is most often
combined with a procedure to revise the reconstructed
breast and reshape the opposite breast. At this time adjust-
ments in nipple position on both breasts contribute to
symmetry and overall aesthetic appearance. Nipple recon-
structions performed at the time of breast reconstruction
carry a high probability of subsequent asymmetry unless
they are done following an ultimate skin-sparing mastec-
tomy where the nipple and areola alone are removed. In
this case, replacement of the skin with a simultaneous
nipple reconstruction on this skin paddle (as described by
Hammond) may yield a good result. Similarly, performing
a simultaneous nipple reconstruction at the time of exchang-
ing the expander for an implant carries with it a small but
defi nite increased risk of losing the implant owing to prob-
lems with wound healing and subsequent exposure and/or
infection at the site of nipple reconstruction.3,4 For this
reason I have not adopted this procedure in my practice.

Cosmetic and Reconstructive Breast Surgery
208
FIGURE 15.1 A Preoperative AP view of a patient who has undergone a left breast reconstruction with an implant. B Postoperative appearance
of same breast reconstruction following nipple reconstruction and areolar tattoo. Note vivid dimension of realism.
A
B
A
FIGURE 15.2 A The distinctive color and position of the nipple–
areolar complex, which ideally is located at the highest point of the
breast mound.
NIPPLE RECONSTRUCTION OPTIONS
Historically, the options for nipple–areola reconstruction
have included tattoo alone, the use of composite grafts such
as toe pulp,5 earlobe,6 labia minora,7 or most commonly a
composite graft of a portion of the contralateral nipple8
from the opposite breast (in patients with extremely large
nipples). Over the past 20 years, ‘pullout’ skin fl aps raised
at the desired nipple position have represented the ‘state of
the art’ in nipple reconstruction.9–14 The most commonly
used fl aps are listed below. Formerly the areolar region was
reconstructed using a full-thickness graft of darkly pig-
mented skin.15 Most recently, however, the areola is repli-
cated by an intradermal tattoo,16,17 which is the best way to
create symmetry of areolar color.
The most recent addition to this lineup of ‘pullout fl ap’
procedures is the double opposing periareolar fl ap recon-
struction, introduced by us.13 A similar procedure has been
popularized by Hammond.14
An intradermal tattoo alone for nipple reconstruction
may be suffi cient in the elderly, high-risk patient who
desires a semblance of visual symmetry17 but in whom it
may not be wise to have a formal reconstruction because
of local tissue conditions (scarring of skin, atrophy of
dermis, and subcutaneous adipose tissue), advanced age, or
senescence.
I believe that there is still a place, albeit in the very rare
situation, for ‘nipple sharing.’8 This technique is applicable
in special circumstances of primary reconstruction where
there are extremely thin and attenuated tissues or scars in
the desired position of nipple reconstruction, in the patient
who has a large opposite nipple which might serve as donor
tissue for reconstruction (Fig. 15.4A–D).
Nipple sharing involves removal of either the distal
or the most anterior aspect of the nipple (Fig. 15.4A), or
the excision of a pie-shaped portion of the nipple including
the most anterior aspect and the core shaft of the nipple,

Nipple–Areola Reconstruction
209
FIGURE 15.2, cont’d B Schematic illustrating ducts draining the lobules and emanating through the nipple. C, D Typical position of nipple
relative to topographical landmarks on the chest wall.
Mid-clavical point
Inframammary
fold
20–24 cm
7–10 cm
Sternal notch
Breast width
Anterior
axillary line
B
C
D
harvested both on its anterior and under surfaces (Fig.
15.4B). This obviously reduces the size of the new nipple,
which in some cases may be a benefi t. It does also result
in a scar on the donor nipple, and obviously a reduction in
size. However, when such composite grafts are placed in
the appropriate location and surrounded by an intradermal
tattoo they can produce a good simulation of the patient’s
opposite nipple (Fig. 15.4D).
Currently the most popular technique for nipple recon-
struction involves the use of a ‘pullout fl ap’9–14 of skin and
subcutaneous adipose tissue at the ideal site on the recon-
structed breast mound, with the application of intradermal
tattoo for the areolar reconstruction. Many designs are pos-
sible, and these are outlined in Figure 15.5. There are
varying degrees of success with pullout fl ap reconstructions,
based on their design. That is to say, the design of the spe-
cifi c nipple fl ap may indeed play a role in the ultimate pro-
jection. I believe that some fl ap designs are inherently better
than others. For example, I have found that the quadrapod
design18 (Fig. 15.6), which employs a direct elevation of the
tissue with closure of fl aps at the base of the nipple, is
unreliable in terms of producing and maintaining long-term
nipple projection. This technique often produces a nipple
which looks excellent on the operating table but loses most
of its projection with time (by 1 year postoperatively). When
studying this design and analyzing the technique of eleva-
tion, the loss of nipple projection would seem to be almost
intuitive. This is because the forces of wound contraction
act to pull this tissue directly back down to the plane of
the breast surface, thereby predisposing it to loss of
projection.
In contrast, the fl ap techniques that elevate skin and
adipose tissue off the reconstructed breast, detaching it at
all areas but the base of the fl ap and then reconfi guring it
into the desired nipple shape, are more successful in terms
of maintaining their projection.9–14,19–26 The elements in the

Cosmetic and Reconstructive Breast Surgery
210
FIGURE 15.3 A Suboptimal nipple reconstruction with signifi cant
loss of projection resulting in major asymmetry. B The areolar tattoo
transforms this suboptimally projecting nipple into an aesthetically
pleasing appearance. C, D The oblique views of the same patient
before and after the tattoo. This is a 7-year postoperative view.
A
B
C
D

Nipple–Areola Reconstruction
211
A
B
C
D
FIGURE 15.4 A ‘Nipple-sharing’ technique of nipple reconstruction, with harvest of the anteriormost aspect wedge of the nipple, which is
ready for transfer as a composite graft. B Alternatively, a wedge of the inferior aspect of the opposite nipple can be harvested for transfer as a
composite graft. C Composite graft of nipple placed on recipient bed. D Healed appearance of composite nipple graft.
dures are variations of the skate design originally proposed
by Hartrampf,11 subsequently modifi ed and refi ned by Little
and Spear12,20 (Fig. 15.7).
It has been my observation that the modifi ed star
design21 can reliably produce small to moderately projecting
nipples (less than or equal to 5 mm) (Fig. 15.8). For the
reconstruction of larger nipples, my choice is the skate
design12,20 (Fig. 15.7). The fi shtail fl ap developed by
McCraw22 (Fig. 15.9) also has the ability to produce a nipple
with very marked projection. Such designs may allow the
maintenance of greater long-term projection. Of particular
advantage is a modifi cation of the fi shtail fl ap design which
is used when there is a transversely oriented scar slightly
above or below the desired nipple position13 (Fig. 15.10).
This design makes it possible to reconstruct the nipple
without creating any new scars on the reconstructed breast.
It may be based either superiorly or inferiorly, depending
on the desired nipple position.
Most recently we further modifi ed the skate fl ap by a
design that closes the donor area primarily by virtue of
employing a second fl ap directly juxtaposed to the nipple
reconstruction and its ‘parent’ fl ap. We have called this
modifi cation the double opposing periareolar or DOPA fl ap
FIGURE 15.5 Pullout fl aps. These are the most commonly used skin
designs of skin and subcutaneous adipose fl aps for nipple
reconstruction.
fl ap responsible for nipple projection are adipose tissue and
the thickness of the dermis. These more reliable designs
are those in which the fl ap tissue used for reconstruction
of the new nipple is elevated or ‘pulled out’ to at least a 90º
angle from the surface of the breast mound. Such proce-

Cosmetic and Reconstructive Breast Surgery
212
A
B
C
D
FIGURE 15.6 A–D The quadrapod fl ap. This is a type of pullout fl ap
that does not involve separation and reconfi guring of the nipple.
Inherently it allows the forces of wound contraction to pull the nipple
back down to the base.
F
E
A
B
C
D
E
F
FIGURE 15.7 A–F The skate fl ap is the classic ‘pullout’ fl ap. It entails
elevating a composite of skin and fat out of the breast to a 90º angle
and confi guring the nipple, with closure of the donor site in a way so
as to support nipple projection.
(Fig. 15.11A–D).13 A very similar procedure was simultane-
ously introduced by Hammond.14
To learn more about the natural history of nipple recon-
struction, we have recently completed a prospective analy-
sis of projection loss studied every 3 months for 1 year
following nipple reconstruction. Our data indicate a loss of
projection of 40% with all types of fl ap, and the majority of
this loss occurs within the fi rst 6 months.10
PRIMARY NIPPLE RECONSTRUCTION:
PLANNING AND PATIENT MARKING
In planning nipple reconstruction the surgeon must study
the opposite breast carefully. It is important to note the
position of the nipple relative to the breast mound on the
contralateral breast. This must be visually assessed and
then careful measurements from a fi xed point, most often
the suprasternal notch, are taken. The next reference point
is the distance from the midline on the horizontal plane to
the position from the suprasternal notch, and this is also
an important parameter. These measurements are then
cross-referenced with the patient’s opinion as to where the
nipple should be created (Fig. 15.2B).
In this regard I will ask the patient to use a removable
EKG lead as a simulated nipple–areola complex and place
it on her reconstructed breast. I will ask her to do this while
standing in front of a full-length mirror as I leave the room.
This affords the best visual scenario for her to check the
position. I then return to the room and will either agree
with the position or make appropriate suggestions for modi-
fi cation. At this time the aesthetic judgment of the surgeon
comes very much into play. This relates to changing the
position relative to the shape and projection of the opposite
breast and considerations imposed by any scars that may
fall directly near or in the selected position for nipple place-
ment. Once the position of the nipple is established, mea-
surements from the suprasternal notch and the midline are
recorded, and reviewed the evening before surgery.
The projection of the opposite nipple, its base width,
and the shape and position of the areola all need to be
carefully assessed and considered in the preoperative plan

Nipple–Areola Reconstruction
213
for nipple reconstruction, in conjunction with its planned
position relative to existing scars on the reconstructed
breast (Fig. 15.12A–C). Occasionally the patient will request
that the nipple be positioned well away from the most pro-
jecting point of the breast mound so as to simulate the
position on the opposite breast. Such requests generally
result from signifi cant breast ptosis, as in the patient
in Figure 15.12D, who had signifi cant ptosis of her contra-
lateral breast and specifi cally requested that no modifi ca-
tion of that breast be done, and that the nipple be
reconstructed in a position to match that on her native
breast mound.
The base width and the projection of the normal nipple
on the contralateral breast determine the base dimension
and width of the lateral wings of the fl ap used for the new
nipple. These are important guides no matter which tech-
nique is selected. These features are taken into account
during the preoperative planning and are highlighted in
Figures 15.7, 15.8 and 15.11: the skate fl ap, the modifi ed
star, and the DOPA fl ap.
The essential steps in reconstruction of the nipple are:
● Establish the best possible position for the nipple to be
reconstructed.
● Verify the patient’s acceptance of the nipple position.
● Plan to match the base width of the opposite nipple.
● Select the best technique to match the projection of the
opposite nipple.
● Maintain all of the scars for the nipple reconstruction
within the area of the intended areola (the area that will
be tattooed).
Base width of
opposite nipple
Lateral flap
Central flap 1.5 cm
4 mm
adipose tissue
Note: distal tip of flap
is past midline to permit
‘stacking’ increasing
projection
1.5 cm
2 cm
A
B
C
D
E
FIGURE 15.8 A–E The modifi ed star fl ap. This is very useful in
primary and secondary reconstruction of the nipple. It is a derivative
of the skate fl ap.
1–1.5 cm
b
a
2.5 cm
b
a
b
a
b
a
b
a
b
a
a
A
B
C
D
E
FIGURE 15.9 A–E The design and elevation of the fi shtail fl ap.

Cosmetic and Reconstructive Breast Surgery
214
● Review the procedure with the patient using photo-
graphs to illustrate average outcomes, emphasizing that
a medical tattoo is the fi nishing touch that will confer
the maximum possible realism to the reconstructed
nipple.
SURGICAL TECHNIQUE
This procedure is routinely performed under local anesthe-
sia in the outpatient setting unless the patient is having
additional procedures necessitating general anesthesia. I
will generally use local anesthesia containing epinephrine
for all areas of the procedure, except for the very base of the
nipple fl ap, where I will use xylocaine without epinephrine.
The nipple reconstruction need not be performed in the
hospital operating environment as it can be safely done in
an offi ce operating room or even in a treatment room.
However, in cases where an implant breast reconstruc -
tion has been performed I believe that maximizing an
environment of sterility by performing the procedure in
an operating room environment is essential. Therefore, in
my opinion, a nipple reconstruction procedure following
an implant-based breast reconstruction requires the use
of an operating room where sterility can be maximally
preserved.
In performing nipple reconstruction the surgeon must
realize that, no matter which technique is used, these are
Heated transverse
mastectomy incision
Fishtail flaps designed
180 to each other
o
1.0–1.5 cm
A
B
FIGURE 15.10 A, B Alternative and very useful design of the fi shtail
fl ap which can be used when there is a transverse scar on the breast.


20% increase in
areola diameter
m
m
5
4
m
m
4
5
10–12 mm nipple
base width
10–12 mm
20–22 mm
A
B
C
D
FIGURE 15.11 A Plan for positioning of the nipple on the
reconstructed breast. Ideally the nipple is placed at the highest point
of the breast mound. It can be positioned according to dimensions
derived from fi xed points on the torso, including the suprasternal
notch, and distance from the midline. The base (here lateral) of the
new nipple should not be encroached upon by existing scars on the
breast. B Outline for modifi ed star fl ap reconstruction with 15 mm
base width. C Nipple placed in dependent position on left breast
reconstruction to match right nipple, which was in a dependent
position.

Nipple–Areola Reconstruction
215
A
B
C
D
FIGURE 15.12 A–D Planning for a combination of lipocontouring of
the breast and modifi ed star fl ap reconstruction.

Cosmetic and Reconstructive Breast Surgery
216
E
FIGURE 15.12, cont’d
delicate fl aps. They must be handled with extreme care
using skin hooks or fi ne forceps employed primarily with
sharp dissection with the scalpel or sharp scissors for fl ap
elevation. In confi guring and suturing the fl aps, the surgeon
must be careful not to twist or bend the fl aps excessively.
Flap loss due to ischemia may result from ‘overtightening’
the skin, excessive bending of the fl ap(s), or usng too many
sutures. Any element of fl ap compromise must be recog-
nized at the time of the nipple reconstruction and necessary
sutures removed or fl ap transpositions altered so as to
immediately reverse any fl ap ischemia during folding and
confi guring the nipple. Generally only one or two sutures
need to be removed to avoid such a problem.
Achieving primary wound healing is a key concept. As
already mentioned, the surgeon must avoid ischemia of
these delicate fl aps, which most often will lead to fl ap sepa-
ration and open wounds. This condition results in increased
wound contraction, often dramatically reducing nipple pro-
jection or altering the shape, inclination, and even the
position of the reconstructed nipple.
Following nipple–areola reconstruction, I feel it is neces-
sary to protect the nipple from external compressive forces.
To do this I use a ‘foam rubber doughnut’ placed around
the nipple, which I ask patients to wear inside their bra for
approximately 1 month. I believe that such a device may
help prevent the loss of projection due to early mechanical
compression (Fig. 15.13).
If a skin graft is used for the areolar reconstruction a
‘bolster-type’ dressing is placed to ensure maximal contact
of the graft with the underlying graft bed. This is left in
place for a minimum of 5 days. When skin grafts are needed,
full-thickness grafts are my preference. I do not feel it neces-
sary or advisable to harvest pigmented skin from the area
of the proximal inner thigh or labial region, as these donor
sites can be uncomfortable and/or painful. Almost all full-
thickness skin grafts undergo hypopigmentation with the
passage of time. It has been my experience that an intra-
dermal tattoo is the best way to optimize the color match
between the normal areola and areolar tissue around the
new nipple.
A skate fl ap requires a small or large skin graft to close
the donor area. The traditional skate involved a doughnut
or ‘washer-shaped’ skin graft, whereas more recent designs
have employed smaller rectangular skin grafts at the base
of the nipple. It is important to oppose the edges of the
dermis to close the donor area of the fat component on the
deep surface of the skate fl ap (Fig. 15.7D,E).
The use of the star fl ap (Fig. 15.8A–E) includes primary
closure of the donor area and does not require a skin graft.
The donor area in this technique is closed directly by edge-
to-edge skin approximation (Fig. 15.8D) in two layers. It is
important to realize that for this technique the sutures
which have been used to confi gure the nipple must be left
in for at least 2 weeks (Fig. 15.8E). A subsequent areolar
tattoo can camoufl age the scars from the donor closure
areas which extend radially away from the nipple base (Fig.
15.8D,E). Direct closure of the donor area slightly fl attens
the contour of the reconstructed breast.
FIGURE 15.13 Sterile foam rubber ‘doughnut’ to be placed around
the reconstructed nipple at the time of surgery to protect it from
compression over the fi rst 3 weeks of healing.

Nipple–Areola Reconstruction
217
When assessing a patient for nipple reconstruction the
surgeon must be especially wary of tissues that are exces-
sively thin, and this situation is common following the
use of tissue expansion for breast reconstruction (Fig.
15.14). Because tissue expansion defi nitely results in thin-
ning of subcutaneous fat layer and dermis, at the time of
exchange of the expander for the chosen implant I will
always make special note of the thickness of the muscle
layer, subcutaneous adipose tissue, and dermis, specifi cally
noting any signifi cant atrophy in the subcutaneous adipose
layer. As previously mentioned, I believe that it is helpful
to perform the nipple reconstruction at a third stage in
individuals who are undergoing implant reconstruction fol-
lowing the placement of a tissue expander.
The presence of scars (Fig. 15.14) on the breast is often
a signifi cant factor in selecting the type of nipple recon-
struction. Their position, width, and the quality of the
surrounding skin and deep tissue must be carefully assessed
and a plan developed to minimize any negative impact they
might have on the nipple reconstruction.
Scars from previous biopsies or the mastectomy can be
very problematic. They do infl uence the choice of tech-
nique, and especially if the scar runs right through the area
of the planned base of a new nipple reconstruction. In this
situation it is often advisable to use a technique that ‘strad-
dles’22–27 the scar (Fig. 15.15). The technique that best
accomplishes this is the double opposing tab fl ap described
by Knoll.23,27 Scars can be particularly important when they
lie right where the nipple is to be centered. Previous radia-
tion therapy causes fi brosis of the skin and dermis, and
confers to the skin fl aps a stiff quality which makes folding
and confi guring diffi cult. There is also decreased circulation
in such fl aps. A history of smoking further complicates
these conditions and poses special problems. Therefore I
urge all patients who smoke to quit completely for at least
4 weeks prior to surgery.28
In summary, I believe that it is essential to alter the
design of the nipple reconstruction procedure so that the
blood supply to the fl aps is minimally affected by existing
scar tissue. Radiation therapy poses its own set of diffi cul-
ties, especially if multiple skin scars are also present.
Patients who smoke also appear to have more in the way
of circulatory problems in the breast skin. As mentioned
above, this must be pointed out to the patient preopera-
tively and a plea made for temporary cessation of
smoking.28
Finally, primary nipple reconstruction must be carefully
planned and executed in a precise manner, as secondary
reconstructions are more diffi cult. For this reason, a few
FIGURE 15.14 Patient with signifi cant scar and atrophy of
subcutaneous tissue following a right breast reconstruction with
tissue expander and implant.
18 mm
15 mm
A
B
C
D
E
FIGURE 15.15 The double opposing tab fl ap. This is a nipple
reconstruction based on fl aps which are elevated and wrapped
around each other. It is useful when the scar from the mastectomy
runs directly through the site of intended nipple reconstruction. It is
important to make the base of these fl aps suffi ciently wide (18 mm)
to ensure vascularity to the reconstructed nipple.

Cosmetic and Reconstructive Breast Surgery
218
comments about the planning and technique of primary
nipple reconstruction are in order.
NIPPLE RECONSTRUCTION TECHNIQUES
My choice of nipple reconstruction technique depends on
the projection of the nipple I am attempting to match on
the contralateral breast. For nipples with 5 mm or less of
projection I favor the modifi ed star fl ap (Fig. 15.8A–E). For
nipples with greater projection I will sometimes use a skate
fl ap (Fig. 15.7A–F). Another indication for the skate fl ap is
the situation where no fl attening of the anterior contour of
the breast is desired. Here, a skate fl ap and a skin graft may
be preferable. Finally, I will consider the use of a double
opposing tab fl ap (Fig. 15.15A–E) when the mastectomy
scar runs directly through the site where the base of the
nipple would be ideally located. The following section out-
lines how I perform each of these techniques.
The modifi ed star fl ap
The design of the fl ap in a particular case is dependent on
the base width and projection of the opposite nipple: the
base width of the new nipple is created to match that of the
opposite nipple. The width of the lateral limbs determines
the ultimate nipple projection. When planning this dimen-
sion it is important to realize that there will be an approxi-
mately 30–40% loss of projection with time. Therefore, I
usually make the lateral limbs a minimum of 1.5 cm wide
and 2 cm long (Fig. 15.8A). The total height of the nipple
is planned for at least 1 cm. By making the distance from
the base of the lateral fl ap to the tip 2 cm, the fl ap will fold
around the central core of the nipple, allowing skin closure
without tension. These fl aps are elevated with 2–4 mm of
adipose tissue (Fig. 15.8B) on their deep surface (deep to
the dermis), which allows folding of the fl aps without
tension.
After the injection of 1% xylocaine without epinephrine,
the lateral fl aps or ‘wings’ are elevated fi rst, followed by the
central fl ap. The dissection proceeds toward the central
portion of the design. As the central core of the nipple is
approached it is important to access a deeper plane in the
adipose layer. In a primary nipple reconstruction the dis-
section proceeds unencumbered. In secondary cases the
surgeon will be elevating scarred elements of the previous
unsuccessful nipple, and so it is important to preserve the
maximal amount of blood supply to the adipose tissue and
skin arising deep within the fl ap. For this reason I elevate
the most proximal portion of the fl ap at its base, delicately
with blunt dissection, using either a tenotomy scissors or,
in some cases, the handle of the scalpel. This tends to
optimally preserve the blood supply to the central core of
adipose tissue and skin of the new nipple. The donor area
is closed primarily and in layers, with the deep dermis
closed fi rst (with coated polyglycolic acid suture Maxxon or
PDS 3/0) followed by a skin closure with interrupted 5/0
nylon. The nipple elements are then assembled, starting
with the lateral fl aps. These fl aps are advanced past the
midline to achieve a ‘stacking’ in the portion of the nipple
opposite the base so as to maximally increase the projection
(Fig. 15.8D).
The 5/0 nylon sutures used for confi guration of the
nipple are left in place for 3 weeks to ensure good healing
and to prevent the folded fl aps ‘unfurling’. Removing these
sutures before the end of the 3-week period has resulted in
wound separation in several cases. Finally, the newly recon-
structed nipple is protected from direct compression by a
foam rubber ‘doughnut’ (Fig. 15.13), which can be inserted
into a bra during the fi rst month of healing.
The skate fl ap
The skate fl ap (Fig. 15.7A–F) can produce a large nipple
with signifi cant projection and is my choice when the con-
tralateral nipple has a projection of 7 mm or more. The
nipple is located according to patient wishes and aesthetic
concerns. It is optimally positioned at the highest point of
the breast mound.
I will often give the patient an EKG lead which she can
place on her reconstructed breast, so as to choose her pre-
ferred position for the new nipple. The design of the skate
fl ap is variable, and the dimensions are dependent on the
projection of the opposite nipple. The base width is planned
to match that of the opposite nipple, with an approximately
equal distance of skin on either side to comprise the ‘lateral
wing.’ The distance from the base of the nipple to the por-
tion of the areola furthest from it is approximately twice
the projection of the opposite nipple (Fig. 15.7A). This 2 : 1
dimension of the central axis of the nipple allows for loss
of projection due to the normal processes of contraction and
wound healing. The patient should be informed preopera-
tively of the discrepancy in nipple height that will be present
immediately after surgery, the reconstructed nipple being
much larger. This central axis is also the region from which
the core of fat comprising the main substance of the nipple
will be elevated. The central core of the fl ap is adjoined on
either side by extensions of skin which, elevated together,
leave a circular outline (Fig. 15.7D,E). The position of the
nipple and design of the fl ap are checked just prior to taking
the patient to surgery.
The skin markings of the fl ap are injected with local
anesthetic without epinephrine (1% xylocaine). The outline
of the design is incised peripherally on all sides. Next the
lateral fl aps are elevated from peripheral to central at the
deepest dermal level. Yellow adipose tissue should not be
visible at this point. As the point of transition between the
lateral elements and the central core of the fl ap is reached,
the dissection is deepened by incising completely through
the dermis into the adipose tissue, thereby raising a core or
‘fi nger-like projection’ of adipose tissue in continuity with
the skin in the central portion of the fl ap. This core is gently
raised with a scalpel, leaving behind a deep V-shaped trough
defect in the subcutaneous adipose tissue. The width of this
core progressively increases as the dissection moves toward
the base of the fl ap. As the base of the fl ap is reached it is
important to preserve as much blood fl ow to the fat as pos-
sible. This blood fl ow is derived from vertically oriented
blood vessels running in the fat, and to spare them I will

Nipple–Areola Reconstruction
219
gently spread or stretch this tissue with either the dissecting
scissors or the handle of the scalpel. The dermis on either
side is incised to the nipple base to permit a full 90º eleva-
tion of the fl ap. When the elevated fl ap is held perpendicu-
lar to the plane of the breast it resembles a sunfi sh or skate
– hence its name, the skate fl ap.
The V-shaped donor area in the center (Fig. 15.7D) is
then closed with 4/0 chromic sutures which bring dermis
edge to dermis edge, taking care to bury the knots. This
closed wound will create a platform on which to assemble
the new nipple. The nipple is reconstructed by confi guring
the lateral wings around the central core, by starting at its
base and working towards the apex. The most lateral tip of
each lateral wing is sewn to its counterpart with interrupted
5/0 chromic sutures. The fl aps are closed without excessive
tension.
The donor area of the skate fl ap is most often closed
with a full-thickness skin graft, harvested from any area of
skin excess. It need not be taken from an area of skin with
increased pigmentation, such as the inner thigh or labia.
The graft is thoroughly defatted and sutured to the periph-
ery of the defect. It is preferable to raise a skin graft rather
than to close the wounds under excess tension. Closure
under tension will almost invariably produce a spread scar,
which will be unsightly and which does not take tattoo
pigment well.
A tie-over bolster dressing is used to maximize contact
between graft and recipient bed, and is usually left in place
for a minimum of 5 days. The reconstructed nipple is again
protected from compression by clothing with a foam rubber
doughnut, which is worn for 1 month.
The optimal time for areolar reconstruction with an
intradermal tattoo is approximately 3–4 months after
healing of the skin graft. The skate fl ap method permits the
reconstruction of a nipple of virtually any size, and it is my
technique of choice when the projection of the contralateral
nipple exceeds 6 mm.
The double opposing periareolar fl ap
My current fl ap of choice for nipple reconstruction in most
circumstances is a derivative of the skate fl ap. This is a
pullout fl ap which involves the construction of two fl aps
within a circular construct of a new areola. The site of the
nipple is located as with the other techniques just described.
The nipple itself is derived from the larger of two fl aps. The
base width of the fl ap is determined by the base dimension
of the nipple on the opposite breast. The width of the lateral
wings determines the eventual projection of the nipple, and
this dimension is determined by assessing the projection of
the opposite nipple. It typically varies in width between 10
and 12 mm (Fig. 15.11A). The nipple is elevated by raising
the ‘lateral wings’ and the central aspect of the nipple fl ap.
The lateral wings are raised with 1 mm or 2 mm of adipose
thickness until the central aspect of the nipple is reached.
Here it is necessary to include a plug of additional adipose
tissue that will vary from 4 to 8 mm in thickness. This
adipose tissue is raised in contiguity with the fl ap, as in the
development of both the skate and modifi ed star fl aps. The
dissection of the wings is complete when the nipple stands
upright without sutures. Care is taken to maintain as much
blood supply as possible to the nipple fl ap. A small addi-
tional ‘cap’ of skin is included with the elevation of the
lateral wings (Fig. 15.11C), creating a central donor area.
The nipple is then reconstructed using 5/0 nylon sutures.
The ‘cap’ closes over the most projecting aspect of the
nipple.
The central donor area thus created is closed by mobiliz-
ing both the parent fl ap for the nipple and the ‘opposing
fl ap’ designed opposite to it. These fl aps are mobilized by
releasing the dermis peripherally. This is done by placing
the fl aps on tension with a double skin hook and incising
through the dermis only with a sharp scalpel. There will be
a defi nite ‘give’ when the dermis is divided. The dissection
stops at that point so as to preserve the subdermal plexus
of blood vessels. This maneuver creates considerable ability
of the fl aps to ‘slide’ toward each other on their subcutane-
ous pedicles. There is no undermining of either the parent
fl ap or the opposing fl ap. This maneuver allows easy
approximation of the fl ap edges, permitting closure of the
central donor area. The nipple fl ap itself is sutured to the
edge of the smaller fl ap or to a small de-epithelialized
surface on this smaller fl ap. This fl ap surface provides a
solid foundation for the nipple fl ap and this may minimize
subsequent loss of nipple projection
A peripheral donor area is produced by this maneuver.
The peripheral donor area is then closed with a ‘purse-
string’ suture of 2/0 or 3/0 Maxon to create the appearance
of an areola. The skin is closed with interrupted sutures of
5/0 nylon. A protective dressing using Adaptic non-adher-
ent layer, gauze, and a sterile foam doughnut is then applied,
and the patient placed in a surgical bra. The sutures are
removed no sooner than 2 weeks after surgery.
The double opposing periareolar fl ap has become our
technique of choice for nipple reconstruction in primary
cases. It avoids the use of skin grafts and seems to have the
advantage of maximizing nipple projection in the long term.
The appearance of the peripheral and central scars follow-
ing surgery simulates the appearance of the visual lines of
a nipple (Fig. 15.12E), even prior to intradermal tattooing.
This technique is similar to that described by Hammond.14
It is different in that, apart from the nipple fl ap itself, there
is no undermining of the parent or opposing fl aps.
Caution is needed when using this technique in patients
who have undergone previous irradiation of the breast skin
fl aps, and in those who have very thin fl aps following previ-
ous tissue expansion and implant placement. In the former
situation there may be concern about the blood supply of
the fl aps, and it may be advisable to design the parent fl ap
of the nipple and the corresponding ‘opposing’ fl ap as large
as possible so as to maximize the area of the subcutaneous
pedicles. In the latter case care must be taken when the
fl aps are very thin following previous surgery and tissue
expansion. Preservation of the subcutaneous plexus is
essential, as is allowing suffi cient time to elapse from the
implant placement procedure so that the mobility and the
elasticity of the tissues at the site of nipple reconstruction
will have returned as close to normal as possible. This

Cosmetic and Reconstructive Breast Surgery
220
A
B
C
D
E
FIGURE 15.16 A Partial loss of previous left nipple reconstruction
following tissue expander and implant noted on AP view. B Lateral
view of same patient. Note lack of projection in the reconstructed
nipple. C Composite nipple graft harvested from opposite nipple.
D Postoperative result of redo nipple reconstruction 9 months after
surgery on AP view. E Lateral view of composite nipple reconstruction
9 months following surgery.

Nipple–Areola Reconstruction
221
Redo nipple reconstruction
with modified star flap
On-table nipple projection
following redo nipple
Modified star flap incision closure
Design of modified star flap in bed of
previous nipple reconstruction
A
B
C
D
usually means that the interval between implant placement
and nipple reconstruction is 4–6 months.
The double opposing tab fl ap
As previously mentioned, a potential problem situation for
nipple reconstruction results when the scar from the mas-
tectomy runs directly through the intended site of recon-
struction. This scar can cause problems with the vascularity
of the fl ap(s) used for the nipple reconstruction, and reduces
the amount of subcutaneous adipose tissue available on the
deep surface of the skin fl aps. The situation can be addressed
with the use of fl aps raised on either side of the scar. Such
a technique is that of the double opposing tab fl ap as pro-
posed by Kroll23,27 (Fig. 15.15A,E).
If this double opposing design is used it is essential to
make the base width of the fl aps a minimum of 15 mm.
This will help ensure an adequate blood supply to the fl aps
as they are elevated. Unfortunately, closure of the created
donor defect does confer a defi nite ‘fl atness’ to the recon-
structed breast mound at this point. This remains an
unsolved problem. Nevertheless, the double opposing tab
fl ap remains a useful technique when the mastectomy scar
runs directly though the ideal position for nipple creation.
It is important to realize that, no matter which tech-
nique is selected, contraction will occur as part of the
healing process, and therefore the nipple needs to be made
larger than the opposite nipple at the time of reconstruc-
tion. Prior to the study noted above we had the strong
clinical impression that the ‘shrinkage’ rate was somewhere
between 40% and 60% when projection is seen as a function
of time from surgery and the projection is carefully studied
for 1 year. As corroborated in our study, most of the projec-
tion is lost within the fi rst 6 months, loss continuing for
up to a year but being apparently stable after that. This is
an important concept for the surgeon to be aware of when
trying to achieve long-term nipple symmetry from the
standpoint of projection.
REVISING THE SUBOPTIMAL NIPPLE
RECONSTRUCTION
Cases of minor projection loss may be compensated for
by an intradermal tattoo (Fig. 15.3A–C). This tends to
produce color patch symmetry, giving the visual appearance
of a normal breast and nipple symmetry on casual glance.
I believe that a well-done tattoo can ‘rescue’ or salvage
a suboptimal nipple reconstruction in many cases (Fig.
15.3D).
Major loss of projection following nipple reconstruction
is disappointing for both the patient and the surgeon. This
result is an asymmetry which detracts from the overall
appearance of the reconstruction. This situation can be
addressed in several ways.
An uncommon but helpful method is to use a composite
graft of nipple from the opposite breast – if the nipple is
suffi ciently large and the patient is willing to permit a
surgical procedure on it with the placement of incisions.
The utility of this technique is illustrated by the following
case.
The patient in question had undergone a previous nipple
reconstruction following breast reconstruction with a tissue
expander and subsequent implant. The reconstructed nipple
had suboptimal projection (Fig. 15.16A,B). Because the
patient had a wide thin scar at the intended site of nipple
reconstruction only, with attrition of the skin and subcu-
taneous fat from the tissue expansion process, and a very
large contralateral nipple, we addressed this problem by
de-epithelialization of the skin overlying the suboptimal
nipple reconstruction and placing a composite graft from
the opposite nipple (Fig. 15.16C). This remedied the defi -
cient projection and enhanced symmetry between the
nipples (Fig. 15.16D,E).
More commonly a modifi ed star fl ap21 is very helpful as
a source of ‘booster’ tissue (Fig. 15.17) for the suboptimal
nipple reconstruction. This fl ap can be elevated at the site
of the original nipple reconstruction as long as it is oriented
such that the base is not encroached upon or compromised
by existing scar tissue. The use of this fl ap to augment
nipple projection in a patient who had previously under-
gone nipple reconstruction with a modifi ed star procedure
is illustrated in Figure 15.18(A–F). This was a young woman
who had had an immediate left breast reconstruction with
a TRAM fl ap. Eight months after surgery she underwent
FIGURE 15.17 Outline of redo nipple reconstructed with a modifi ed
star fl ap. The fl ap is designed such that the base (blood supply) is
oriented in the same direction as the previous reconstruction.

Cosmetic and Reconstructive Breast Surgery
222
A
B
C
D
FIGURE 15.18 Modifi ed star fl ap used as a ‘boost’ to inadequate previous nipple reconstruction. A Inadequate projection of reconstructed
nipple compared to signifi cant projection of the nipple on the patient’s opposite breast. B Design of redo nipple reconstruction with the
modifi ed star fl ap used as a ‘boost’ to address the inadequate projection of the previous reconstruction. C, D Surgical elevation of the fl ap.
Gentle handling of the tissue is accomplished with a skin hook.

Nipple–Areola Reconstruction
223
E
F
FIGURE 15.18, cont’d E Flap tissue being ‘confi gured’ into the shape of a nipple. F Enhanced projection noted postoperatively on the lateral
view.
nipple reconstruction with a superiorly based modifi ed star
fl ap. She sustained wound separation at the site of fl ap
inset, which resulted in excessive wound contraction and a
70% loss of nipple projection. Five months after complete
healing we performed another modifi ed star fl ap to increase
her nipple projection (Fig. 15.18B,C). This was done by
orienting the fl ap in the exact same direction as the original
fl ap, elevating most of the previous fl ap with the new modi-
fi ed star fl ap (Fig. 15.18D). This produced a very satisfac-
tory outcome from the standpoint of symmetry with the
contralateral nipple (Fig. 15.18E,F).
REFERENCES
1. Bostwick J 3rd. Plastic and reconstructive breast surgery. St Louis:
Quality Medical Publishing, 1990; 1174.
2. Shestak KC. Re-operative plastic surgery of the breast.
Philadelphia: Lippincott Williams & Wilkins, 2006.
3. Slavin SA, Colen SR. Sixty consecutive breast reconstructions with
the infl atable expander: a critical appraisal. Plast Reconstruct Surg
1990; 86: 910–919.
4. Maxwell GP, Falcone PA. Eighty-four consecutive breast
reconstructions using a textured silicone tissue expander.
Plast Reconstruct Surg 1992; 89: 1022–1034; discussion
1035–1036.
5. Klatsky SA, Manson PN. Toe pulp free grafts in nipple
reconstruction. Plast Reconstruct Surg 1981; 68: 245.
6. Brent B, Bostwick J 3rd. Nipple–areola reconstruction with
auricular tissues. Plast Reconstruct Surg 1977; 60: 353.
7. Adams WM. Labial transplant for correction of loss of the nipple.
Plast Reconstruct Surg 1949; 4: 295.
8. Bhatty MA, Berry RB. Nipple–areola reconstruction by tattooing
and nipple sharing. Br J Plast Surg 1997; 50: 331–334.
9. Little JW. Nipple–areolar reconstruction. In: Cohen, Mimis (ed.)
Mastery of surgery: plastic and reconstructive surgery. Vol. II.
Boston: Little, Brown, 1994.
10. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-
term nipple projection: a comparison of three techniques. Plast
Reconstruct Surg 2002; 110: 780–786.
11. Hartrampf CR Jr, Culbertson JH. A dermal-fat fl ap for nipple
reconstruction. Plast Reconstruct Surg 1984; 73: 982.
12. Little JW 3rd. Nipple–areola reconstruction. Clin Plast Surg 1984;
11: 351.
13. Shestak KC, Nguyen TD. The double opposing peri-areolar fl ap: a
novel concept for nipple–areola reconstruction. Plast Reconstruct
Surg 2007; 119: 473–480.
14. Hammond DC. Nipple reconstruction with a variation of the skate
fl ap. Plast Reconstruct Surg (in press).
15. Broadbent TR, Woolf RM, Metz PS. Restoring the mammary
areola by a skin graft from the upper inner thigh. Br J Plast Surg
1977; 30: 220.
16. Spear SL, Convit R, Little JW 3rd. Intradermal tattoo as an adjunct
to nipple–areola reconstruction. Plast Reconstruct Surg 1989; 83:
907.
17. Becker H. The use of intradermal tattoo to enhance the fi nal result
of nipple–areola reconstruction. Plast Reconstruct Surg 1986; 77:
673.
18. Little JW 3rd, Munasifi T, McCulloch DT. One-stage
reconstruction of a projecting nipple: the quadripod fl ap. Plast
Reconstruct Surg 1983; 71: 126.
19. Little JW. Nipple–areolar reconstruction. In: Cohen, Mimis ed.
Mastery of surgery: plastic and reconstructive surgery. Vol. II.
Boston: Little, Brown, 1994.
20. Little JW. Nipple–areola reconstruction. In: Spear SL, Little JW,
Lippman ME, Wood WC, eds. Surgery of the breast: principles and
art. Philadelphia: Lippincott-Raven, 1998.

21. Eskenazi L. A one-stage nipple reconstruction with the ‘modifi ed
star’ fl ap and immediate tattoo: a review of 100 cases. Plast
Reconstruct Surg 1993; 92: 671–680.
22. McCraw JB, Colen L. The fi sh-tail fl ap in nipple reconstruction.
Personal communication.
23. Kroll SS, Hamilton S. Nipple reconstruction with the double-
opposing-tab fl ap. Plast Reconstruct Surg 1989; 84: 520.
24. Hugo NE, Sultan MR, Hardy SP. Nipple–areola reconstruction
with intradermal tattoo and double-opposing pennant fl aps. Ann
Plast Surg 1993; 30: 510–513.
25. Weiss J, Herman O, Rosenberg L, Shafi r R. The S nipple–areola
reconstruction. Plast Reconstruct Surg 1989; 83: 904–906.
26. Lossing C, Brongo S, Holmstrom H. Nipple reconstruction with a
modifi ed S-fl ap technique. Scand J Plast Reconstruct Hand Surg
1998; 32: 275–279.
27. Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple
projection with the modifi ed double-opposing tab and star fl aps.
Plast Reconstruct Surg 1997; 99: 1602–1605.
28. Rohrich RJ, Coberly DM, Krueger JK, Brown SA. Planning elective
operations on patients who smoke: survey of North American
plastic surgeons. Plast Reconstruct Surg 2002; 109: 350–355;
discussion 356–357.
Cosmetic and Reconstructive Breast Surgery
224

225
Index
Page numbers relating only to illustrations are in italics.
aspirin 36
asymmetry
after breast augmentation 130
correction 136, 138, 142
natural 119–21, 120, 121, 125, 130
augmentation mammaplasty see breast
augmentation
augmentation mastopexy
circumareolar technique 135, 138–9,
141
circumvertical technique 135, 139–40,
141–2, 143
complications and side effects 135,
140–4
indications and contraindications 135–6
markings 137–8
operative approach 137–40
optimizing outcomes 140
patient risk factors 136
pearls and pitfalls 140
postoperative care 144
preoperative history and
considerations 136
revision 143
vertical technique 135
in weight loss patient 185
auranofi n 198
axillary lymph node biopsy 86
B
Becker implant 9–10
bioprosthetic materials 4, 5
biosynthetic materials 4
body habitus 1, 2, 27, 119
brachioplasty, L 191–3, 193, 195
breast augmentation
complications 126–32
contraindications 119
incisional approach 123–4
indications 119
operative approach 125–6
optimizing outcomes 126
patient motivation and expectations 119,
122–3
patient selection 119
popularity 119
postoperative care 126
preoperative considerations 119–23, 125
prior to breast cancer diagnosis 96–7
reoperation rate 126, 127
scarring 126–7
unsatisfactory 127–8
breast cancer
breast reduction reduces risk 95
local recurrence 97
in men 197
postoperative surveillance 95
breast conserving surgery see lumpectomy
breast implants see implants
breast parenchyma
defect location 98
resection 162, 166–7
breast reconstruction 84, 91
after BCT 96
autogenous 21–34
bilateral 9, 10, 68
clinical outcomes 8
complications 15–18
delayed 11–12, 13, 14, 63, 68, 96
delayed-immediate 12–14
failed 91
free TRAM fl aps 35–47
immediate 3, 84
implantable Doppler monitoring 76
indications and contraindications 1–3
one-stage, with implants 8–11
operative approach 3–11
optimal size and shape 44
partial 49
patient selection 1–2
pedicled TRAM fl ap 21–34
perforator fl aps 49–67
pre- and postoperative photographs 3
prosthetic selection 2–3
results 27–8, 28–34
revision procedures 47
scars 3
secondary 57
sensate 75–6
two-stage, with expanders and
implants 3–8
unilateral 9
breast reduction
choice of technique 157–8
complications and side effects 149–50
historical background 145–6
indications and contraindications 96,
146–7
informed consent 149
liposuction-only techniques 157–8
optimizing outcomes 104–6, 149
in partial mastectomy defect repair 99–
104, 105
patient preferences 146
A
abdomen, zones 50
abdominal donor site
bulging 46, 58, 63, 65
closure and management 23, 25, 26, 45,
63–4, 195
morbidity 49, 65
abdominal fat, for breast
reconstruction 49–50
abdominal fl aps
blood supply 50
contraindications 84
for repair of partial mastectomy
defect 98
abdominal scars 22, 36
abdominal surgery, previous 22, 35, 36, 49,
184, 185
acellular dermal matrix see bioprosthetic
materials
adrenal neoplasms 198
alcohol 198
AlloDerm, insertion 5, 7–8
ambulatory care surgery centers 108
amiodarone 198
amphetamines 198
anabolic steroids 198
androgen synthesis inhibitors 198
androgen-insensitivity syndromes 198
androgens 198
anti-ulcer medicines 198
antiandrogens 198
antibiotics
and capsular contracture 131, 139
and gynecomastia 198
prophylactic 125–6, 139
routine use 5, 8, 80, 88, 89, 118, 169–
70, 177
in treatment of complications 16, 18,
77, 127
arcuate line (semicircular line, arc of
Douglas) 23, 36, 45, 50
areola
appearance and symmetry 207
closure 168–9
dehiscence 179
intradermal tattoo 207, 208, 208, 210,
214, 216, 221
support 166
see also nipple–areolar complex; nipple–
areolar reconstruction
areolar opening, marking 160
aromatase 198

Index
226
patient risk factors 150
popularity 145
postoperative care 150
reduces risk of breast cancer 95
revision rate 173
scars 148, 149
short scar (vertical) techniques 157–81
sutures 149
symmetry 14
Wise pattern techniques 145–55
breast reshaping see mastopexy
breast size
assessment 4, 110
bra sizing mechanics 1, 2
and choice of reduction technique
157–8
impact on repair 96–7
large 96, 157
and radiation dose 95
small 83
breast surgery
complications 76
in patient with massive weight
loss 183–96
breastfeeding 119, 124, 149, 159, 163, 166
breasts
anatomy 109–10, 135, 136, 189–90
blood supply 158
congenital aplasia 67
ducts 159, 207, 209
effects of weight changes 109–10, 117,
143
esthetic considerations 11, 26, 35, 49,
85, 109, 145, 175, 183, 207
innervation 158–9
involutional changes 120
matching see contralateral breast,
remodeling
meridian 159, 160
natural asymmetry 119–21, 120, 121,
125
physiologic alterations 109
preoperative assessment 4, 119, 121
skin defect, size and location 97–8
surgical anatomy 125, 158–9
tuberous deformity 116, 117, 124, 137
upper border, important landmark 159,
160
zone designations 99
C
cancer agents (anchorin agents) 198
capsular contracture 15–16, 89, 124, 130–2
capsulectomy 70, 89, 131–2
capsulorrhaphy sutures 129
capsulotomy 89
captopril 198
carcinoma, occult 95
cardiac bypass surgery 22
cardiovascular drugs 198
cellulitis 16, 127
cesarian section, scarring 22
chemotherapy 68, 95
chest donor site, closure 195
chest wall, skin quality 11–12
choke vessels 37
cholecystectomy, open 22
chorionic gonadotropin estrogens 198
cimetidine 198
circumareolar techniques 135, 138–9, 141,
157
clomid 198
connective tissue disease 21
contralateral breast, remodeling 24, 47, 53,
68, 75, 83, 91, 95, 104
cyproterone 198
D
deep inferior epigastric artery 50, 58
deep inferior epigastric perforator (DIEP) fl ap
additional venous drainage 59, 60
conversion to TRAM fl ap 64–5
in delayed reconstruction 58
dissection 57–8, 62
donor site 46, 60
double-pedicle 55, 57
failed reconstruction 68–9
indications and contraindications 49
marking 57, 63
operative approach 56–64
optimizing outcomes 64–5
pitfalls 61
preoperative considerations 49–56
selection criteria 41
shaping 59–63
territory and design 56
diabetes 21, 23, 68, 150
diazepam 198
DIEaP fl ap see deep inferior epigastric artery
perforator (DIEP) fl ap
DIEP fl ap see deep inferior epigastric artery
perforator (DIEP) fl ap
digitoxin 198
dog-ears
excising 140
minimizing 6, 24, 25, 57, 69, 139, 140,
148
revision 27, 75, 118, 149, 157
Doppler see ultrasound
double opposing periareolar (DOPA)
fl ap 208, 211–12, 213, 220, 221
double opposing tab fl ap 217, 221
double-bubble appearance 129, 130
drains, rarely used 169, 177
drugs of abuse 198
dual-plane technique 3, 4, 5, 6, 10
ductal anatomy 159
E
electric dermatome 189, 194
enalapril 198
epigastric arteries and veins 22, 23, 37
estrogen-binding blockers 198
expander see tissue expander
external iliac artery 50
F
fascia-sparing technique 39, 40, 45, 46
fat necrosis 46, 65, 106
feminization 197
fi ll port failure 16–17
fi shtail fl ap 211, 213, 214
fl ap procedures, surgical stress 36
fl aps
avoiding ischemia 216
failure 76
loss due to vessel thrombosis 45
necrosis 28, 89, 96, 150, 195
venous drainage 58
fl utamide 198
free TRAM fl ap
advantages 35
complications 36, 45–6
harvesting 39–40
high-risk patients 35–6
indications and contraindications 35–6
markings 36, 37
operative approach 38–45
optimizing outcomes 39
postoperative care 46–7
preoperative considerations 36
recipient site 43
second-stage operation 47
see also transverse rectus abdominis
musculocutaneous (TRAM) fl ap
G
gastric bypass surgery 185
glandular reshaping 116
gluteal arteries, perforators 69
gluteal donor site
closure 73
scar 75
gluteal tissue, use for autogenous breast
reconstruction 67
gluteus muscle, blood supply 69
gonadal failure 198
gynecomastia 197–205
appearing during puberty 197
associated conditions 197, 198
direct excision 199, 201, 202
drug-induced 197, 198
idiopathic 198
operative treatment 197–8
repair 199, 200
skin resection/removal 199, 203
work-up 197
H
haloperidol 198
hematoma
after breast augmentation 127
after breast reconstruction 17
after breast reduction 177, 180
hemi-TRAM fl ap, pedicled 98
hemostasis 77
hermaphroditism 198
hernia 36, 46, 49
see also abdominal donor site
heroin/opiates 198
human chorionic gonadotropin (HCG),
atopic production 198
hyperaxilla, reduction 186–8, 191
hypertension 21
hypomastia, developmental 120, 123
hypothyroidism/thyrotoxicosis 198
I
imaging
preoperative 49
see also MRI; multidetector row CT
(MDCT) scanning
implant reconstruction,
contraindications 67

Index
227
implants
in breast reconstruction 2–3, 15, 67
capsular contracture 130–1
choice of silicone vs saline 2–3, 8, 10,
12, 17–18, 86–7, 121–2, 126
contribute to ptosis 109
dual plane location 124–5
fi nite lifespan 3, 15
handling 5, 125–6
infection 16
malfunction/failure 3, 15, 78, 89, 132
malpositioned 127–9
permanent 8
placement 86, 124, 125
postoperatively adjustable 9, 10
saline
complications 126
insertion 126
rupture 132
selection 12, 86–7, 137
shape 123
silicone
complications 127
FDA approval 119, 121–2, 126
insertion 126
rupture 132
size 122–3
texture 17–18, 123
uses and limitations 119, 121
inclusion cysts 195
infection, after breast augmentation 127
inferior gluteal artery perforator (IGAP) fl ap
reconstruction 75
inferior pedicle technique 147, 149, 157,
158, 180
infi ltration 161
inframammary folds
in breast reconstruction 8, 24
in delayed reconstruction 11
guideline for nipple position 159
and implant malposition 128–9
location 44–5, 109, 125
low 43
marking 36
position 119
(re)creation 4, 12, 58
remote valve position 10
repositioning after weight loss 183, 190
scar 157
inframammary incision 124, 125
inguinal hernia repair 49
intercostal nerves 125, 158
blocks 195, 196
internal mammary vessels
anatomy 22, 158
exposure 71
re-use as recipients 98
as recipients 43, 58–9, 60–2, 65, 68–9
inverted T techniques 145–55
popularity 110–11, 117, 145, 157
see also Wise pattern techniques
irradiation see radiation therapy
isoniazid 198
K
ketoconazole 198
kidney cancer 198
Kocher clamp 162
L
lateral intercostal artery perforator (LICAP)
fl ap, in revision surgery 65
lateral mammary folds 4, 8, 11, 12
lateral pedicle 158
latissimus dorsi
anatomy and blood supply 83–4
donor site scar 75
loss of muscle function 85
preoperative assessment 86
latissimus dorsi myocutaneous (LDM)
expander/implant reconstruction
delayed 87–9, 91
immediate 89, 90
two-stage 84
latissimus dorsi myocutaneous (LDM) fl ap
in breast reconstruction 83–93
complications 89
dissection/harvesting 87
does not compromise abdominal wall
84
implant generally required 84
indications and contraindications 84,
85
insetting 87–8
necrosis 89
optimizing outcomes 89
patient selection 83
and permanent prosthesis 83
positioning 86
preoperative considerations 86–7
revision procedure 28
single-stage vs two-stage procedure 83
skin color and texture 98
tissue volume 98
LDM fl ap see latissimus dorsi
myocutaneous (LDM) fl ap
LICAP fl ap see lateral intercostal artery
perforator (LICAP) fl ap
linea alba 37, 49
linguini sign 15
lipofi lling techniques 65
lipoplasty, ultrasound-assisted 195
liposuction
areas 164, 166
in breast reduction 157–8
in gynecomastia repair 198, 200, 201,
202
previous 36, 49
liver disease 198
local anesthesia, for nipple–areolar
reconstruction 214
local tissue, for immediate repair 96, 99
local tissue rearrangement 96, 97, 98, 99,
101, 106
lower body lift 184
lower extremity weakness 85
lumpectomy defect see partial mastectomy
defect repair
lumpectomy and postoperative radiation
therapy 49, 84, 90, 91, 95
failed 59
lung cancer 198
lymph node dissection 39, 86
M
McKissock technique 145–6, 157
macromastia 150, 151, 152, 153, 154, 155
male breasts, benign enlargement see
gynecomastia
malpractice litigation 135
mammogram, preoperative 121
mammostat, use 113
marijuana 198
mastectomy
nipple–areolar preservation 3, 4
non-skin-sparing 84
quality of skin fl aps 4
salvage 84, 90, 91
skin pattern 24
skin preservation 3
skin-sparing 3, 4, 6, 14, 24, 28
mastectomy fl ap
evaluation 24, 43
necrosis 96
mastectomy scar
as access incision 24
evaluation 43
mastopexy 109–18
after weight loss 183–9
at time of augmentation 121, 122
Benelli procedure 116
complications 110, 114, 117
indications 110
inverted T technique 117
malpractice litigation 135
patient education 110
patient selection 116
periareolar 115–17
popularity 109
postoperative care 118
preoperative considerations 110
revision 184
scars 110, 114, 116, 117
surgical techniques 110–17
temporary improvement 110
vertical procedures 111–15, 118
Wise pattern 184, 190
see also augmentation mastopexy
medial pedicle approach
closure 167–8
design 160–1, 162
markings 159–60, 161, 162
operative procedure 158–71
Medusa’s head 69, 71, 72
mesh reinforcement 26, 28, 45
methyldopa 198
metronidazole 198
microvascular technique, for DIEP fl ap
reconstruction 59
MRI, for implant rupture 15
MS-TRAM fl ap 40–2, 46
multidetector row CT (MDCT)
scanning 56, 57–8, 64
muscular coverage, total 3, 4, 5
N
nerve repair, inclusion in SGAP
reconstruction 75–6
nifedipine 198
nipple
free graft 98, 99, 100, 101
free reduction 146–7
innervation 158
necrosis 143–4, 177, 179
optimal appearance 207, 208

Index
228
position assessment 135
repositioning 159, 160, 199
sensation changes 114, 125, 127, 199
sharing 208–9, 211
nipple–areolar complex
innervation 125
location 109
loss 149
male 199
malpositioned 144
proximity of breast parenchymal
defect 98
relocation 115, 138, 147, 150, 190
sensory changes 127, 149
support 149
symmetry 212–13
tattooing 75, 79, 81
nipple–areolar reconstruction 75, 79, 81,
207–24
assessment 217
guidelines 207
options 208–12
planning and patient marking 212–14
postoperative care 216
revision 220, 221
surgical technique 214–18
techniques 218–21
timing 207, 217
O
obesity
considerations in fl ap surgery 39, 46
relative contraindication 1, 15, 22, 36,
39, 189
risk factor 67
omeprazole 198
oncologic considerations, take
precedence 11
oxygen, hyperbaric 149–50
P
pain, postoperative 77–8, 195
paraesthesia, inner thigh 65
partial mastectomy defect repair 85, 95–108
abdominal fl ap 98
breast reduction technique 99–104, 105
clinical pearls 107
complications and side effects 106–7
indications and contraindications 96–7
operative approach 99–104
postoperative care 107
preoperative history and
considerations 97–9
revision procedures discouraged 107
scheduling burden 108
timing 96, 104
see also lumpectomy
patients
discomfort during expansion process 3
education/expectations 1–2, 3, 4, 68,
189
general health 22, 67, 68
high-risk 65, 68, 76, 83, 89
postoperative pain 77–8, 195
primary motivation 135, 136
selection 76
pectoralis expander method 3, 86
pedicled TRAM fl ap breast reconstruction
anatomic factors 22
complications 21
indications and contraindications 21–2
marks 23–4
operative approach 22–7
postoperative chemotherapy 28
preoperative history and
considerations 22
second-stage procedure 27, 29
pedicles
blood supply 158
in breast reduction 145, 146
creation 162, 163, 166
full thickness 159, 163
role 146
penicillamine 198
perforator fl aps 49–67
secondary options 68
perforators
anatomy 50
dissection 58
periumbilical 22–3, 37
preoperative assessment 56–7, 64
as recipient vessels 43, 46, 75
in TRAM fl ap 36, 37, 40
ultrasound location 64, 69, 70–1, 70, 74
periareolar incision 123–4, 125
Pfannenstiel incision 49
phenothiazines 198
phenytoin 198
pinch test 57
pneumothorax 78
postoperative care
augmentation mastopexy 144
breast augmentation 126
breast reduction 150
free TRAM fl ap 46–7
importance 76–7
mastopexy 118
nipple–areolar reconstruction 216
partial mastectomy defect repair 107
perforator fl aps 65
short scar breast reduction 178
spiral fl ap reshaping 196
superior gluteal artery perforator (SGAP)
fl ap 78–80
pot-belly habitus 35, 36
pregnancy 84, 109, 119, 121
prostheses see implants
pseudogynecomastia 197
pseudoptosis 110, 160
psychoactive agents 198
ptosis
classifi cation 110
defi nition 2
minimal 83
physiologic 109
preoperative evaluation 135, 138
preservation 86
puckers, disappearance/correction 171, 172,
173, 174, 175, 180
pullout fl aps, for nipple reconstruction 208,
209–11, 211
Q
quadrapod fl ap 209, 212
R
radiation therapy
complication 217
compromises skin expansion 12
effects on quality of prosthetic
reconstruction 12–13
prior 4, 68, 83, 84
relative contraindication for breast
reconstruction 1
and tissue expander 5
upcoming 4
ranitidine 198
recipient site, preparation 58, 69–70
recipient vessels
exposure 58–9
re-use in subsequent reconstruction
98
rectus abdominis muscles 22–3, 36–7, 38
rectus sheath 36–7
reduction mammaplasty see breast
reduction
Regnault classifi cation 110, 135
renal disease 198
reserpine 198
reverse abdominoplasty, closure 195
rib cartilage resection, complications 77–8
rippling, following breast
reconstruction 17–18
S
saphenous vein surgery 49
Scarpa’s fascia 25, 38, 50, 56, 74
scarring
from previous irradiation 59
in gynecomastia repair 199, 204
patient education 77
problematic in nipple–areolar
reconstruction 217
revisions after mastopexy 118
seroma
after breast reconstruction 17
after breast reduction 177, 178
at donor site 77, 89
formation 65, 106
SGAP fl ap see superior gluteal artery
perforator (SGAP) fl ap
short scar breast reduction
complications 177–8
indications and contraindications
157–8
optimizing outcomes 171
postoperative care 178
preoperative history and
considerations 158
sickle cell trait 150
SIEA fl ap see superfi cial inferior epigastric
artery (SIEA) fl ap
skate fl ap 211, 212, 213, 216, 218–19
skin
excision 140, 146
laxity after weight loss 183, 190
post-radiation changes 80
quality 11–12, 110, 157
resection 97–8, 160, 162, 167
skin grafts, pigmented 207, 216
skin pattern, separate entity from
pedicle 146

Index
229
smoking
increases complication rate 35–6, 67,
217
preoperative abstention/cessation 36,
137
relative contraindication 22, 23, 39, 46,
49, 189
see also patient risk factors
Spectrum implant 9
spiral fl ap reshaping
complications and side effects 195–6
description of fl ap 190
indications and contraindications 189
operative approach 189–95
optimizing outcomes 189, 195
postoperative care 196
results 186–8, 191–3
sickle pattern modifi cation 190, 193,
194
with upper body lift 183
spironlactone 198
Staphylococcus epidermidis 16
star fl ap, modifi ed 211, 213, 215, 216, 218,
221–3
starvation 198
sterile technique, importance 125–6
sulindac 198
superfi cial inferior epigastric artery,
anatomical variations 51–6
superfi cial inferior epigastric artery (SIEA)
fl ap 39, 49–67
anatomic considerations 49
complications and side effects 65
dissection 62
indications and contraindications 49
insetting and shaping 63–4
marking 57
pitfalls 61
preoperative considerations 49–56
territory and design 56
superfi cial inferior epigastric vein 39, 43,
56, 59
superior gluteal artery perforator (SGAP)
fl ap 67–82
anastomosis and inset 73–4, 75
bilateral 75, 77, 78, 81
complications and side effects 76–8
disadvantages 68
dissection 70–3
donor site scarring 69, 77, 79, 82
indications and contraindications 67–8,
76
markings 69, 70
operative approach 68–76
optimizing outcomes 76
patient selection 68, 76
postoperative care 78–80
preoperative history and
considerations 68
recipient site preparation 69–70
sensate 75–6
staged revisions 75, 77, 78, 79, 81
superior pedicle 157, 158
superomedial glandular technique 149
superomedial pedicle 146, 148, 150
suspensory ligaments of Cooper 109
symmetry, normal 138
synmastia, after breast
augmentation 129–30
T
tail of Spence, recreating 63
tan lines 138
tattoo, intradermal 207, 208, 208, 210,
214, 216, 221
teardrop sign 15
Tegaderm 118
testicular neoplasms 198
testosterone production defects 198
theophylline 198
thoracodorsal artery perforator (TDAP)
fl ap, pedicled, in revision
surgery 65
thoracodorsal nerve 83, 86
thoracodorsal vessels
compromised 86
as recipients 69, 83, 98
thoracoepigastric advancement fl ap 12
thoracotomy, posterolateral 86
tissue expander
contour profi le 2
exchange procedure 88–9
placement 3, 4, 87–8
postoperative expansion 88
selection 4, 86
serial infl ation 5
superior displacement 3
under the LDM fl ap 83
tissue volume
adequate 49, 107
see also breast volume
tobacco use see smoking
total body lift 186–8
single stage 190, 191–3
TRAM fl ap see transverse rectus abdominis
musculocutaneous (TRAM) fl ap
transaxillary incision 124, 125
transumbilical incision 124, 125
transverse rectus abdominis
musculocutaneous (TRAM)
fl ap
blood supply 21, 23, 28, 37–8
complications 28–34
contralateral 43
double pedicle–bilateral 25–6
elevation 24–5
free 35–47
full-muscle 39–40
insetting and shaping 43–5
ipsilateral, pedicled 98
necrosis 28
in partial mastectomy defect repair 98
pedicled 21–34
shaping 26–7
skin zones 38
see also free TRAM fl ap; pedicled TRAM
fl ap breast reconstruction
tricyclic antidepressants 198
tumor type, importance 68
tumors
early detection 95
ipsilateral recurrence 84
margins 95, 97
U
ultrasound 56–7, 64, 65
see also lipoplasty, ultrasound-assisted;
perforators, ultrasound location
umbilicus
repositioning 25, 39, 45, 46
zone of adherence 49
underweight, contraindication for
mastopexy 189
upper body lift 189, 190
V
venous coupler device 74
verapamil 198
vertical scar mastopexy see mastopexy,
vertical procedures
vertical skin resection pattern 158
vertical thighplasty 184, 186
W
weight
fl uctuation, effect on breast 109–10,
117
loss 143, 183–96
wheelchair transfer 85
Wise pattern
developed from brassiere design 167
historical background 145
modifi cations 97
when not preferred 101
Wise pattern techniques
in breast reduction 100, 102, 145–55
closure 106, 148, 149
operative approach 147–9
preoperative markings 147, 150
in repair of partial mastectomy
defect 106–7
revision rate 149
unsuitable for male breast 199
Wise wire pattern, method of use 147
wound healing, delayed 18
wrinkling, following breast
reconstruction 17–18