Reoperative Plastic Surgery of the Breast

SURGICAL MODIFICATION OF BOTH
BREASTS FOLLOWING LUMPECTOMY
AND RADIATION THERAPY
There is a circumstance in which it is propitious to per-
form surgery to alter the appearance of both breasts fol-
lowing a previous lumpectomy: when an ipsilateral breast
is deformed in the face of macromastia and a bilateral
breast reduction would facilitate symmetry. It is possible
to operate on most breasts that have undergone lumpec-
tomy, but with a marked increase in the risk for complica-
tions. Of course the greater the extent of local scarring or
radiation-induced tissue damage, the greater the risk for
complications.
This situation is illustrated by this 53-year-old patient
(Fig. 9-19), who had undergone a lumpectomy 5 years pre-
viously for a stage II breast cancer located superior to the
NAC at the 12 o’clock position on the right breast. There
was a contour deformity present in the upper central
aspect of the right breast marked by an indentation in the
contour (Fig. 9-19A) that was especially apparent on lat-
eral view (Fig. 9-19B). The patient was 5 feet 4 inches tall
and the bra cup size of the left breast was DD. She desired
a breast reduction on the left side and a procedure on the
right side that would optimize the symmetry between
the breasts. Because of her surgery in the upper pole
of the right breast, I did not think it was prudent to per-
form a limited scar procedure and therefore we planned
for an inferior pedicle reduction on the left breast and an
inferior pedicle mastopexy on the right breast (Fig.
9-19C). The procedure established good symmetry
between the right and left breasts, both of which demon-
strated an attractive appearance (Fig. 9-19D).
Both unilateral modification of the opposite breast
following a previous lumpectomy and modification of
both breasts at the appropriate time after surgery are
the treatment options with the highest satisfaction rat-
ing across the board in the postlumpectomy patient
population.
ONCOPLASTIC SURGICAL TREATMENT
FOR THE POST-LUMPECTOMY PATIENT
Not infrequently following lumpectomy and radiation
therapy, the patient will exhibit a marked asymmetry
between the breasts and a definite deformity on the side
from which the tumor was resected. This deformity can
be quite severe as is seen in the following case. This 56-
year-old female presented for consultation 12 months fol-
lowing partial mastectomy and radiation done to treat a
right breast cancer in the lower outer aspect of the breast
(Fig. 9-20A,B). This produced a marked contour abnor-
mality, nipple areola dislocation with the nipple pointing
inferiorly, and nipple retraction. There was a healed scar
442
Reoperative Plastic Surgery of the Breast
FIGURE 9-19. Postlumpectomy breast asymmetry 5 years fol-
lowing previous surgery. Note contour deformity of right breast
on AP view (A) and lateral view (B). (continued)

in the lower outer quadrant of the breast. The patient had
macromastia, and the contralateral left breast was a DD
cup in size. She requested a procedure to improve the
symmetry between the breasts and to treat the abnormally
positioned NAC (Fig. 9-20C). The best operative plan was
that of a bilateral breast reduction.
Oncoplastic surgery is a discipline wherein the sur-
geon alters the breast affected by the cancer most often
by some combination of repositioning the nipple areola
complex and the adjacent breast parenchyma and skin
flaps so as to produce a better shape in the breast from
which the tumor was resected. This oncoplastic surgical
treatment can be performed at the time of tumor ablation
or at a much later time after the patient has undergone
radiation therapy to the affected breast. In general I pre-
fer to wait 9 to 12 months after the radiation is completed
before operating on such a breast. This will afford the tis-
sues the necessary time to “recover” and allow the wound
healing process to progress well into its chronic phase. It
is at this time when healing in these tissues is most pre-
dictable. It is important to enter into a discussion about
this time line with every patient seeking post-lumpec-
tomy reconstruction.
In all such cases the plastic surgeon must carefully
analyze the treated breast for the position of scars. Such
scars often determine the selection of the pedicle to be
used. The aesthetic plan for nipple transposition is then
outlined on both breasts (Fig. 9-20D). In this particular
case an inferior pedicle technique was planned. It was
apparent that a considerable release of scar tissue that
was “tethering” or holding the NAC in the abnormal
position was necessary. During the procedure the sur-
geon must release this cicatrix within the breast
parenchyma while a hook is placed on the nipple area
with traction in a direction so as to place the nipple in
an appropriate position. This must be (and usually can
be) done without compromising the circulation of the
NAC. I prefer to use the electrocautery device on the
cutting mode for this maneuver. In this case the internal
scar release allowed the dislocated and retracted nipple
to be repositioned in the appropriate location on the
affected breast. A contralateral breast reduction was
carried out, and this created good symmetry between
the breasts (Fig. 9-20E,F).
The option of surgically altering both breasts is the
most common strategy used in oncoplastic procedures to
treat post-lumpectomy deformities. I predict it will have
far greater impact in the treatment of such patients with
severe deformities in the near future.
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
443
FIGURE 9-19. (CONTINUED) C, Patient is treated with a right
mastopexy and left breast reduction. D, Immediate restoration of
better breast symmetry at the completion of surgery on AP view.

444
Reoperative Plastic Surgery of the Breast
FIGURE 9-20. A, AP view of patient who has undergone a partial mastectomy to remove a breast can-
cer in the lower outer quadrant of the breast. B, Note the extreme dislocation of the NAC on lateral
view. C, Scar causing invagination of skin and dislocation of the NAC. D, The plan for the reduction is
marked on the skin including intended new nipple position. (continued)

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
445
RECONSTRUCTION OF
POSTLUMPECTOMY DEFECTS WITH
FLAPS
There are two settings in which flaps have been used to
treat a postlumpectomy deformity. The first, and classically
the most common, setting is breast reconstruction follow-
ing mastectomy to treat a local recurrence where a comple-
tion mastectomy is indicated and a breast reconstruction
using a flap is then performed. The second is reconstruc-
tion of a partial mastectomy defect marked by a significant
deformity of the breast remnant. The breast remnant is
reconstructed preserving the NAC and the majority of the
remaining breast tissue. This latter situation represents the
most difficult type of breast reconstruction from the stand-
point of achieving consistently good results.
The most common scenario in my practice is that of
using a musculocutaneous flap for immediate breast
reconstruction at the time of total mastectomy done to
treat a local recurrence in the previously operated and
radiated breast. The following two cases illustrate the use
of a TRAM flap and an autogenous latissimus flap in this
setting.
This 42-year-old patient (Figs. 9-21 and 9-22) presented
with a local recurrence 4 years after lumpectomy and
radiation therapy (5,000 cGy) to treat a breast cancer in
the upper outer quadrant of her left breast. She had a sig-
nificant deformity marked by an indentation in the upper
outer aspect of her breast, a dislocation of the NAC, and a
volume deficiency. The plan was for a completion mastec-
tomy and immediate breast reconstruction with a TRAM
flap (Fig. 9-21). In this case the flap was successful in
replacing the volume deficit and in restoring a normal
contour. A secondary nipple reconstruction provided an
excellent finishing touch in terms of producing symmetry
with the opposite breast (Fig. 9-22).
This next patient had a significant deformity of the left
breast following a previous lumpectomy and radiation for
breast cancer (Fig. 9-23A). She developed a local recur-
rence whose treatment required a mastectomy. She had
undergone five previous intra-abdominal procedures with
incisions in both the upper and lower abdomen that con-
traindicated the use of a TRAM flap (Fig. 9-23A,B). She
was moderately obese with excess adipose tissue in the
back region, including the axilla and lateral chest (Fig. 9-
22C). The plan for breast reconstruction included an auto-
genous latissimus dorsi flap with harvest of a significant
amount of adipose tissue with the latissimus dorsi muscle
(Fig. 9-23C) and a contralateral (right) mastopexy for
symmetry. In a patient of this body habitus it is possible to
harvest a significant amount of adipose tissue with the
muscle (Fig. 9-23D). Her reconstruction and contralateral
mastopexy resulted in an excellent appearance of her
breasts in terms of symmetry (Fig. 9-23E). She also
demonstrates the extreme extent of a back deformity that
can result from an abundant harvest of adipose tissue
from the back (Fig. 9-23F).
Such contour deficits in the back wound from a latis-
simus dorsi flap donor site can improve with the accumu-
lation of a small seroma, or they may be benefited by the
injection of autologous fat grafts. In any event, in patients
for whom such a flap is planned, the reality of substantial
depression at the latissimus flap donor site should be
reviewed preoperatively. Patients such as this one, who
are at a high risk for a suboptimal outcome, and in reality
for a myriad of complications using any method, are often
well served by a latissimus dorsi flap reconstruction with-
out the use of an implant. When harvesting such a flap the
surgeon should maintain all of the adipose tissue above
the dorsal thoracic fascia on the skin flaps of the back. In
addition, the adipose tissue anterior to the muscle, espe-
cially that proximally in the region of the axilla, can be—
and must often be—harvested with the muscle tissue. The
FIGURE 9-20. (CONTINUED) E–F, At 2 months following sur-
gery marked improvement in the appearance of the breasts is
seen. The symmetry is good and the appearance of the right NAC
is dramatically improved.

446
Reoperative Plastic Surgery of the Breast
flap is best designed so that the skin closure can be
achieved without undue tension.
RECONSTRUCTION OF THE PARTIAL
MASTECTOMY DEFECT WITH
AUTOGENOUS TISSUE
Philosophically I have always been in favor of using flap
tissue to perform an entire breast reconstruction, i.e.,
after all of the remaining tissue has been removed with a
completion mastectomy. However, Slavin12 and others6
have demonstrated the oncologic safety of reconstructing
such deficits from the standpoint that long-term surveil-
lance of such a breast is possible by both a physical exam-
ination and x-ray studies. Therefore, I am more and more
often performing partial breast reconstruction in patients
who have undergone a lumpectomy that has resulted in a
significant deformity but who nevertheless wish to keep
their native breast.
This first patient underwent a lumpectomy with
removal of tissue in the upper central portion of her breast
to excise her tumor. This, combined with the subsequent
radiation therapy, resulted in a significant volume asym-
metry and contour depression in her central and
lateral breast regions with upward displacement of the
NAC (Fig. 9-24A,B). She requested reconstruction but
expressed a desire to maintain her native breast.
FIGURE 9-22. Preoperative and postoperative appearance of the breast after subsequent nipple
reconstruction and intradermal tattoo.
FIGURE 9-21. AP view of a 34-year-old patient who has been pre-
viously treated with a left lumpectomy and radiation therapy.
Patient has dislocation of the NAC and a significant contour
deformity of the left breast. She has developed a recurrent breast
cancer, and the plan now is for completion mastectomy and
immediate breast reconstruction with a single pedicle TRAM flap.

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
447
FIGURE 9-23. A significant postlumpectomy deformity of left
breast on AP view (A) and lateral view (B). C, Patient has recur-
rent left breast cancer and requires a mastectomy. The plan is for
an autogenous latissimus dorsi flap reconstruction. (continued)

448
Reoperative Plastic Surgery of the Breast
FIGURE 9-23. (CONTINUED) D, The latissimus flap is har-
vested with a segment of de-epithelialized skin, and the entire
deep adipose layer overlying the muscle is kept with the skin. E,
Patient shows an excellent cosmetic outcome from the combina-
tion of the latissimus flap reconstruct and a contralateral inferior
pedicle mastopexy. F, The flap donor defect is seen at 1 year post-
operative.

The plan was for a staged reconstruction with the
placement of a tissue expander (Fig. 9-24C) in the subg-
landular position to stretch both the breast parenchyma
and skin so that there would be an ample space for the
latissimus dorsi flap. The space was overexpanded slightly
(Fig. 9-24D). At the completion of her course of tissue
expansion the affected breast was slightly larger than the
opposite breast in its appearance (Fig. 9-24D). The latis-
simus muscle with a small de-epithelialized skin paddle
harvested through a bra line incision was harvested and
transferred (Fig. 9-24E) simultaneously with the removal
of the tissue expander. This produced good symmetry with
the opposite breast (Fig. 9-24F,G) and an acceptable
donor site scar (Fig. 9-24H), both noted at 6 weeks follow-
ing surgery. The patient was very satisfied with the correc-
tion of the abnormal contour and with the fact that the
breast was soft to the touch.
It is not usually necessary to employ an intermediate
phase of tissue expansion in cases where the latissimus
dorsi flap is used to reconstruct partial mastectomy
defects. However, because of the anticipated parenchy-
mal scar and that we would be burying the entire flap, I
choose to create a space into which to place the de-
epithelialized latissimus dorsi musculocutaneous flap
that would minimally constrict the flap during the early
phases of healing.
This final patient illustrates the use of the TRAM flap
for correction of severe deformities of the lower breast
pole following lumpectomy procedures in which too
much breast tissue was resected. This 52-year-old patient
presented with a marked deformity following the exci-
sion of a tumor in the lower pole of the left breast. This
resulted in a marked contour deformity with an inferior
displacement of the NAC (Fig. 9-25A–C) and a volume
asymmetry. She expressed a desire to maintain her
native breast and sought correction of her deformity. The
only real option was the transfer of autologous tissue to
reconstruct this scarred, irradiated, substantial defect.
She had a mild excess of lower abdominal skin and
subcutaneous adipose tissue. There was no history of pre-
vious abdominal surgery. The plan was a surgically
delayed ipsilateral TRAM flap. Following the delay she
underwent careful templating of the defect (Fig. 9-25D,E).
Only minimal new skin was required. The TRAM flap pro-
duced a restoration of the contour of the lower pole of the
breast, and she is extremely please with the restoration of
her previous breast shape, contour, and volume. The
patient is shown 6 months postoperatively with excellent
correction of her contour abnormality and a relatively
normal breast appearance in terms of nipple symmetry
(Fig. 9-25F–H).
In summary, correction of moderate to significant
deformities following partial mastectomy or lumpectomy
with subsequent radiation therapy is most often best
achieved by the addition of flap tissue. The most com-
monly used tissue composites are the rectus abdominis
and latissimus dorsi musculocutaneous flaps. Free tissue
transfer is also an option for the particularly adept
microvascular surgeon.
CLOSING THOUGHTS
Reconstruction of partial mastectomy defects will
become much more common in the near future. This is
because so many patients with breast cancer are being
treated with breast conservation therapy, and the sur-
geons performing the procedure continue to “push the
envelope.” This is a challenging and rewarding area of
plastic surgery. The popularity of oncoplastic surgery is
increasing, and many patients who have larger tissue
resections will undergo breast tissue rearrangements at
the time of their breast tumor removal and before radia-
tion therapy. I have found that the principles outlined in
this chapter have helped me in approaching these
patients.
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
449

450
Reoperative Plastic Surgery of the Breast
FIGURE 9-24. AP view (A) and oblique view (B) of postlumpectomy defect of the right breast. C, The
plan is for reconstruction in stages with placement of a tissue expander in the subglandular position
through the old lumpectomy scar. D, Tissue expansion is completed. (continued)

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
451
FIGURE 9-24. (CONTINUED) E, Tissue expander has been removed and the latissimus flap is ready
for transfer. F–G, Postoperative appearance at 6 months following surgery showing symmetry of
breasts. H, Appearance of flap donor area on patient’s back.

452
Reoperative Plastic Surgery of the Breast
FIGURE 9-25. A–C, Significant deformity of left breast following lumpectomy for resection of a
tumor from the inferior pole of the breast and subsequent radiation therapy. D–E, The plan is for a sin-
gle pedicle TRAM flap after releasing the scar and recreating the defect. F–H, Dramatic improvement in
the contour and symmetry of left breast following TRAM flap reconstruction.

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
453
FIGURE 9-25. (CONTINUED)

454
Reoperative Plastic Surgery of the Breast
REFERENCES
1. Fisher B, Bauer M, Margolese R, et al. Five-year results of a
randomized clinical trial comparing total mastectomy and
segmental mastectomy with or without radiation in the treat-
ment of breast cancer. N Engl J Med. March 14, 1985;312(11):
665–673.
2. Jacobson JA, Danforth DN, Cowan KH., et al. Ten-year
results of a comparison of conservation with mastectomy in
the treatment of stage I and II breast cancer. N Engl J Med.
April 6, 1995;332(14):907–911.
3. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and
results after 12 years of follow-up in a randomized clinical
trial comparing total mastectomy with lumpectomy or with-
out irradiation in the treatment of breast cancer. N Engl J
Med. November 30, 1995;333(22):1456–1461.
4. Dooley WC. Breast Cancer: Surgical Therapy. In: Cameron
JL, ed. Current Surgical Therapy. 3rd ed. St. Louis, Mo:
Mosby; 1995.
5. Matory WE Jr, Wertheimer M, Fitzgerald TJ, et al. Aesthetic
results following partial mastectomy and radiation therapy.
Plast Reconstr Surg. May 1990;85(5):739–746.
6. Clough KB, Cuminet J, Fitoussi A, et al. Cosmetic sequelae
after conservative treatment for breast cancer: classification
and results of surgical correction. Ann Plast Surg. 1998;
41(5):471–481.
7. Clough KB, Kroll SS, Audretsch W. An approach to the repair
of partial mastectomy defects. Plast Reconstr Surg.
1999;104(2):409–420.
8. Audretsch WP, Rezai M, Kolotas C, et al. Tumor-specific
immediate reconstruction (TSIR) in breast cancer patients.
Perspect Plast Surg. 11:71, 1998.
9. Kroll SS, Singletary SE. Repair of partial mastectomy
defects. Clin Plast Surg. April 25, 1998;25(2):303–310.
10. Shestak KC. The definitive treatment of radiation ulcers.
Presented at: The 2004 Plastic Surgery Educational
Foundation Perspectives and Advances in Plastic Surgery;
March 2004; Vail, Co.
11. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast
Surg. January 2001;28(1):111–119.
12. Slavin SA, Love SM, Sadowsky NL. Reconstruction of the
radiated partial mastectomy defect with autogenous
tissues. Plast Reconstr Surg. 1992;90(5):854–865; discussion
866–869.

455
C h a p t e r 1 0
◗Revision of Nipple Areola
Reconstruction
Nipple Reconstruction Options 459
Commonly Encountered Problems with
Reconstructed Nipples 461
Avoiding Problems During the Primary
Procedure—Planning and Patient
Marking 462
Surgical Technique 464
Planning in the Difficult Case 465
Nipple Reconstruction Techniques 468
The Modified Star Flap 468
The Skate Flap 469
The Double-Opposing Tab Flap 469
Revision and Salvage of the Suboptimal
Nipple Reconstruction 471
Subtotal and Total Nipple Loss 472
Redo Nipple Reconstruction with a
Double-Opposing Sliding Periareolar
Flap 477
Redo Nipple Reconstruction with
AlloDerm 477
Incorrect Nipple Position 477
Incorrect Nipple Inclination 484
Problems with Tattooing 485
Nipple Loss Following Breast Reduction
or Mastopexy 486
References 488
The nipple is a unique structure that in its natural state
has an important physiologic function in terms of breast-
feeding. It also confers to the breast both an aesthetic and
sexual dimension. Reconstruction of the nipple following
mastectomy visually transforms the newly created breast
mound into a breast, and subsequent areola color patch
duplication gives to the reconstructed breast the maxi-
mum amount of realism that any breast reconstruction
can ever achieve (Fig. 10-1A,B).
The nipple is an essential aesthetic feature of the breast
(Fig. 10-2A) and it is the hub around which the rest of the
gland emanates. Anatomically the nipple represents the
terminus of the multiple lactiferous ducts1 (usually 20 to
30) that run through the breast (Fig. 10-2B). These ducts
are clustered in the nipple and functionally they allow
egress of mother’s milk. They contain fibrous tissue and
specialized muscle elements. The nipple is surrounded by
areola tissue, which is a darkly pigmented epithelium that
has a small number of ducts opening into it. In addition,
this areola tissue contains Montgomery glands or tuber-
cles and lanugo hairs (Fig. 10-2A). The areola skin is visu-
ally darker than the surrounding breast skin but is slightly
lighter in pigmentation than the nipple.1 The nipple is
most aesthetically positioned at the point of maximal pro-
jection on the breast mound.1 It can be located by the
transposition of the inframammary (IM) fold (done rou-
tinely in planning a breast reduction) or by measurements
from fixed points of reference on the anterior chest (done
in most nipple reconstructions following a previous breast
reconstruction). The distance from the nipple to the
suprasternal notch and the IM fold varies from patient to
patient (Fig. 10-2C,D). In the absence of previous surgery

or an obvious developmental asymmetry the nipple posi-
tions are roughly symmetric.
When nipple areola reconstruction is performed the
optimal visual appearance of the reconstructed nipple is
achieved by simulating the best possible color match with
the opposite areola. In the past this was accomplished
with the transplantation of a darkly pigmented full-thickness
skin graft (vulva or proximal medial thigh skin). Currently,
however, this is best done with an intradermal tattoo,
which can produce the most predictable symmetry with
the opposite areola in a wide variety of colors.1
Symmetrically reproducing the size, shape, and color
of the opposite areola must be the surgeon’s goal in every
nipple areola reconstruction. In my opinion the most
important characteristics of successful nipple areola
reconstruction are pigmentation, position, and projec-
tion—in that order.
Visual symmetry between the color and location of the
nipple areolar complex (NAC) on the opposite breast and
its position on the reconstructed breast mound is para-
mount for the optimal visual appearance of the recon-
structed nipple. This symmetry can be most ideally
enhanced and most consistently reproduced using an
intradermal tattoo, with which the surgeon can best simu-
late the color patch of areola skin on the opposite breast.
As stated, the color of the areola around the reconstructed
nipple is more important than either the position or the
projection of the areola. Indeed, color patch symmetry
can compensate for partial or even significant loss of nip-
ple projection or slight abnormalities in position. This is
illustrated in this patient (Fig. 10-3), who sustained a sig-
nificant loss of nipple projection, marring what was other-
wise a good left breast reconstruction with a TRAM flap.
This situation was rescued by a well-done intradermal tat-
too, which produced an excellent aesthetic outcome.
(Fig. 10-3A–D).
456
Reoperative Plastic Surgery of the Breast
FIGURE 10-1. 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 recon-
struction and areola tattoo. Note vivid dimension of realism.
FIGURE 10-2. A, Photograph of distinctive color and position
of the NAC, which ideally is located at the highest point of the
breast mound. B, Schematic illustrating ducts draining the lob-
ules and emanating through the nipple. C–D, Typical position of
nipple relative to topographic landmarks on the chest wall.

Chapter 10
Revision of Nipple Areola Reconstruction
457
FIGURE 10-2. (CONTINUED)

In terms of timing, I believe that nipple areola recon-
struction is best done at a second stage rather than during
the primary breast reconstruction procedure. This allows
the breast mound to mature in terms of evolution of shape
and gravitational settling. In my practice nipple recon-
struction is most often combined with a procedure to
revise and reshape the reconstructed breast. In cases
where the reconstruction is performed with tissue expan-
sion followed by secondary placement of an implant,
I perform the nipple reconstruction as a third stage,
458
Reoperative Plastic Surgery of the Breast
FIGURE 10-3. A, Suboptimal nipple reconstruction with significant loss of projection resulting in a
major asymmetry. B, The areola tattoo transforms this suboptimally projecting nipple into a nipple
with an aesthetically pleasing appearance. C, Pre-operative oblique view. D, Post-operative oblique
view. This is a 7-year postoperative view.

although others2,3 will perform the procedure at the time
of subsequent implant placement. Performing a simulta-
neous nipple reconstruction at the time of exchanging the
expander for an implant carries with it a small but definite
increased risk of losing the implant due to problems with
wound healing and subsequent exposure and/or infection
at the site of nipple reconstruction.2,3
NIPPLE RECONSTRUCTION OPTIONS
Historically, the options for nipple areola reconstruction
have been tattoo alone; the use of composite grafts such as
toe pulp,4 earlobe,5 labia minora6; or most commonly a
composite graft of a portion of the contralateral nipple7
from the opposite breast (in patients with extremely large
nipples). Over the past twenty years pullout skin flaps
raised at the desired nipple position have represented the
state of the art8–12 in nipple reconstruction. The most com-
monly used flaps are listed in Table 10-1. Reconstruction
of the areolar region is then performed using either a full-
thickness skin graft with darkly pigmented skin13 or, as
noted earlier, an intradermal tattoo,14,15 which is the best
way to create symmetry of areola color.
An intradermal tattoo alone for nipple reconstruction
may be sufficient in the elderly, high-risk patient who
desires a semblance of visual symmetry15 but in whom it
may not be wise to have a formal nipple reconstruction
due to local tissue conditions (i.e., scarring of skin, atro-
phy of dermis, and subcutaneous adipose tissue).
Chapter 10
Revision of Nipple Areola Reconstruction
459
FIGURE 10-3. (CONTINUED)
◗TABLE 10-1 Nipple Reconstruction Options
I. Tattoo only
II. Composite grafts
a. Toe pulp
b. Earlobe
c. Labia minora
d. Opposite nipple
III. Pullout skin flaps
a. Skate
b. Star
c. Modified star
d. Fishtail
e. Mushroom
f. Double-opposing tab flaps
g. Areola tattoo

With the exception of nipple sharing,7 composite
grafts, which were important in the early days of nipple
reconstruction (e.g., earlobe, toe pulp), are largely rele-
gated to the role of historic significance alone. I believe
that there is still a place, albeit rarely, for nipple sharing.
This technique is applicable in special circumstances of
primary reconstruction where there are extremely thin
and attenuated tissues or scarring in the desired position
of nipple reconstruction in the patient who has a large
opposite nipple that might serve as donor tissue for nipple
reconstruction (Fig. 10-4A–D). In addition, a composite
graft of the nipple is also helpful in a difficult secondary
case to treat the complication of loss of nipple projection
in selected instances where the option of local flap recon-
struction is unavailable. Such a case is illustrated in
Figure 10-4.
Nipple sharing involves removal of either the distal or
most anterior aspect (Fig. 10-4A) of the nipple or excision
of a pie-shaped portion of the nipple on its undersurface
(Fig. 10-4B). It obviously decreases the size of the donor
nipple, which in some cases may be a benefit. It also results
in a scar on the donor nipple. However, when such compos-
ite grafts are placed in the appropriate location and sur-
rounded by an intradermal tattoo, they can produce a good
simulation of the patient’s opposite nipple (Fig. 10-4D).
Currently the most popular technique for nipple recon-
struction involves the use of a pullout flap8–10 of skin and
subcutaneous adipose tissue at the ideal site on the recon-
structed breast mound with the application of an intrader-
mal tattoo for the areola reconstruction. Many designs are
possible and these are outlined in Figure 10-5. Varying
degrees of success can be achieved with pullout flap
reconstructions based on their design. That is to say, the
design of the specific nipple flap may indeed play a role in
the ultimate projection. I believe that some flap designs
are inherently better than others.
For example, I have found that the quadripod design16
(Fig. 10-6), which employs a direct elevation of the tissue
with closure of flaps at the base of the nipple, is unreliable
in terms of producing and maintaining long-term nipple
460
Reoperative Plastic Surgery of the Breast
FIGURE 10-4. A, Nipple-sharing technique of nipple reconstruction with harvest of the most anterior
aspect of the 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.

projection. This technique often produces a nipple that
looks excellent on the operating table but it loses most of
its projection with time (by 1 year postoperatively). To the
surgeon who studies this design and analyzes the tech-
nique of elevation, this loss of projection would seem to be
almost intuitive. The forces of wound contraction would
act to directly pull this tissue back down to the plane of
the breast surface, thereby predisposing it to and potenti-
ating loss of projection.
In contrast, the flap techniques that elevate skin and adi-
pose tissue off of the reconstructed breast, detaching it at
all areas but the base of the flap and then reconfiguring it
into the desired nipple shape, are more successful in terms
of maintaining their projection.8–11,17–20 The elements in the
flap responsible for the nipple projection are adipose tissue
and the thickness of the dermis. The more reliable designs
are those in which the flap tissue used for reconstruction of
the new nipple is elevated, or pulled out, to at least a 90-
degreen angle from the surface of the breast mound. Such
procedures are variations of the skate design originally pro-
posed by Hartrampf,11 which were subsequently modified
and refined by Little and Spear (Fig. 10-7).17,18
It has been my observation that the modified star
design19 can reliably produce small to moderately project-
ing nipples (Fig. 10-8; ≤5 mm). For the reconstruction of
larger nipples, my choice is the skate design18 (Fig. 10-7).
The fishtail flap developed by McCraw20 (Fig. 10-9) also
has the ability to produce a nipple with very marked pro-
jection. Such designs may allow the maintenance of
greater long-term projection. Of particular advantage is a
modification of the fishtail flap design that is used when
there is a transversely oriented scar slightly above or
slightly below the desired nipple position (Fig. 10-10).
This design makes it possible to reconstruct the nipple
without placing any new scars on the reconstructed
breast. It may be based either superiorly or inferiorly,
depending on the desired nipple position.
COMMONLY ENCOUNTERED
PROBLEMS WITH RECONSTRUCTED
NIPPLES
Problems associated with nipple reconstruction include
asymmetries of position or a slight tilt of the nipple to one
side or the other, or in a superior or inferior direction; differ-
ences in skin pigmentation, and the most commonly noted
problem, projection loss. Loss of projection is multifactor-
ial. It is related certainly to the natural processes inherent
with wound healing, most notably contraction. Additionally,
loss of projection can be attributed to ischemia of the skin
and adipose tissue in the nipple flap itself. This is most often
marginal ischemia of the skin flap used for the nipple recon-
struction at the point of inset. The latter can result in an
open wound, which accentuates the problem of wound con-
traction and increases the loss of nipple projection. To learn
about the natural history of nipple reconstruction, we have
recently completed a prospective analysis of projection loss
studied every 3 months for 1 year following nipple recon-
struction. Our data indicates a loss of projection of 40%
Chapter 10
Revision of Nipple Areola Reconstruction
461
FIGURE 10-5. Pullout flaps. These are the most commonly
used skin designs for skin and subcutaneous adipose flaps used
for nipple reconstruction.
A
B
C
D
Quadripod flap
FIGURE 10-6. A–D, The quadripod flap. This is a type of pull-
out flap that does not involve separation and reconfiguring of
the nipple. Inherently it allows the forces of wound contraction
to pull the nipple back down to the base.

with all types of flaps, and the majority of this loss occurs
within the first 6 months of surgery.9
AVOIDING PROBLEMS DURING THE
PRIMARY PROCEDURE—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 fixed point, most often
the suprasternal notch, are made. 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. 10-11A,B). At this time the aesthetic
judgment of the surgeon comes very much into play.
The projection of the opposite nipple, its base width,
and the shape and position of the areola all need to be
462
Reoperative Plastic Surgery of the Breast
A
C
E
D
F
B
The Skate flap
FIGURE 10-7. A–E, The skate flap is the classic pullout flap. This entails elevating a composite of skin
and fat out of the breast to a 90-degree angle and configuring the nipple with closure of the donor site in
a way to support the projection of the nipple.

carefully assessed and considered in the preoperative
plan for nipple reconstruction, in conjunction with its
planned position relative to existing scars on the recon-
structed breast (Fig. 10-11A,B). The base width of the
normal nipple on the contralateral breast determines
the base dimensions of the flap used for the new nipple
and is an important guide no matter what technique
is selected. These features are outlined in the illustra-
tions (see Figs. 10-7 and 10-8) for the skate flap and mod-
ified star flap.
The surgeon next focuses his or her gaze on the recon-
structed breast and must analyze its shape and degree of
projection and visually assess where the nipple might best
be aesthetically placed. Ultimate placement is performed
using a combination of this assessment, patient desires,
and aesthetics. I believe that when possible the nipple
should be placed at the highest point of the breast mound,
but definitely not above this point. It is acceptable to place
it slightly below this point should the patient have ptosis
of the opposite breast and not request or refuse surgery to
Chapter 10
Revision of Nipple Areola Reconstruction
463
The Modified star flap
base width of
opposite nipple
lateral flap
1.5cm
2cm
1.5 cm
4mm adipose tissue
Note distal tip of flap
is past midline to
permit "stacking"
increasing projection
A
B
C
D
E
FIGURE 10-8. A–E, The modified star flap. Very useful in primary and secondary reconstruction of
the nipple. A derivative of the skate flap. (continued)

correct the ptosis (Fig. 10-11C). The relevant factors most
commonly considered and important planning measure-
ments before a primary nipple reconstruction are illus-
trated in this patient, who will undergo nipple areola
reconstruction and mound revision following a TRAM
flap breast reconstruction (Fig. 10-12).
The procedure of nipple reconstruction can almost
always be done in an outpatient setting under local
anesthesia with sedation. In the situation of previous auto-
genous tissue breast reconstruction, the nipple reconstruc-
tion need not be performed in the hospital operating
environment because it can be safely done in an office oper-
ating room or even in a treatment room. However, in cases
where an implant breast reconstruction has been per-
formed, I believe that the maintenance of the best possible
sterility in terms of the operating room environment and
surgical technique is essential. Therefore the nipple recon-
struction procedure following an implant breast recon-
struction requires the use of an operating room where
sterility can be maximally preserved.
SURGICAL TECHNIQUE
In performing nipple reconstruction the surgeon must
realize that no matter what technique is used, these are
delicate flaps. They must be handled with extreme care
using skin hooks or fine forceps employed primarily with
sharp dissection with a scalpel or sharp scissors for flap
elevation. In configuring and suturing the flaps, the sur-
geon must be careful not to excessively twist or bend the
flaps. Flap loss due to ischemia is may result from over-
tightening the skin, excessively bending the flap(s), or
using too many sutures. Any element of flap compromise
must be recognized at the time of the nipple reconstruction,
and necessary sutures must be removed or flap transposi-
tions altered to immediately reverse any flap ischemia dur-
ing folding and configuring the nipple. Generally only one or
two sutures need to be removed to avoid such a problem.
Achieving primary wound healing is key. The surgeon
must avoid ischemia of these delicate flaps, which most
often will lead to flap separation and open wounds. This
condition results in increased wound contraction, often
dramatically decreasing nipple projection or altering the
shape, inclination, and even position of the reconstructed
nipple.
Following nipple areola reconstruction, I feel it is nec-
essary to protect the nipple from external compressive
forces. I do this by placing a foam rubber donut around
the nipple. I ask patients to wear this inside their bra for
approximately 1 month as a means of protecting the
newly reconstructed nipple. I believe that such a device
may play a role in preventing loss of projection due to
early mechanical compression of the reconstructed nipple
(Fig. 10-13).
If a skin graft is used for the areola reconstruction, a
bolster-type dressing is placed to ensure maximum con-
tact of the graft with the underlying graft bed. This bolster
is left in place for a minimum of 5 days. When skin grafts
are needed, full-thickness skin grafts are my preference.
I do not feel that it is necessary or advisable to harvest pig-
mented skin from the area of the proximal inner thigh or
labial region. Harvesting skin from these donor sites can
be uncomfortable or painful for the patient. Almost all
full-thickness skin grafts will undergo hypopigmentation
with the passage of time. An intradermal tattoo is usually
the best way to optimize the color match between the nor-
mal areola and areolar tissue around the new nipple.
A skate flap requires a small or large skin graft to close
the flap donor area. The traditional skate involved a donut
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 flap (Fig. 10-7D,E).
The use of the star flap (Fig. 10-8A–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. 10-8D). This is done in
two layers. It is important to realize that with this tech-
nique the sutures that have been used to configure the
464
Reoperative Plastic Surgery of the Breast
FIGURE 10-8. (CONTINUED)

nipple must be left in for at least 3 weeks (Fig. 10-8E).
A subsequent areola tattoo can camouflage the scars from
the flap donor closure areas, which extend radially away
from the nipple base (Fig. 10-8D,E). Direct closure of the
donor area flattens the contour of the reconstructed
breast slightly.
PLANNING IN THE DIFFICULT CASE
Although seemingly very simple in concept, creation of
consistently successful nipple areola reconstructions with
long-term projection that simulates the opposite NAC is
an art. This straightforward operation can in some com-
mon circumstances be treacherous, and it is fraught with
problems related to the natural forces of wound healing;
the type of previous breast reconstruction; the quality,
thickness, and degree of attenuation of the local tis-
sues, most importantly the thickness of the dermis and
subcutaneous adipose tissue layers at the site of the pro-
posed reconstruction.
When assessing a patient for nipple reconstruction, the
surgeon must be especially wary of tissues that are exces-
sively thin. This situation is common following the use of
tissue expansion for the breast reconstruction (Fig. 10-
14). Because tissue expansion definitely results in thin-
ning of the subcutaneous fat layer and dermis, at the time
of exchange of the expander for the chosen implant
Chapter 10
Revision of Nipple Areola Reconstruction
465
Fishtail Flaps
A
B
C
D
E
FIGURE 10-9. A–E, The design and elevation of the fishtail flap.

466
Reoperative Plastic Surgery of the Breast
FIGURE 10-10. A–C, An alternative and very useful design of
the fishtail flap that can be used when a transverse scar is pres-
ent on the breast.
FIGURE 10-11. 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 fixed points on the torso, including the
suprasternal notch, and the distance from the midline. The base
(here lateral) of the new nipple should not be encroached on by
existing scars on the breast. B, Outline for modified star flap
reconstruction with 15-mm flap base width. C, Nipple placed in
dependent position on left breast reconstruction to match right
nipple, which is in a dependent position.
Alternative Design of Fishtail Flaps
Healed Transverse
Mastectomy
Incision
Fishtail flaps designed 1808
to each other
A
B

I always make special note of the thickness of the muscle
layer, subcutaneous adipose tissue, and dermis, specifi-
cally noting any significant atrophy that exists in the sub-
cutaneous adipose layer. As previously mentioned,
I believe that it is helpful to perform the nipple recon-
struction at a third stage in individuals who are undergo-
ing implant reconstruction following the placement of a
tissue expander.
The presence of scars (Fig. 10-14) on the breast is often
a significant factor in selecting the type of nipple recon-
struction. Their position and width, as well as the quality
of the surrounding skin and deep tissue, must be carefully
assessed, and a reconstructive plan must be developed to
minimize any negative impact these scars might have on
the nipple reconstruction.
Scars from previous biopsies or the mastectomy can be
very problematic. They do influence the choice of tech-
nique, and this is especially true 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 straddles21–25 the scar (Fig. 10-15). The
technique that best accomplishes this is the double-
opposing tab flap described by Knoll.25 Scars can be a par-
ticularly important factor, especially when they lie right
where the nipple is to be centered. Previous radiation
Chapter 10
Revision of Nipple Areola Reconstruction
467
FIGURE 10-11. (CONTINUED)
FIGURE 10-12. Planning for combination of lipocontouring
of breast and modified star flap reconstruction.
FIGURE 10-13. Sterile foam rubber donut used to be placed
around reconstructed nipple at the time of surgery to protect it
from compression over the first 3 weeks of healing.

therapy causes fibrosis of the skin and dermis and confers
to the skin flaps a stiff quality that makes folding and con-
figuring them difficult. There is also decreased circulation
in such flaps. 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 before surgery.26
In summary, I believe that it is essential to alter the
design of the nipple reconstruction procedure so that the
blood supply to the flaps is minimally affected by the exist-
ing scar tissue. Radiation therapy poses its own set of diffi-
culties, especially if multiple skin scars are also present.
Patients who smoke also appear to have more problems
related to circulation in the skin of the breast. As mentioned,
this must be pointed out to the patient preoperatively and a
plea made for temporary cessation of smoking.26
Combinations of these risk factors for nipple recon-
struction can often lead to problems. As previously noted,
an open wound anywhere in the area of a nipple recon-
struction will in my opinion definitely predispose the
patient to experience accelerated contraction and loss of
projection in the reconstructed nipple.
Major loss of projection following nipple areola recon-
struction is very disappointing for both the patient and
the surgeon. This outcome results in an asymmetry that
detracts from the overall appearance of the reconstruc-
tion. In addition, it places scar tissue directly at the site
where the nipple should be positioned. Therefore the pri-
mary nipple reconstruction must be carefully planned and
executed in a precise manner because secondary recon-
structions are more difficult. For this reason a few com-
ments 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 of projection or
less I favor the modified star flap (see Fig. 10-8A–E). For
nipples with greater projection I sometimes use a skate flap
(see Fig. 10-7A–F). Another indication for the skate flap is
the situation where I do not wish to produce any flattening
of the anterior contour of the breast. Here a skate flap and a
skin graft may be preferable. Finally, I will consider the use
of a double-opposing tab flap (Fig. 10-15A–E) when
the mastectomy scar runs directly through the site where
the base of the nipple would be ideally located. The follow-
ing section outlines how I perform each of these techniques.
THE MODIFIED STAR FLAP
The design of the flap in a particular case is dependent on the
base width and projection of the opposite nipple. The base
width is created to match that of the nipple of the opposite
side. The width of the lateral limbs determines the ultimate
nipple projection. When planning this dimension it is impor-
tant to realize that approximately a 30% to 40% loss of pro-
jection will occur over time. Therefore I usually make the
lateral limbs a minimum of 1.5 cm wide and 2 cm in length
(see Fig. 10-8A). The total height of the nipple is planned for
at least 1 cm. By making the distance from the base of the
lateral flap to the tip 2 cm, the flap will fold around the cen-
tral core of the nipple, allowing skin closure without tension.
These flaps are elevated with 2 to 4 mm of adipose tissue (see
Fig. 10-8B) on their deep surface (deep to the dermis), which
allows folding of the flaps without tension.
After injection of 1% lidocaine (Xylocaine) without epi-
nephrine, the lateral flaps, or wings, are elevated first fol-
lowed by the central flap. 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 reconstruc-
tion the dissection proceeds unencumbered. In the second-
ary case the surgeon will be elevating scarred elements of
the previous unsuccessful nipple and so it is important to
preserve the maximum amount of blood supply to the adi-
pose tissue and skin arising deep within the flap. For this
reason I elevate the most proximal portion of the flap at its
base, delicately with blunt dissection, using either teno-
tomy scissors or in some cases the handle of the scalpel
blade. This tends to optimally preserve the blood supply to
the central core of adipose tissue and skin of the new nip-
ple. The donor area is closed primarily and in layers, with
the deep dermis closed first with coated polyglycolic acid
suture [3-0 Maxon (Sherwood-Davis & Geck, St. Louis,
Mo) or 3-0 PDS (Ethicon, Inc., Somerville, NJ)], followed
468
Reoperative Plastic Surgery of the Breast
FIGURE 10-14. A: Patient with significant scar and atrophy of
subcutaneous tissue following a right breast reconstruction with
tissue expander and implant.

by a skin closure with interrupted 5-0 nylon. The nipple
elements are then assembled starting with the lateral flaps.
These flaps are advanced past the midline to achieve stack-
ing in the portion of the nipple opposite the base to maxi-
mally increase the projection (Fig. 10-8D).
The 5-0 nylon sutures used for configuration of the nip-
ple with these flaps are left in place for 3 weeks to ensure
good healing and to prevent unfurling of these folded
flaps. Removal of these sutures before 3 weeks has in sev-
eral cases resulted in wound separation of the flaps used
to create the nipple. Finally, the newly reconstructed nip-
ple is protected from direct compression by a foam rubber
donut (Fig. 10-13), which can be inserted into the bra dur-
ing the first month of postoperative healing.
THE SKATE FLAP
The skate flap (see Fig. 10-7A–F) can produce a large nip-
ple with significant projection, and it is my choice when
the existing contralateral nipple has a projection of 7 mm
or greater. 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 electrocardiogram lead to
place on her reconstructed breast. In this way she chooses
the position for the nipple to be created. The design of the
skate flap 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 approx-
imately an equal distance of skin on either side to com-
prise the lateral wing. The distance from the base of the
nipple to the portion of the areola furthest from it is
approximately twice the projection of the opposite nipple
(see Fig. 10-7A). This 2 to 1 dimension of the central axis of
nipple allows for loss of projection occurring from the nor-
mal processes of contraction and wound healing. The
patient should be informed preoperatively of the discrep-
ancy in nipple height that will be present immediately after
surgery, with the reconstructed nipple much larger than
the opposite nipple. This central axis is also the region
from which the core of fat that will comprise the main sub-
stance of the nipple will be elevated. The central core of the
flap is adjoined on either side by extensions of skin that
elevated together leave a circular outline (see Fig. 10-7D,E).
The position of the nipple and design of the flap are
checked just before taking the patient to surgery.
The skin markings of the flap are injected with local
anesthetic (1% lidocaine) without epinephrine. The out-
line of the design is incised peripherally on all sides. Next,
the lateral flaps 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 flap is
reached, the dissection is deepened by incising completely
through the dermis into the adipose tissue, thereby raising
a core or finger-like projection of adipose tissue in conti-
nuity with the skin in the central portion of the flap. This
central core of adipose tissue 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 flap. As the base of the flap is reached, it is
important to preserve as much blood flow to the fat as
possible. This blood flow is derived from vertically ori-
ented blood vessels running in the fat, and to spare them
I will gently spread or stretch this tissue with either the
dissecting scissors or handle of the scalpel. The dermis on
either side is incised to the nipple base to permit a full
90-degree elevation of the flap. When the elevated flap is
held perpendicular to the plane of the breast, it resembles
a sunfish or skate—hence its name, the skate flap.
The V-shaped donor area in the center (see Fig. 10-7D)
is then closed with 4-0 chromic sutures that bring dermis
edge to dermis edge, with care taken to bury the knots.
This closed wound will create a platform on which to
assemble the new nipple. The nipple is reconstructed by
configuring the lateral wings around the central core by
starting at its base and working toward the apex. The lat-
eral-most tip of each lateral wing is sewn to its counter-
part with interrupted 5-0 chromic suture. The flaps are
closed without excessive tension.
The donor area of the skate flap is most often closed
with a full-thickness skin graft that is 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 full-thickness graft is thoroughly defatted
and sutured to the periphery 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 invari-
ably produce a spread scar that will be unsightly and that
does not take tattoo pigment well.
A tie-over bolster dressing is used to maximize graft to
the recipient bed contact. The bolster is usually left in
place for a minimum of 5 days. The reconstructed nipple
is again protected from compression by clothing it with a
foam rubber donut that is worn for 1 month.
The optimal time for areola reconstruction with an
intradermal tattoo is approximately 3 to 4 months follow-
ing healing of the skin graft. This skate flap method per-
mits 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 TAB FLAP
As previously mentioned, a potential problem situation
for nipple reconstruction results when the scar from the
mastectomy runs directly through the intended site of the
Chapter 10
Revision of Nipple Areola Reconstruction
469

nipple reconstruction. This scar position can cause prob-
lems with the vascularity of the flap(s) used for the nipple
reconstruction and reduces the amount of subcutaneous
adipose tissue available on the deep surface of the skin
flaps. This situation can be addressed with the use of flaps
raised on either side of the scar. Such a technique is that
of the double-opposing tab flap, as proposed by Kroll21,25
(Fig. 10-15A,E).
If this double-opposing design is used, it is essential for
the surgeon to make the base width of these flaps consid-
erably wide (minimum of 15 mm). This will help ensure
adequate blood supply to the flaps as they are elevated.
Unfortunately, closure of the created donor defect does
confer a definite flatness to the reconstructed breast
mound at this point. This remains an unsolved problem.
Nevertheless, the double-opposing tab flap remains a use-
ful technique for nipple reconstruction when the mastec-
tomy scar runs directly though the ideal position for
nipple creation.
It is important to realize that no matter what technique
is selected, contraction will occur as part of the wound
healing process and therefore the nipple needs to be made
larger than the opposite nipple at the time of the nipple
reconstruction surgery. Before the study9 noted earlier
was done, we had the strong clinical impression that the
shrinkage rate was somewhere between 40% and 60%.
This was based on evaluation of projection as a function
of time from surgery, with projection carefully studied for
470
Reoperative Plastic Surgery of the Breast
Double opposing tab flaps
A
B
C
D
E
FIGURE 10-15. A–E, The double-opposing tab flap. This is a nipple reconstruction based on flaps that
are elevated and wrapped around each other. It has utility when the scar from the mastectomy runs
directly through the site of intended nipple reconstruction. It is important to make the base of these
flaps sufficiently wide (18 mm) to ensure vascularity to the reconstructed nipple.

1 year. As corroborated in our study,9 most of the projec-
tion is lost within the first 6 months. Projection loss does
continue up to 1 year, but it seems to be stable after that.
This is an important concept for the surgeon to be cog-
nizant of when trying to achieve long-term nipple symme-
try from the standpoint of projection.
REVISION AND SALVAGE OF THE
SUBOPTIMAL NIPPLE
RECONSTRUCTION
Cases of minor nipple projection loss may be compen-
sated for with an intradermal tattoo procedure (see
Fig. 10-3A–C). This tends to produce color patch symme-
try, giving the appearance of a normal breast and nipple
symmetry on casual glance. I believe that a well-done tat-
too can salvage a suboptimal nipple reconstruction in
many cases (see Fig. 10-3).
Major loss of projection following nipple areola recon-
struction is disappointing for both the patient and the sur-
geon. This outcome results in an asymmetry that detracts
from the overall appearance of the reconstruction. This
situation can be addressed in several ways. An uncommon
but helpful technique is to use a composite graft of nipple
from the opposite breast—if the nipple is of sufficient size
and the patient is willing to permit a surgical procedure
on it with the placement of incisions. The utility of this
technique is illustrated in the following case.
The patient in question had undergone a previous nip-
ple reconstruction following breast reconstruction with a
tissue expander and subsequent implant. The recon-
structed nipple had suboptimal projection (Fig. 10-
16A,B). Because the patient had a wide thin scar at the
intended site of nipple reconstruction only, with attrition
of the skin and subcutaneous fat from the tissue expan-
sion process and a very large contralateral nipple, we
addressed this problem by de-epithelializing the skin over-
lying the suboptimal nipple reconstruction and placing a
composite graft from the opposite nipple (Fig. 10-16C).
This remedied the deficient projection and enhanced sym-
metry between the nipples (Fig. 10-16D,E).
More commonly a modified star flap19 is very helpful
as a booster tissue substrate (Fig. 10-17A–D) for the sub-
optimal nipple reconstruction. This flap can be elevated
at the site of the original nipple reconstruction as long as
it is oriented such that the base is not encroached on or
compromised by existing scar tissue. The use of this
modified star flap to augment nipple projection in a
patient who had previously undergone nipple recon-
struction with a modified star procedure is illustrated in
(Fig. 10-18A–F). This was a young female who had an
immediate left breast reconstruction with a TRAM flap.
Eight months following surgery she underwent nipple
areola reconstruction with a superiorly based modified
Chapter 10
Revision of Nipple Areola Reconstruction
471
FIGURE 10-16. A, Partial loss of previous left nipple recon-
struction following tissue expander and implant noted on AP
view. B, Lateral view of same patient. Note lack of projection in
the reconstructed nipple. (continued)

star flap. She sustained wound separation at the site of
flap inset, which resulted in excessive wound contraction
and a 70% loss of nipple projection. Five months follow-
ing complete healing we performed another modified
star flap to increase her nipple projection (Fig. 10-
18B,C). This was done by orienting the flap in the exact
same direction as the original flap, elevating most of the
previous flap with the new modified star flap (Fig. 10-
18D). This produced a very satisfactory outcome from
the standpoint of symmetry with the contralateral nipple
(Fig. 10-18E,F).
SUBTOTAL AND TOTAL NIPPLE LOSS
Failure of nipple reconstruction is extremely disappoint-
ing for the patient and the surgeon. Fortunately it is rare.
The foregoing section highlights the conditions most
often responsible for excessive or complete loss of nipple
projection. It is obviously critical for the surgeon to care-
fully assess each patient for the presence of these factors
and to make adjustments in the surgical plan to compen-
sate for scars or tissue atrophy.
What do you do when the patient sustains either sig-
nificant or complete loss of nipple projection? My
approach has been to first allow wound conditions to
equilibrate. The acute inflammation, tissue edema, and
stiffness in the wound must be allowed to resolve com-
pletely. This means waiting the appropriate time for tis-
sue equilibrium to occur. The patient must be informed
of the critical importance of this healing period, which is
at minimum a period of 3 months, but it may be consider-
ably longer.
When this point of tissue equilibrium is reached, usu-
ally my approach is to use a pullout flap in the same loca-
tion, most often oriented in the same way as the original
flap design. The optimal orientation of the flap is deter-
mined by dermal blood supply and the presence of previ-
ous scars. When possible, the base of the flap should be
positioned in such a way as to avoid encroachment by pre-
vious skin scars. There is some evidence to show that
there is blood flow across a scarred dermal bed when 3
months has been allowed to elapse. However, it is most
prudent not to orient a new flap such that scars will trans-
gress on the blood supply at its base.
In virtually all cases of redo nipple areola reconstruc-
tion I use a modification of the skate design, namely the
modified star flap (Fig. 10-8). I have found this to be very
reliable because it has the advantage of direct closure of
the donor area. The only disadvantage is slight flattening
of the anterior contour of the breast if the lateral limbs are
made too wide. The design of the flap has been previously
described.
In summary, it is important to realize that the tissue of
the previously unsuccessful nipple reconstruction can be
elevated as part of a new or secondary skate flap that is
being used to treat the problem of the suboptimal projec-
tion. The following two cases illustrate the use of this
technique after unacceptable loss of nipple projection fol-
472
Reoperative Plastic Surgery of the Breast
FIGURE 10-16. (CONTINUED) C, Composite nipple graft har-
vested from opposite nipple. D, Postoperative result of redo nip-
ple reconstruction seen at 9 months following surgery on AP
view. E, Lateral view of composite nipple reconstruction 9
months following surgery.

lowing primary reconstruction with a skate flap, a BELL
flap, and a previous modified star flap.
The first patient underwent a left breast reconstruction
with a free microvascular TRAM flap. She had a subse-
quent nipple areola reconstruction with a skate flap. The
areola was reconstructed with a full-thickness skin graft.
The patient experienced separation at the suture line
between the skate flap and skin graft that produced excess
wound contraction This resulted in loss of nipple projec-
tion such that there was less projection on the recon-
structed side (Fig. 10-19A,B). She desired a procedure to
increase nipple projection. We addressed this problem by
performing a modified star flap with the base oriented
superiorly (Fig. 10-19C). The nipple reconstruction star
flap was elevated as described earlier, incorporating por-
tions of the previously placed skin graft as part of both lat-
eral flaps and the central flap. She healed without
difficulty and demonstrates stable projection that is sym-
metric with the opposite nipple at a 2-year postoperative
follow-up (Fig. 10-19D,E).
The next patient had undergone a BELL flap27 (Fig.
10-20A–F) for bilateral nipple areola reconstruction
Chapter 10
Revision of Nipple Areola Reconstruction
473
A
B
C
D
design of modified star flap
in bed of previous mipple
reconstruction
redo nipple reconstruction
with modified star flap
modified star flap
incisional closure
on-table nipple projection
following redo nipple
FIGURE 10-17. A–D, Outline of redo nipple reconstructed with modified star flap. Note that the flap is
designed such that the base (blood supply) is oriented in the same direction as the previous reconstruction.

following a tissue expander (synthetic implant breast
reconstruction for her bilateral mastectomy reconstruc-
tions. The BELL flap was selected because of the signifi-
cant areola projection of the contralateral nipple. At one
time I felt that the purse string closure (Fig. 10-20E) of the
donor area of this flap could produce a projecting areola.
However, both the areolar projection and nipple projec-
tion are short lived in most cases so I no longer use this
flap. The patient had normal primary healing but experi-
enced total loss of nipple projection of both nipples over
the ensuing 9 months (Fig. 10-21A). There was good vas-
cularity of the nipple flap but a diminished thickness in
474
Reoperative Plastic Surgery of the Breast
FIGURE 10-18. Modified star flap used as a boost to inadequate previous nipple reconstruction.
A, Inadequate projection of reconstructed nipple when compared with significant projection of the nip-
ple on the patient’s opposite breast. B, Design of redo nipple reconstruction with the modified star flap
used as a boost to address the inadequate projection of the previous nipple reconstruction. C–D, Surgical
elevation of the flap. Gentle handling of the tissue is accomplished with skin hook. E, Flap tissue being
configured into the shape of a nipple. F, Enhanced projection noted postoperatively on lateral view.

both the dermis and the subdermal adipose layer noted at
the initial procedure.
This loss of nipple projection was addressed using a
modified star flap (Fig. 10-21B), in which a portion of the
underlying pectoralis major muscle (PMM) was elevated
(Fig. 10-21C). Incorporating the PMM in this manner can
increase the tissue bulk (Fig. 10-21D) available and prob-
ably provides increased circulation to the skin of the nip-
ple flap. When elevating the PMM (Fig. 10-21C) it is
important not to violate the periprosthetic capsule to
minimize danger to the implant. If the capsule is inadver-
tently opened it may be closed with a 4-0 chromic suture.
In this patient and others I have seen with similar defi-
ciency of subcutaneous fat at the site of planned nipple
reconstruction, raising the PMM as part of the nipple recon-
struction has resulted in excellent long-term nipple pro-
jection following the previously suboptimal outcome
(Fig. 10-21E,F).
Chapter 10
Revision of Nipple Areola Reconstruction
475
FIGURE 10-18. (CONTINUED)
FIGURE 10-19. Modified star flap used to rescue subtotal loss
of nipple projection following skate flap nipple reconstruction
done in patient who underwent an immediate reconstruction of
the left breast with a free microvascular TRAM flap Nipple pro-
jection was lost as a result of contraction of wound at base of
skate flap following skin graft loss. A, Preoperative AP view.
(continued)

476
Reoperative Plastic Surgery of the Breast
FIGURE 10-19. (CONTINUED) B, Oblique view. C, Surgical
plan for an inferiorly based modified star flap. D, On table view
of increased nipple projection provided by the modified star
flap. E, Follow-up view after redo nipple reconstruction seen 2
years postoperatively on AP view. F, Lateral view of same
patient.

REDO NIPPLE RECONSTRUCTION WITH
A DOUBLE-OPPOSING SLIDING
PERIAREOLAR FLAP
A flap that I have used over the past year (and now
strongly favor) for both primary and secondary nipple
reconstructions is a derivative of the skate flap design that
incorporates features of the BELL flap. It is a flap with a
circular incision peripherally, whose diameter is made
30% larger than the opposite areola (Fig. 10-22A). Within
this circular design a modification of the skate flap is
drawn. The base diameter of the nipple matches that of
the opposite breast, and the horizontal flaps extending on
either side of this are at least 1.5 cm in length and 1 to 1.4
cm in width, depending on the height of the opposite nip-
ple (Fig. 10-22B). The flap is then raised by making full
thickness incisions on all sides of the nipple flap without
traversing the base and elevating 1 to 2 mm of adipose tis-
sue with the wings. The nipple is then configured using
the same method as seen with a skate or modified star flap
with the wings curled toward the center and the cap com-
ing over the top of them (Fig. 10-22C). This creates a cen-
tral donor area (Fig. 10-22C). At the same time the circular
incision is made just into the subcutaneous adipose tis-
sue so that the skin of the base of the nipple flap and the
opposite crescent flap can slide toward each other (Fig.
10-22D). This central donor site is closed with interrupted
5-0 nylon suture. The peripheral or peri-areolar donor
area is closed with a purse-string suture of 2-0 PDS (Fig.
10-22E), which is used to shrink the size of the circular
defect and establish a new areolar diameter that will
match the areolar diameter of the opposite breast (Fig. 10-
22E). The cloure of the periareolar wound is completed
with 5-0 chromic suture (Fig. 10-22F) and the post-opera-
tive appearance is shown in Figure 10-22G.
The advantages of this flap are that its blood supply is
robust, the nipple has stable projection after the first 8
months when only 30% is lost, and, most importantly,
there is a circular scar at the periphery of the nipple that
can be completely camouflaged by a subsequent tattoo
procedure. It is useful in both primary and secondary
cases of nipple reconstruction.
REDO NIPPLE RECONSTRUCTION WITH
ALLODERM
I have had experience with the use of AlloDerm (LifeCell
Corp., Branchburg, NJ) to salvage a partially failed nipple
reconstructions in four patients. This acellular dermal
matrix material28 can be implanted beneath the skin at the
site of a suboptimal nipple reconstruction. It is important
that there be sufficient unscarred skin to permit draping
over this material without excessive tension. A tightly con-
stricting scar covering tends to flatten out this graft and
limits its effectiveness. The illustrated case (Fig. 10-23)
shows the design and creation of skin flaps that will cover
the AlloDerm graft. The patient is shown with a 4-month
postoperative result (Fig. 10-23A–H).
I have not found the injection of collagen, the use of
autologous fat injections, or dermis fat grafts to be useful,
and I have no experience with the use of stacked cartilage
grafts, which require incisions and a deformity at a sepa-
rate donor site and therefore have limited appeal for this
indication. Finally, I have not implanted silicone nipple-
shaped implants into the tissues at the site of a previously
failed nipple reconstruction. In such cases the existing
scar tissue would not drape well over this type of implant.
INCORRECT NIPPLE POSITION
When a reconstructed nipple comes to lay in the incorrect
position, it can be moved, but usually only a short dis-
tance. This may take the form of re-elevating the nipple by
dissecting toward its base and beyond its base, taking care
to preserve its blood supply. The resulting defect or
extended donor area of the flap must be closed by a direct
Chapter 10
Revision of Nipple Areola Reconstruction
477
FIGURE 10-19. (CONTINUED)

478
Reoperative Plastic Surgery of the Breast
advancement closure, a V to Y closure, or a full-thickness
skin graft. Scars and skin grafts that are maintained
within 2 cm of the nipple that has been relocated can be
camouflaged by an areola tattoo.
If the nipple has been reconstructed on top of a skin
paddle from a musculocutaneous flap, a change in loca-
tion can often be achieved by moving the skin paddle a
short distance in any direction. The donor area in such a
case is usually closed using a purse string suture or V to Y
closure technique (Fig. 10-24A–D).
If the nipple is significantly displaced the challenge is
more formidable. The options are to transfer the nipple as
a rotation flap or on a subcutaneous pedicle. The resulting
open wound where the nipple was located must be closed
with a direct advancement closure, a V to Y technique, or
a skin graft. When such wounds are located superior to
BELL flap
base width of nipple = 1/2r
radius of areola = r
elevation of superiorly
based flap
flap folded on itself and donor
area closed with transfer of
adjacent flaps
A
B
D
C
F
E
FIGURE 10-20. The BELL flap. This reconstruction can potentially produce a projecting
areola. Because of my own problems with maintenance of nipple projection I no longer recommend
its use.

FIGURE 10-21. A, Complete loss of bilateral nipple projection in patient previously reconstructed with bilateral BELL flaps. There
is thinning of the dermis and subcutaneous adipose layer following the tissue expander–implant breast reconstruction. B, Reoperative
nipple reconstruction is to be performed with bilateral modified star flaps where PMM will be raised with the skin. C, The PMM can
be raised with the skin of the modified star flaps to provide additional tissue bulk for the nipple reconstructions. D, On table view illus-
trating excellent projection in these redo nipple reconstructions. E, AP view at 2 years after redo nipple reconstruction in this patient
demonstrates maintenance of nipple projection. F, Oblique view at 2 years in the same patient.

480
Reoperative Plastic Surgery of the Breast
FIGURE 10-22. A, Design of the double opposing periareolar flap. The areolar diameter is usually
30% larger than the opposite areola. The base width of the flap matches the base width of the opposite
nipple. The length of the wings is variable (1.5-2.0 cm) and the width varies between 1.0 and 1.4 cm. B,
The nipple flap is elevated with 2 mm of adipose tissue on the deep side of each wing and more adipose
in the center. C, The nipple is assembled by curling the wings in toward the center and bringing the cap
over them, D, An incision is made in the periareolar outline into the subcutaneous tissue until there is a
definite “give” when centrally direct traction is exerted on the flaps, indicating that they can slide
toward each other. The central donor area is closed with interrupted 5-0 nylon sutures. (continued)

Chapter 10
Revision of Nipple Areola Reconstruction
481
FIGURE 10-22 (CONTINUED) E, The peripheral donor area is closed with a 2-0 PDS purse-string
suture, which creates an areolar dimension equal to that of the opposite breast. F, The peripheral skin
incision is closed with interrupted 5-0 chromic suture. G, The typical appearance of the nipple recon-
struction at 6 weeks following surgery.

482
Reoperative Plastic Surgery of the Breast
FIGURE 10-23. A, Total loss of nipple projection following tissue expander–implant reconstruction.
The patient has completely absent thickness in the subcutaneous fat layer due to attrition produced by
the tissue expansion process. B, The plan for reconstruction with AlloDerm includes elevation of skin
flap with which to wrap the AlloDerm. C, AlloDerm substrate after it is removed from package and rehy-
drated. D, AlloDerm strip rolled around a sterile toothpick like a bale of hay. E, The AlloDerm is put into
position and is about to be wrapped by the skin flaps. F, Appearance of redo nipple reconstruction after
redraping the skin flaps. G–H, Appearance of reconstructed nipple 4 months following redo with
AlloDerm graft on AP view (G) and oblique view (H). (continued)

FIGURE 10-23. (CONTINUED)

the new location of the nipple, the outcome is usually less
than aesthetically ideal. In such cases it may be best to
excise the reconstructed nipple with the shortest possible
scar and redo the nipple reconstruction in the more
appropriate position.
INCORRECT NIPPLE INCLINATION
If the inclination of the nipple is incorrect, this can be
corrected by excising skin into the very superficial dermal
level at the base of the nipple and the inclination of the
nipple. This is needed when either the nipple is very large
and gravity causes it to tilt inferiorly or there is excess
contraction from scar tissue. Either of these problems
can be corrected. The former is simple and involves an
excision of skin from the base of the nipple. This is done
in a way that preserves the deep dermis to preserve maxi-
mal blood supply to the nipple (Fig. 10-25A,B). In the lat-
ter situation, where scar contracture has resulted in an
abnormal inclination, the scar must be released (excised)
and adjacent tissue advanced to form a new platform
onto which to position the corrected nipple construct
(Fig. 10-25A,B).
484
Reoperative Plastic Surgery of the Breast
A
B
D
E
C
FIGURE 10-24. A–E, Partial dermal excision to correct downward inclination of previously recon-
structed nipple.

PROBLEMS WITH TATTOOING
As mentioned many times in this chapter, the intrader-
mal tattoo provides a critical visual dimension to the
reconstructed nipple. Every reconstructive surgeon will
acknowledge that the best nipple reconstructions in his
or her practice exhibit excellent tattoos. Most medical
tattoos fade with time, and usually they must be redone
at least once. This is not a problem, and each patient
must be informed of this possibility before the initial
procedure.
A more difficult situation is when the tattoo is too dark.
It may be possible use a lighter pigment and tattoo over a
darker area. However, this procedure is not successful in
most cases. In this situation it may be necessary to depig-
ment the area. The most common maneuvers involve der-
mabrasion of the hyperpigmented area. On rare occasions
the area is excised and skin is grafted to the open wound,
with a redo tattoo planned for a later time.
Fortunately this is a rare situation, and it is better to
use a slightly lighter tattoo pigment at the primary tattoo
procedure if there is any question about the shade of the
pigment to be used.
Chapter 10
Revision of Nipple Areola Reconstruction
485
FIGURE 10-25 A–G, Re-establishment of base skin by advancement of skin flaps and de-epithelializa-
tion so that the nipple can be seated on a better foundation.
A
B
C
G
F
E
D
nipple
inclined
inferiorly
nipple lifted
off scar
superiorly
De epithelialized
crescent

NIPPLE LOSS FOLLOWING BREAST
REDUCTION OR MASTOPEXY
Loss of the nipple—either complete or partial, with combi-
nations of NAC loss—is uncommon, but it is a potential
risk that accompanies every breast reduction or mastopexy
procedure. This is true for mammoplasty procedures in
which a pedicle is used to carry the nipple to a new posi-
tion, and also in procedures where the nipple is removed
and repositioned as a full-thickness skin graft. The occur-
rence of nipple areola loss is between 1% and 2%.
Nipple necrosis is the result of ischemia that produces
an open wound. These wounds heal by a combination of
contraction and epithelialization. The scar tissue contrac-
tion occurring in the wound may further diminish nipple
projection that results from tissue necrosis. In addition,
areas of hypopigmentation involving either the nipple and
or the areola commonly occur.
Loss of nipple projection following breast reduction
can be very disturbing for some patients. In such cases it
is most often possible to increase nipple projection with a
modified star flap designed right over the existing nipple.
This allows augmentation of the remaining nipple. The
costs of such a maneuver are the additional scars within
the areola and a narrower areola shape. The altered areola
can be adjusted using an intradermal tattoo. As previously
mentioned, this can be done to treat areas of hypopigmen-
tation, as well as to restore symmetry to the areola in
terms of shape. An example of this combination is illus-
trated in Figure 10-26.
Loss of nipple projection in the setting of a previous
breast reduction can be treated in the same ways as loss
following a postmastectomy nipple reconstruction. This is
illustrated by this 42-year-old patient (Fig 10-26), who sus-
tained loss of projection of the right nipple following an
inferior pedicle breast reduction. After 9 months had
elapsed and softness had returned to her tissues, we pro-
ceeded with a superiorly based modified star flap (Fig. 10-
26A–E) and subsequent intradermal tattoo. This resulted
in a very good appearance of the NAC noted at a 2-year
follow-up.
Areolar hypopigmentation can be treated and often
improved by an intradermal tattoo procedure. I have found
that the uptake of the tattoo pigments is often more diffi-
486
Reoperative Plastic Surgery of the Breast
FIGURE 10-26. Loss of nipple projection following breast reduction reconstructed with modified star
flap. A, AP view showing suboptimal appearance and projection of right nipple with hypopigmentation
following previous breast reduction. B, Outline for reconstruction with modified star flap. C, Nipple
substance elevated to include previous ductal tissue at site of scarred nipple. D, Flaps configured into
the shape of a nipple using the stacking technique described earlier. E, Appearance of nipple recon-
struction 9 months following completion of modified star flap reconstruction and intradermal tattoo to
re-establish normal appearance of areola. (continued)

cult due to scar tissue resulting from the ischemia and the
wound contraction. The NAC pigmentation on the opposite
breast serves as a template for selecting the most appropri-
ate pigment. Often it is necessary to blend various pigments
to obtain the correct shade. All tattoos are done to increase
areolar color fade. Often these have to be redone. It is best
to inform the patient of this preoperatively. The temptation
to use a slightly darker color of dye must be avoided. This
may result in an areola tattoo that is too dark.
If the resulting areolar pigment is dark following a tat-
too, it is best to wait and allow sufficient time for it to
lighten. If lightening does not take place, then the darker
pigment can be addressed using a YAG laser, dermabra-
sion, or excision of the skin with replacement using a full-
thickness skin graft. It is uncommon to resort to the latter
option, but if it is chosen at least 2 months should be
allowed to elapse before pursuing a redo of the tattoo
procedure.
Chapter 10
Revision of Nipple Areola Reconstruction
487
FIGURE 10-26. (CONTINUED)

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JW, Lippman ME, et al., eds. Surgery of the Breast: Principles
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488
Reoperative Plastic Surgery of the Breast

489
I N D E X
A
Abdominal donor site, seroma and, 356
Abdominal wall closure, TRAM flap and,
337–338, 338f
Abdominal wall hernia
prolene mesh and, 416, 416f, 418,
418f, 419
TRAM flap breast reconstruction and,
416, 416f
Acute complications, breast augmenta-
tion and, 86–88
Acute fat necrosis, TRAM flaps and,
358, 359f
Acute wounds, 428
Adipose tissue
aspiration, 363
contour abnormalities, skin scar, 432
contour defects and, 404
excision, volume reduction by,
366, 367f
flap techniques for, 461
tissue expander placement and,
252, 253f
TRAM flap breast reconstruction and,
303, 307, 308f, 313
volume excess, flap and, 362
Adjacent contour adjustment, liposuc-
tion and, 368, 368f–369f
Adjustab implant, 102
Aesthetic analysis. See also Cosmetic
outcome
breast and, 19f
Age, breast changes and, 21f
AlloDerm
nipple projection loss with, 482f–483f
redo nipple reconstruction, 477, 482f
skin wrinkling and, 134
Anaphylaxis, fluorescein and, 342
Ancef. See Cefazolin
Anesthesia. See also General anesthesia
abdominal wall closure and, 337–338,
338f
hernia and, 416, 416f, 417f
reoperative surgery and, 4
Angiosomes, TRAM flap and, 311, 313f
Antibiotic therapy
fat transplantation and, 432
infection and, 91, 259, 259f
TRAM flap breast reconstruction
and, 353
Applied aesthetics, 22–24
Areola tissue, 455, 456f
Areolar hypopigmentation, intradermal
tattoo procedure and, 486, 487
Areolar tattoo. See Tattooing
Arterial insufficiency, TRAM flap
and, 335
Aspirin, breast augmentation and, 86
Augmentation mastopexy, vertical scar
technique and, 41
Autogenous latissimus dorsi flap, 445
Autogenous tissue breast reconstruction,
464, 467f
Autogenous tissue conversion, 291
advanced capsular contracture and,
297, 297f
following breast augmentation, 178,
178f, 179f
Autogenous tissue conversion, Contd.
following suboptimal breast recon-
struction, 180, 180f, 181f
following suboptimal implant-based
reconstruction, 180, 181f
TRAM flap and, 297, 297f–298f
Autogenous tissue reconstruction, post-
mastectomy defect and, 384f
Autologous fat
injection, 405
sites for, 432f–433f, 434
transplantation, contour of breast and,
432–433
Autologous fat grafts, contour deficit
reconstruction and, 404–405
Autologous tissue, pedicled TRAM flap,
399, 404
Axillary incision, 75–76
subpectoral pocket dissection and, 81
B
Bacitracin
subglandular pocket dissection and, 79,
80f
subpectoral pocket dissection and, 82
Baker Classification Score, 149, 151t
Baker III capsular contracture, 111, 295
silicone augmentation and, 168f
Baker IV capsular contracture, 111, 138f,
166, 168f
autogenous conversion, 297, 297f
silicone implant and, 164, 164f
Balloon dissector, subpectoral pocket
dissection and, 82
Base dimension
breast augmentation and, 71, 71f
breast reconstruction and, 371f
problems with, contour and, 50,
51f–52f
tissue expander and, 243, 244f
TRAM flap and, 370
Base width of breast
implant choice and, 68, 70f, 243
TRAM flap and, 323, 324f
Becker expander/implant, 245f
Bell flap, nipple areola reconstruction,
473–474, 478f
Bilateral breast reduction, 443
Biofilm, breast augmentation and, 88
Biopsy, intraductal carcinoma of breast
and, 333
Bipedicle TRAM flap reconstruction
rectus muscle and, 320f, 327, 327f
synthetic mesh and, 321f
technique for, 319
BLAKE drain, seroma and, 163
Bleeding, transaxillary breast augmenta-
tion and, 76
Bleeding points, TRAM flap breast
reconstruction and, 353
Blood supply
breast parenchyma and, 74f
double-opposing sliding periareolar
flap, 477
nipple reconstruction and, 468
Body habitus, breast aesthetics and,
32–33, 34f, 35–37
Bovie, capsulectomy and, 159
Bra
cup size, 9
hypertrophy and, 42
medial implant malposition and, 128
subglandular pocket dissection and, 79
Breast aesthetics, 382. See also
Symmetry of breast(s); Tubular
breast deformity
creating breast mount, 321, 322f–323f,
323, 324f, 325–327
determinants of, 20
fat necrosis and, 406, 406f–407f
folds and, 287–289
nonoperated breast and, reoperated
breast and, 17–64
postoperative, 385f
revision surgery and, 51f–52f
skin paddle and, 379, 382
skin scars and, 379, 382
Breast asymmetry, 100–101, 396,
398f
disfigurement and, 9
expander malposition, 265, 267f–268f
multifactorial, 101–102, 103f
postoperative view, 106f
pre existing, 102, 105f
preoperative view, 105f, 108f
radiation and, 429
reoperative view, 107f
superior skin flaps and, 298–299,
299f, 301
TRAM flap Breast reconstruction
and, 302
treatment plan, 378f
vertical mastopexy and, 440, 441f
Breast augmentation. See also Skin
envelope; Transaxillary breast
augmentation
acute complications of, 86–88
breast size reduction after, 97, 100
complications of, 85–86, 85f
informed consent and, 93
larger cup size
postoperatively, 119f
preoperatively, 118f
litigation and, 8
malpractice insurance companies
and, 5
medial malposition and, 125
patient evaluation and, 67–68
reoperative
overview of, 84t
reasons for, after saline implant, 97t
six months postoperative, 127f
revisional surgery following, 67
reasons for, 66
transaxillary approach to, 75–76
volume asymmetries and, 56f, 58–59
worksheet, 70f
wrong size, malpractice insurance
companies and, 5
Breast bud, 19
Breast cancer. See also Mastectomy
breast-conserving therapy and, 420
partial mastectomy for, 444f–445f
periareolar incision, 332f, 333
post-lumpectomy deformity and,
445, 447f

Breast deformities. See also Combination
breast deformity
combined, reoperation and, 62–63
tumor resection and, 432
Breast gland. See also Ptosis of breast
anatomy, 18–20, 18f
deformities, 30, 31f
development, anatomic distribution
and, 18–20, 18f
dimensions, breast aesthetics and, 33
puberty and, 19–20, 21f
radiation and, 420
supporting structures of, 24–26, 27f,
28–30, 31f
Breast hypoplasia, 89f, 100, 101f
Breast implantation multifactorial, skin
wrinkling, etiology of, 132t
Breast implants. See Implant(s)
Breast malposition, TRAM flap and,
63, 63f
Breast mound
breast aesthetics and, 379, 382
nipple and, 455
Breast mount, creating, flap inset and,
321, 322f–323f, 323, 324f, 325–327
Breast orientation, breast asymmetries
and, 101–102, 103f
Breast parenchyma
blood supply to, 74f
mastopexy and, 183
pregnancy and, 20, 21f
vascularity, implant effect on, 47–48
Breast projection. See Projection
Breast ptosis. See Ptosis of breast
Breast reconstruction. See also Breast
augmentation; Delayed breast
reconstruction; TRAM flap
skin replacement in, 370
volume requirements in, 370, 370f
Breast reconstruction tissue expander.
See Tissue expander
Breast reduction
inverted T incision and, 60
litigation and, 8, 9
malpractice insurance companies
and, 5
nipple loss following, 486–487,
486f–487f
revision surgery following, 183–235
skin loss, 53, 53f
volume asymmetries and, 56f, 58–59
Breast remnant, deformity of, 445
Breast shape. See Shape of breast
Breast skin. See also Native breast skin
flap necrosis
asymmetry, 41, 41f
sensation of, 9
Breast skin flaps, skin scars and, 44f
Breast sonography. See Sonography
Breast surgery. See Surgery
Breast symmetry. See Symmetry of
breast
Breast tissue, stretched, 39f
Breast volume, 36
asymmetries, 55f, 58–59, 101
lumpectomy and, 60f, 62–63
TRAM flap and, 376f
breast aesthetics and, 20, 21f
breast asymmetries and, 101–102, 103f
breast cancer treatment and, 420,
421f, 422f
deficiency, 391f
Breast volume, Cont’d
internal adipose flap and, 399,
402f–403f
post-lumpectomy deformity and,
424, 445, 446
projection of breast, 399, 404
tissue volume and, lower abdomen
and, 370, 370f, 372, 375
discrepancies, nipple position and,
62–63
excess, 384f
flap insertion for, 171f
implant choice and, 243
post-lumpectomy deformity and,
426, 426f
reduction, adipose tissue excision and,
366, 367f
TRAM flap Breast reconstruction
and, 303
Breast-conserving therapy, breast cancer
and, 420
C
Calcification, periprosthetic capsule and,
158f
Capsular contracture
advanced, 111, 112f
breast augmentation and, 8–9
breast implant and, 66
breast reconstruction and, 372,
373f–374f
causes of, 375
classification of, 138t
early, 138
established, 138–139, 141
infra-areolar incision and, 172f
pre v. post-treatment, 140f
saline implant and, 137
therapeutic approaches, 294
Capsular flaps, lateral implant malposi-
tion and, 280
Capsular fluid, infection and, 91
Capsular space, suture capsulorrhaphy
and, 100f
Capsular suture technique, raising IM,
272, 273f, 274f
Capsulectomy, technique of, 159–160
Capsulotomy, implant malposition and,
117, 121
Cefazolin (Ancef)
subglandular pocket dissection and,
79, 80f
subpectoral pocket dissection and, 82
Cellulitis
breast augmentation and, 88
periprosthetic capsulectomy and, 92f
Cephalaxin, fat transplantation and, 432
Cephalosporin
infection and, 91
TRAM flap breast reconstruction and,
353
Chart(s)
breast distances and, 23
implants and, surface dimensions
for, 72f
Chest dimension, wide, 32, 32f
Chief complaint, reoperative breast
augmentation and, 84
Chromic sutures, implant removal
and, 133f
Cicatrix, post-lumpectomy deformity
and, 426
Cigarette smoking
explantation with mastopexy alone
and, 170
mastectomy flap necrosis and,
341, 341t
reoperative surgery and, 4
TRAM flap breast reconstruction, 306
Circulation, fat necrosis and, 405–406,
406f–407f
Cleavage, wide-set, 101f
Closed capsulotomy, 108, 112f
Color patch symmetry, 456
Combination breast deformity, autoge-
nous conversion and, 291, 292f
Combination dermis-fat grafts and autol-
ogous fat injection, nonradiated
patient and, 433–435, 433f–435f
Combination saline silicone tissue
expander, 244, 245f
Communication, reoperative surgery
and, 1–2
Complete capsulectomy, implant removal
and, 155–158
Completion mastectomy, reconstruction
of breast following, 425
Complications, 9
Composite grafts
contralateral nipple and, 472
nipple reconstruction and, 460
Connective tissue, IM fold and, 26, 28f
Consent form, reoperative surgery
and, 76
Constricted breast deformity, 29f, 30, 87,
89f, 90f
IM fold asymmetries and, 104
periareolar incision and, 75f
Consultation
informed consent and, 7
notes, patient documentation and, 8
Contour abnormalities, 44, 45f, 46,
429, 432
adjacent tissue and, muscle pedicle
and, 399, 404
autologous fat transplantation for,
432–433
correction of, tissue shifts and,
429, 432
dermis fat graft and, 50f
dimension problems and, shape prob-
lems and, 50, 51f–52f
implants for, 430, 434, 436, 436f,
437f–438f
TRAM flap reconstruction, malposi-
tioned volume and, 389–390, 395
TRAM flap volume redistribution and,
396, 399
Contour deficit reconstruction, autolo-
gous fat grafts and, 404–405
Contour deformity, 60f, 62–63, 299,
299f–300f
Contour lines, skin scar and, 43
Contour of breast
autologous fat transplantation for,
432–433
breast cancer treatment and, 420,
421f, 422f
post-lumpectomy, 449, 452f–453f
Contralateral breast
breast aesthetics of, 382, 383f
TRAM flap and, 308, 311, 313–314
IM fold lowering and, 389, 391f
NAC and, visual symmetry and, 456
490
Index