• Archives of Plastic Surgery
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• v.32 no.6
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• pp.706-709
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• 2005

The absence of the nipple-areolar complex(NAC) in men are seldom stated, as a result of trauma, burn, mastectomy, or after the correction of extreme bilateral gynecomastia. A total of 50 healthy men aged 21 to 27 years were examined. We recorded the configuration (dimensions and shape) and the location of the NAC with respect to fixed skeletal anatomic landmarks. Of the 50 subjects examined, 44 had oval and 6 had a round NAC. The mean diameter for a round NAC was 24.3 mm. The center of the NAC was in the fourth intercostal space in 41 volunteers and in the fifth intercostal space in 9 of the subjects. To localize the NAC on the chest wall, at least three reproducible measurements proved to be necessary, composed of a horizontal line(distance from the midsternal line to the nipple, A), a medial oblique line(distance from the sternal notch to the nipple, B) and a lateral oblique line(distance from the acromioclavicular joint to the nipple, C). Using these three parameters, we recommend that the appropriate location can be calculated derived from the circumference of the chest.

• Archives of Plastic Surgery
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• v.33 no.5
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• pp.570-576
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• 2006

Purpose: Skin-sparing mastectomy(SSM) with immediate breast reconstruction is becoming a proved option for early-stage breast cancer patients. Recently, skin-sparing mastectomy with preserving the nipple-areolar complex is becoming popular procedure. Methods: During a 13-month period, from April 2004 to January 2005, 101 cases of immediate breast reconstructions with pedicled TRAM flap were performed after 40 cases of nipple-areolar sparing mastectomies, 57 cases of skin-sparing mastectomies and 4 cases of modified radical mastectomies. Results: During the 11 months follow up period, necrosis of mastectomy skin flap occurred in 17.5%(n=10) after skin-sparing mastectomy and necrosis of mastectomy skin flap and nipple-areolar necrosis occurred in 30%(n=12) after nipple-areolar sparing mastectomy. These complications were healed after simple dressing without any surgical procedure. Conclusion: Nipple-areolar sparing mastectomy and immediate breast reconstruction with TRAM flap is good option for early breast cancer patients and some modifications are needed to reduce skin necrosis.

• Archives of Plastic Surgery
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• v.49 no.5
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• pp.580-586
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• 2022

Background Appropriate position of the nipple-areolar complex (NAC) is crucial following nipple-sparing mastectomy (NSM). The prevention of NAC malposition in two-stage implant-based breast reconstruction has not been well described, and the efficacy of the techniques has not been evaluated. This study aimed to evaluate the efficacy of our technique to prevent NAC malposition in patients who underwent implant-based breast reconstruction after NSM. Methods Patients who underwent two-stage implant-based breast reconstruction with NSM between January 2012 and December 2019 were included. We used a surgical technique to fix the NAC to the rigid base, assuming a pocket-like appearance, with pectoralis major muscle and lateral adipofascial flap at the time of tissue expander (TE) insertion. Patients were classified into two groups based on the performance of the technique for the prevention of NAC malposition. Results In 35 patients who underwent implant-based breast reconstruction after NSM, the clavicle-to-nipple distance ratio was 96.0±5.0% in those who underwent NAC fixation and 86.1±11.5% in those who did not undergo NAC fixation. Conclusions Using our technique, NAC malposition could be prevented in two-stage implant-based breast reconstruction. NAC fixation during TE insertion was found to be extremely effective. This procedure successfully prevented NAC malposition without the formation of extra scars.

• Archives of Plastic Surgery
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• v.48 no.1
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• pp.44-48
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• 2021

Previously reported nipple-areolar complex reconstruction (NAR) methods involve multiple incisions and wide skin redraping, which increase retraction forces and heighten the risk of nipple-areolar complex (NAC) flattening. We introduce a NAR method using the long V-Y advancement technique that can overcome these disadvantages. A V-shaped flap is designed with the width of the flap base 4-5 mm larger than the diameter of the normal nipple. The flap length is designed to be at least 2.5 times its width. Dissection is performed to the top of the artificial dermal matrix or muscle layer. The nipple is constructed with the same projection as the contralateral side by folding the elevated flap. The tip of the elevated flap is apposed in the middle of the donor defect to minimize the deformity during donor site closure. A 3-point skin suture is applied to the upper third of the folded flap to mold its shape. Using this long V-Y advancement technique, we successfully decreased skin tension in NAC flaps and improved the maintenance of reconstructed nipple projection. The long V-Y advancement technique provides an easy, simple NAR method, effectively maintaining longer nipple projections and reducing breast deformities, especially in Asian women with relatively large nipples.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.715-717
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• 2011

Purpose: In cases of breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy with nipple-areolar complex (NAC) removal, the flat contour of the flap's skin paddle can easily look unnatural and dissatisfying. Reconstructed NAC on the flap surface lacks the elevated contour that the normal areola possesses, resulting in an unnatural final result. Therefore, we would like to introduce a novel method to improve this problem and report the satisfactory results we obtained. Methods: Operations were conducted on 19 patients who underwent immediate breast reconstruction with a free TRAM flap and skin-sparing mastectomy from January 2009 to January 2010, with a mean follow-up of nine months. While the TRAM free flap was being inset, a purse-string suture was carried out on the dermal layer of skin flap to create a slight protrusion with Gore-$Tex^{(R)}$ sutures. Results: The elevated mound surrounding the NAC was well maintained for an average follow-up period of nine months. Nipple projection was also well maintained. There was no complaint about breast contour or nipple height reduction. In addition, there was no reported incidence of other complications. Conclusion: The purse-string suture technique presents a more natural breast silhouette around the NAC and helps to maintain nipple projection. Furthermore, it does not require any supplementary incisions or complicated skills. There has been no report of additional complications using this technique.

• Korean Journal of Radiology
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• v.24 no.8
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• pp.739-751
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• 2023

Objective: This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer. Materials and Methods: The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values. Results: Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%. Conclusion: Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.

• Archives of Plastic Surgery
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• v.36 no.6
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• pp.784-787
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• 2009

Purpose: Reduction mammaplasty is one of the most commonly performed operations in plastic surgery. Although secondary surgery is occasionally required for minor aesthetic problems or for treatment of the complications of the primary surgery, there are no clear operative guidelines of management. We report here two cases of secondary reduction mammaplasty using differrent pedicle from the initial ones. Methods: One case of secondary reduction mammaplasty were performed using medial pedicle after central (19 years) pedicle reduction mammaplasty because of subsequent breast ptosis and asymmetry. The other case were performed using medial pedicle after superior (4 years) pedicle reduction mammaplasty with contralateral immediate breast reconstruction with TRAM flap because of subsequent breast ptosis and asymmetry. Care was taken to include sufficient width of pedicle and adequate soft tissue attachment beneath the nipple - areolar complex. Results: There was no significant complication such as nipple - areolar necrosis or fat necrosis. The results were well maintained throughout the follow - up period. Conclusion: Medial pedicle reduction mammaplasty can be safely performed after central or superior pedicle reduction mammaplasty when sufficient width of pedicle and adequate soft tissue attachment beneath the nipple - areolar complex are maintained.

• Archives of Plastic Surgery
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• v.41 no.4
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• pp.366-373
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• 2014

Background The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer. Methods We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision. Results 281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction. Conclusions Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.

• Archives of Plastic Surgery
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• v.46 no.2
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• pp.129-134
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• 2019

Background Nipple-areolar complex (NAC) reconstruction is the final stage of breast reconstruction. Ideal reconstruction of the NAC requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there is no gold standard technique. The technique devised by the authors is very versatile, with excellent results, and it enables 1-step reconstruction with optimal results in terms of shape and nipple projection. Methods Our technique consists of a combination of modified local flaps and a full-thickness skin graft. Patients were observed for 18 months to estimate the amount of retraction. This procedure was performed in 40 patients, four of them bilaterally. The duration of the follow-up was 30 months. Complications occurred in 10% of patients, and included infections (5%), ischemia (2.5%), and hematoma (2.5%). Results No cases of total nipple necrosis were reported. The NAC shape remained optimal in all cases, with a very small reduction of the vertical and horizontal diameters of the areola, which maintained its designed round shape well, and negligible retraction in the diameter and projection of the nipple. Conclusions The oval technique represents a major step forward, involving a combination of existing techniques, such as the C-V flap and the cutaneous graft, to achieve excellent results regarding areola shape and nipple projection, significantly reducing the cases of nipple ischemia. These results were substantially obtained through subcutaneous equatorial sutures, skin grafting, and flattening of the apexes of the flap.

• Archives of Plastic Surgery
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• v.43 no.5
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• pp.470-473
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• 2016

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C-V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection.