Plastic & Reconstructive Surgery:
Repairing the High-Riding Nipple with Reciprocal Transposition Flaps; and Classification and Management of the Postoperative, High-Riding Nipple
Bovill, Esta S. Ph.D., F.R.C.S.(Plast.); Macadam, Sheina A. M.D.; Lennox, Peter A. F.R.C.S.
Division of Plastic Surgery, University of British Columbia, and Burn, Plastic & Trauma Unit, Vancouver General Hospital, Vancouver, British Columbia, Canada
Correspondence to Dr. Bovill, Division of Plastic Surgery, University of British Columbia, and, Burn, Plastic & Trauma Unit, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, British Columbia, Canada
We read with interest the recent article by Spear et al.1 describing a useful technique for correction of the postoperative, high-riding nipple, and the subsequent review and classification.2 We too have found nipple-sparing mastectomy reconstruction with either expanders or single-stage implants to confer an excellent aesthetic outcome in suitable patients. With increasing volume and laxity of the skin envelope, however, the potential for shear at the mastectomy flap/implant pocket interface increases, manifest by a tendency for the nipple-areola complex to migrate superolaterally during the postoperative recovery and/or expansion phase. This aesthetically undesirable outcome may also be exacerbated by, but is not exclusive to, postreconstruction radiotherapy.
Several other solutions have been described in the literature, including techniques where the nipple is lowered through a buttonhole,3 transposed as a flap, or Z-plasty.4 Excision and repositioning as a graft may result in the least scarring, but at the risk of nipple loss. Techniques that involve elevating the entire breast relative to the nipple have been described both by elevating the inframammary fold3 and with the use of implants or tissue expanders,3,5 but are less useful for correcting multiple vectors of displacement. Thus, given that these techniques may be complex and often provide suboptimal results,4 prevention should be preferable to cure. We currently use a simple suture technique to anchor the spared nipple-areola complex to the underlying implant pocket, which maintains its position on the breast mound throughout the expansion/postoperative period.
The nipple-sparing mastectomy is performed and submuscular pocket created as described previously. Care is taken to ensure optimal placement of the device such that the nipple-areola complex is located and marked at the pinnacle of the breast mound, or for expanders, once the desired intraoperative fill volume is achieved. The nipple-areola complex dermis is then tacked to the muscle pocket using three 4-0 absorbable monofilament anchoring sutures (Fig. 1). The radial mastectomy scar may also be anchored in this way (Fig. 2). Intraoperative sitting of the patient is invaluable, not only in the key assessment of the final nipple-areola complex placement but also in ensuring that no adverse skin folding or traction on the nipple-areola complex is caused by the anchoring sutures. A drain placed between the muscle and skin flap reduces potential shear. The remainder of the procedure and postoperative management is unaltered.
We have successfully used this technique over a series of 25 consecutive alloplastic reconstructions following nipple-sparing mastectomy, evenly split between two-stage expander and single-stage reconstructions. Postoperative irradiation was also administered in 16 percent. No revisions to the nipple-areola complex were required over the median 6-month follow-up period (range, 2 to 12 months). Given that the technique results in negligible additional operative time, complications, and costs, we suggest that it be included among solutions to this difficult problem.
Dr. Lennox is a speaker for LifeCell Corp.
Esta S. Bovill, Ph.D., F.R.C.S.(Plast.)
Sheina A. Macadam, M.D.
Peter A. Lennox, F.R.C.S.
Division of Plastic Surgery
University of British Columbia, and
Burn, Plastic & Trauma Unit
Vancouver General Hospital
Vancouver, British Columbia, Canada
1. Spear SL, Albino FP, Al-Attar A. Repairing the high-riding nipple with reciprocal transposition flaps. Plast Reconstr Surg. 2013;131:687–689
2. Spear SL, Albino FP, Al-Attar A. Classification and management of the post-operative, high-riding nipple. Plast Reconstr Surg. 2013;131:1413–1421
3. Millard DR Jr, Mullin WR, Lesavoy MA. Secondary correction of the too-high areola and nipple after a mammaplasty. Plast Reconstr Surg. 1976;58:568–572
4. Frenkiel BA, Pacifico MD, Ritz M, Southwick G. A solution to the high-riding nipple-areola complex. Aesthetic Plast Surg. 2010;34:525–527
5. Colwell AS, May JW Jr, Slavin SA. Lowering the postoperative high-riding nipple. Plast Reconstr Surg. 2007;120:596–599
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.
David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, email@example.com
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