Nipple and areola reconstruction is the final phase of breast reconstruction. Many different techniques have been described, including local flaps, nipple sharing, and, more recently, tattoo-only techniques.1 Yet few seem to result in a truly prominent nipple with lasting projection. The procedure we describe gives good long-term nipple projection.
Fourteen nipple-areola complex reconstructions in 11 female patients were evaluated. Eight patients underwent breast implant reconstruction. Two patients were reconstructed with a latissimus dorsi flap and one patient was reconstructed with a transverse rectus abdominis muscle flap. Three patients had bilateral nipple-areola reconstruction. Each patient was asked to complete a questionnaire with a visual analogue scale. Nipple and areola dimensions were measured 3, 6, and 12 months postoperatively.
The location of the nipple-areola complex is planned with the patient in the standing position (Fig. 1). The procedure is performed with the patient under local anesthesia (lidocaine 1% plus 1:100,000 epinephrine). The nipple can be considered as a cylinder, a three-dimensional structure. It can be unfolded geometrically into a two-dimensional structure. The flap is elevated carefully in order not to damage the flap pedicle. When the flap is elevated, just a little subcutaneous fat is left under the flap to preserve the subdermal blood supply. The surrounding skin is deepithelialized in the shape of the neo-areola. After elevation, the flap is folded into the shape of a cylinder. The flap wings are fixed together with a 5-0 Vicryl suture. Finally, the cup is fixed to the flap wings by interrupted 5-0 Vicryl sutures. In the end, the flap donor site is covered by a full-thickness skin graft taken from the inner thigh (Fig. 2).
Fourteen nipple-areola reconstructions were performed using this technique. The average overall satisfaction rate was 82 percent, and the average patient satisfaction rate with the amount of nipple projection was 52 percent; however, two women stated that the projection was too much. After 12 months, mean nipple projection was 5 mm (50 percent residual projection). Three patients developed partial necrosis of the full-thickness graft. All “Hammond” flaps survived.
Many techniques have been described to create the nipple-areola complex. Nipples reconstructed with local flaps slowly lose their projection due to skin surface tension, retraction of scar tissue, soft-tissue absorption and necrosis, and compression by clothing.2 The Hammond flap consists mainly of dermal tissue instead of fat. The former is more stable over time and results in longer-lasting projection of the nipple, as shown by our results (50 percent residual projection after 12 months). Rubino et al.2 obtained a residual projection of 49 percent using the arrow flap. Shestak et al.3 compared loss of projection among the skate, modified skate, and bell flaps. After 12 months, residual projection varied between 30 and 60 percent. Few et al.4 noted a residual projection of 41 percent with the modified star flap. The blood supply to the nipple flap is mostly subdermal, which has proved to be reliable. The Hammond flap is a simple and safe technique.
Guido H. C. G. Dolmans, M.D.
Annekatrien L. van de Kar, M.D.
Julien H. A. van Rappard, M.D., Ph.D.
Maarten M. Hoogbergen, M.D., Ph.D.
Department of Plastic, Reconstructive, Hand, and Aesthetic Surgery
Catharina Hospital Eindhoven
Eindhoven, The Netherlands
1. Gamboa-Bobadilla, G. M. Nipple reconstruction: The top hat technique. Ann. Plast. Surg.
54: 243, 2005.
2. Rubino, C., Dessy, L. A., and Posadinu, A. A modified technique for nipple reconstruction: The “arrow flap.” Br. J. Plast. Surg.
56: 247, 2003.
3. Shestak, K. C., Gabriel, A., and Landecker, A. Assessment of long-term nipple projection: A comparison of three techniques. Plast. Reconstr. Surg.
110: 780, 2002.
4. Few, J. W., Marcus, J. R., Casas, L. A., et al. Long-term predicable nipple projection following reconstruction. Plast. Reconstr. Surg.
104: 1321, 1999.
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