Nipple-sparing mastectomy is perceived to have certain aesthetic benefits that improve the outcomes of breast reconstruction.1,2 When the spared nipple or areola is necrotized, however, suboptimal outcomes will follow. Conservative treatment with secondary healing has been the main approach to date when nipple-areola complex necrosis occurs.3,4 An early intervention of débridement of the necrotized portion of the nipple-areola complex and prompt individualized reconstruction with banked skin can prevent negative consequences.
If there was suspicion of nipple or areolar skin ischemia, skin banking was planned. Skin banking was performed by generating a skin island under the spared nipple-areola complex without deepithelialization.
When nipple-areola complex necrosis was diagnosed 2 to 3 weeks after nipple-sparing mastectomy, débridement of the necrotized portion of the complex was carried out under local anesthesia. Individualized reconstruction was planned in accordance with the proportional defects after débridement. If a patient lost the entire nipple-areola complex, the nipple was then reconstructed with a modified top-hat flap from the banked skin (Fig. 1). The remaining banked skin was tailored to fit the areolar defect. Necrosis of the part of the areola with the intact nipple was managed by filling the areola skin defect with banked skin after tailoring.
Among the 52 nipple-sparing mastectomy cases, skin banking was performed in 25 (48.1 percent). Nipple-areola complex necrosis occurred in six cases, corresponding to 11.5 percent of all nipple-sparing mastectomy cases and 24 percent of the skin-banking cases. In the six cases of immediate nipple-areola complex reconstruction (Table 1), there were no complications such as infection, hematoma, or ischemic necrosis. In the other 19 cases of skin banking, the spared nipple survived and the wound was closed primarily after removal of the banked skin. The reconstructed nipples showed loss of projection with time to a similar degree as seen in standard nipple reconstruction after skin-sparing mastectomy.
Necrosis of the nipple-areola complex causes loss of projection and depigmentation of the nipple and distortion of the nipple-areola complex by scar formation. Furthermore, attempts to reconstruct the nipple after necrosis are far more difficult than after skin-sparing mastectomy, because the surviving skin and tissue around the nipple are frequently scarred and fibrotic. Therefore, in cases of nipple-areola complex necrosis following nipple-sparing mastectomy, patients have worse outcomes than with skin-sparing mastectomy. Immediate nipple-areola complex reconstruction with banked skin can prevent all the negative consequences of the necrosis and provide at least the same outcome as that with skin-sparing mastectomy.
The innovative idea of banking the skin and using it in cases of mastectomy skin flap necrosis was introduced as “banked” transverse abdominis musculocutaneous flap reconstruction by Kovach and Georgiade5 in 2006. Banking the skin flap is not a harmful procedure even when the whole mastectomy flap survives. Banked skin can easily be excised 2 or 3 weeks after initial reconstruction. There is concern of an increased risk of infection due to the wound being left open in a necrotic environment. In the current series, however, there were no cases of infection.
Nipple-areola complex reconstruction should be performed at an appropriate time, immediately after clear demarcation of the necrotic lesion and before scar contracture and fibrosis occur. Our experience has shown that 2 to 3 weeks from initial reconstruction is an ideal time for diagnosis of nipple-areola complex necrosis as well as for immediate reconstruction.
The authors have no financial interest to declare in relation to the content of this article.
Sung Woo Park, M.D.
Taik Jong Lee, M.D., Ph.D.
Eun Key Kim, M.D., Ph.D.
Jin Sup Eom, M.D., Ph.D.
Department of Plastic Surgery
Asan Medical Center
University of Ulsan College of Medicine
1. Jabor MA, Shayani P, Collins DR Jr, et al. Nipple-areola reconstruction: Satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110:457–463
2. Shaikh-Naidu N, Preminger BA, Rogers K, et al. Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction. Ann Plast Surg. 2004;52:465–470
3. Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki WM, Costa A. Necrotic complications after nipple- and areola-sparing mastectomy. World J Surg. 2006;30:1410–1413
4. Bistoni G, Rulli A, Izzo L, Noya G, Alfano C, Barberini F. Nipple-sparing mastectomy: Preliminary results. J Exp Clin Cancer Res. 2006;25:495–497
5. Kovach SJ, Georgiade GS. The “banked” TRAM: A method to insure mastectomy skin-flap survival. Ann Plast Surg. 2006;57:366–369
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