Journal Logo


Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

Sisti, Andrea M.D.; Tassinari, Juri M.D.; Nisi, Giuseppe M.D.; Grimaldi, Luca M.D.

Author Information
Plastic and Reconstructive Surgery: November 2016 - Volume 138 - Issue 5 - p 936e-937e
doi: 10.1097/PRS.0000000000002706
  • Free


We read with great interest the article from Winocour et al. entitled “A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction.”1 The authors performed a systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Thirty-one studies met the inclusion criteria. The results of this review revealed that synthetic materials have higher complication rates, and allogeneic grafts have nipple projection comparable to that of autologous grafts.

In a recent review,2 we observed a complication rate of 5.3 percent using flaps with autologous graft/alloplastic/allograft augmentation. Furthermore, we observed that the use of flaps with autologous graft/alloplastic/allograft augmentation showed a minor loss of nipple projection compared with local flaps, but may expose patients to a relative increased incidence of postoperative flap necrosis.

We noticed that Winocour et al. did not include in their review three interesting articles that describe the use of grafts in nipple reconstruction, as follows.3–5 McCarthy et al., in 2010, conduced a prospective, clinical trial. They included 23 patients with inadequate nipple projection at least 6 months after C-V flap or modified-skate flap reconstruction.3 Synthetic augmentation graft (Artecoll; Artes Medical, Inc., San Diego, Calif.) was injected under the nipple at two time points: baseline and 3 months. There were no adverse events. Before injection, mean nipple projection was 1.33 ± 1.0 mm. The mean increase in projection over the 9-month study period was both clinically and statistically significant (1.60 ± 1.24 mm; p < 0.001). A history of irradiation was a significant negative predictor of final nipple projection (p = 0.012). The authors concluded that Artecoll injection is both feasible and effective in increasing and maintaining nipple projection in the setting of implant-based breast reconstruction.

Tierney et al., in 2014, described nipple reconstruction using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial (allogeneic augmentation graft).5 A retrospective review of 83 patients who underwent nipple reconstruction using this technique was performed. The only reported complications were extrusions (3.5 percent). Six nipples (5.2 percent) in five patients required surgical revision because of loss of projection. Nipple projection at the time of surgery ranged from 6 to 7 mm, and average projection at 6 months was 3 to 5 mm. Complications were infrequent, and short-term projection measurements were encouraging.

Mori et al., in 2015, used skin-sparing mastectomy, the deep inferior epigastric artery perforator flap, and delayed nipple reconstruction with banked costal cartilage (autologous augmentation graft) on eight patients.4 The authors transferred the deep inferior epigastric artery perforator flap using an internal thoracic vessel and banked costal cartilage into an abdominal wound. Three to 6 months later, they removed the cartilage and cut it into a cylindrical shape. They fixed the cartilage on the dermal base of a modified C-V flap. No flap necrosis or exposure of cartilage was seen and the scar was acceptable in all cases. At a mean follow-up of 12.6 months, 41 percent of the nipple projection was lost in comparison to immediately postoperatively.


The authors have no financial interest to declare in relation to the content of this communication.

Andrea Sisti, M.D.
Juri Tassinari, M.D.
Giuseppe Nisi, M.D.
Luca Grimaldi, M.D.
Division of Plastic and Reconstructive Surgery
University of Siena
Siena, Italy


1. Winocour S, Saksena A, Oh C, et al. A systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg. 2016;137:14e23e.
2. Sisti A, Grimaldi L, Tassinari J, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol. 2016;42:441465.
3. McCarthy CM, VanLaeken N, Lennox P, Scott AM, Pusic AL. The efficacy of Artecoll injections for the augmentation of nipple projection in breast reconstruction. Eplasty 2010;10:e7.
4. Mori H, Uemura N, Okazaki M. Nipple reconstruction with banked costal cartilage after vertical-type skin-sparing mastectomy and deep inferior epigastric artery perforator flap. Breast Cancer 2015;22:9597.
5. Tierney BP, Hodde JP, Changkuon DI. Biologic collagen cylinder with skate flap technique for nipple reconstruction. Plast Surg Int. 2014;2014:194087.


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

Copyright © 2016 by the American Society of Plastic Surgeons