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
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.
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