Rietjens et al1 report 16 cases of nipple grafting. Fourteen of these cases were for treatment of nipple malposition in patients undergoing nipple-sparing mastectomies or breast-conserving surgery and radiation. Two primary breast reduction patients were included, although they presumably did not have malpositioned nipples. Still, 14 cases of nipple grafting to correct nipple malposition is a high volume for 1 surgeon over 3 years. Some cautionary notes are in order lest this operation be considered a “go to” procedure for cases of nipple overelevation.
A high-riding nipple is very common, present in at least 1 breast in 41.9% of published mammaplasties2 (and apparent in the contralateral breast in the authors’ Figs. 3 and 4). In mastopexies and breast reductions, nipple overelevation is usually caused by (1) the inverted-T technique, a design that overelevates the nipple,2,3 and (2) preoperative marking of the planned nipple position.3 Preoperative marking commits the surgeon to a nipple level before the new breast mound is formed. Nipple overelevation may be avoided by (1) using the vertical technique and (2) determining nipple level after breast mound creation and locating the new nipple site at or just below the apex.3 Similarly, technical considerations help reduce the risk of superior nipple migration after a nipple-sparing mastectomy.4
Unfortunately, the authors provide no clinical information for the patient depicted in their Figure 1. The authors’ Figure 3 is evidently an intraoperative photograph of a different woman treated with a right nipple/areola graft. Before-and-after photographs of the same patient would have been helpful. Without at least 1 example of results, the authors’ claim that their technique is superior to other methods1 is unsupported. Nipple and areola tissue loss, as documented here,1 is an expected complication in the context of breast reconstruction in irradiated tissue. The authors promote fat injection but do not provide examples of its efficacy. Might simultaneous fat injection impair the already compromised vascularity of the recipient site?
In 1998, Spear and Hoffman5 published the use of reciprocal skin grafts, essentially the same operation as the one used by these authors, except that the donor site is skin grafted rather than closed primarily. More recently, Spear et al6 have promoted reciprocal skin flaps instead, with no cases of flap loss. These investigators evidently prefer the more reliable vascularity of a local flap. Both skin grafts and flaps leave scarring in the upper pole.5,6 However, skin flaps are thicker, more reliable, and bring vascularized fat with them.
Millard et al7 described skin excisions within the inframammary crease to pull the nipple down in mammaplasty patients with superiorly displaced nipples. Breast implants can assist by providing a fulcrum. The procedure may be repeated, keeping the scar tucked within the inframammary crease where there is often an existing scar (Fig. 1). The advantage of this procedure over reciprocal flaps or Z-plasties8 is avoidance of a scar above the nipple, which can be visible in a low-cut top or bikini. Inframammary skin resection is safe from a vascular and sensory standpoint because there is no periareolar dissection.
The authors recommend not overly thinning the nipple graft to preserve erectility.1 It is unlikely that a grafted nipple will remain erectile.9 It has been known for decades that normal and erotic sensation are lost if a nipple is grafted.10 The devascularized tissue must now survive as a skin graft, with variable degrees of tissue loss (including smooth muscle that provides erectility), depigmentation,1,5 and scarring. Consequently, nipple/areola grafting is highly debilitating to the function and sensation of this unique and irreplaceable body part. Mammaplasty patients value their nipple sensation11 and 80% of women report that nipple stimulation is important sexually.12 Regardless of sexual activity, sensate body parts are always to be preferred.
Even now, almost a century after Thorek13 conceived the procedure, nipple grafting is still used by some plastic surgeons for very large breast reductions.14 However, with greater popularity of the vertical mammaplasty and recognition of the safety advantages of nipple repositioning3 on short pedicles rather than transposition on long ones, it is more difficult to recommend nipple grafting over nipple repositioning. Experienced operators who use the vertical mammaplasty technique exclusively report extremely few or no cases of nipple/areola loss.15
It is not difficult to raise a nipple that is too low, but it is much more challenging to lower one that is too high. A mild degree of ptosis is not necessarily unattractive and of course very natural in appearance. By contrast, an overelevated nipple, with a skyward inclination, looks unnatural. When relocating a nipple, the destructive effects of nipple grafting must be weighed carefully against possible benefits. The causes of nipple malposition, methods to prevent it, and surgical remedies that preserve nipple form and function are important considerations.
The author has no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the author.
Eric Swanson, MD
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