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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Elisabeth K. Beahm, MD, FACS1, Robert L. Walton, MD, FACS2.
1MD Anderson Cancer Center, Houston, TX, USA, 2University of Chicago, Chicago, IL, USA.

Purpose: A wide variety of approaches are employed for nipple/areolar reconstruction (NAR) after breast reconstruction without consensus for the best technique to maximize aesthetic outcome and stability over time. The degree to which NARs lose projection and the factors most significantly linked to outcome are poorly understood and merit objective, long term prospective study.
Methods: A Prospective 5-year study of three techniques of NAR using modified Star (MS), Double Opposing Tab (DOT), and Anderson Purse string (AP) flaps, combined with areolar tattoo pigmentation or split-thickness medial thigh skin grafting (SG) was performed on consecutive, autologous, implant based, or combined autologous/implant breast reconstructions. The NAR technique utilized was that deemed most appropriate by the individual surgeon and patient preference. Skin flap epidermal/dermal thickness was arbitrarily assigned a value of thick, medium, or thin by the operating surgeon. Nipple projection (in cm) was assessed intra-operatively and at 2-3 weeks, 3 months, 6-9 months, 12 months postoperatively, and annually thereafter. All patients were followed for a minimum of 12 months.
Results: 160 breasts in 123 patients were included in this study. Mean pt. age was 48.6 years (range 29-72 yrs.), Mean follow-up was 2.6 years (range 1-5.1 yrs.). Breast reconstruction was 70 % Unilateral (N=86 patients) and 30% Bilateral (N=37 patients) comprising: Lower abdominal flaps (N= 78 patients(63%)/101 breasts ), Implant alone (N=34pts(28%)/44breasts); Latissimus Dorsi (LD) with implant (N=11(9%)/15breasts). Distribution of NAR was: MS=21% (N=26pts/32breasts); DOT=12% (N=15pts/18 breasts); AP= 47% (N=58pts/72breasts) followed with tattoo pigmentation of the areola (75%). SG of the areola was performed in 33pts/38breasts breasts (DOT 18 pts/21 breasts, MS 15 pts/17breasts). All reconstructed nipples lost projection over time (Mean loss =56%) which stabilized at 6 months. Projection loss was greatest with the Star flap (Percentage Loss: MS 68%, DOT 56%, AP 46%, SG 40%: regression analysis p= 0.03). Loss of projection was greater with implant alone reconstructions compared to autologous/implant or autologous reconstructions (53 % vs. 59%, p=0.06) Increased nipple projection and stability appeared directly related to flap thickness and absence of tattoo intervention. Overall patient satisfaction was comparable among techniques (4% very dissatisfied, 10% somewhat dissatisfied, 32% satisfied, 54% very satisfied) although 26% of patients requested and 16 % underwent revision of the initial NAR due to loss of projection. Tattoo coloration required reapplication after 26 months (range 4-40 months), especially in the pink color range. Tattooing the nipple early (< 3 months) appeared to result in the greatest loss of projection (67% vs. 52%, p=0.03), although late applications of the tattoo also appeared to compromise nipple projection to a lesser degree. Thirteen percent of SG patients underwent correction of a pale nipple/areolar complex with tattoo. This intervention resulted in additional loss of projection by 10-20% even in reconstructions >12months old.
Conclusions: All NARs lost significant projection over time. Sustained height of nipple projection was most closely linked to a thicker dermis in the flaps utilized for reconstruction. Nipple projection was found to be optimal when SG, alone, was utilized for areolar reconstruction. Tattooing adversely affected nipple projection.

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