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2008 Annual Meeting Abstracts

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The Missing Link in Nipple Reconstruction is the Areola
John B. McCraw, M.D1, Shushan Jacob, M.D.1, Lawrence Colen, M.D.2, Guy T. Jones, M.D.2, Virginia Huang, M.D.3, Jacqueline Murray, R.N.4, Ann Meng, C.S.T4, Anne Cramer, M.D.5.
1The University of Mississippi Medical Center, Jackson, MS, USA, 2Eastern Virginia Medical School, Norfolk, VA, USA, 3Private practice, Vancouver, WA, USA, 4Private practice, Norfolk, VA, USA, 5Private Practice, Davenport, IA, USA.

PURPOSE:
In virtually all previous reports of nipple reconstruction using local flaps, beginning with Berson’s 1946 report, the primary goal has been to form a “nipple.” The shape of the areola has largely been ignored, so that most of our nipple reconstructions create a “button on a flat surface.” A better shape would place the neo-nipple on top of a neo-areola, in a “dome-on-a-dome” shape. In 1995 McCraw first described a combined nipple and areolar reconstruction (NAR) in autogenous breast reconstructions. Only three subsequent reports have addressed areolar reconstruction (Colen 1998, Kroll 1999, Williams, et. al, 2007). The present report demonstrates, importance of the areolar shape in re-creating the nipple-areolar complex (NAC).
METHODS:
A Prospective 5 year study of NAR was performed on patients undergoing autogenous breast reconstruction. Nipple and areolar flaps are developed from the periphery of the autogenous flaps, so that the normal vasculature of the autogenous flap will not be affected. A “dome” shaped areola is formed first, and wrapping flaps are then inset on top of the areolar “dome.” An independent panel of health care personnel rated shape and symmetry of the NAR at end of one year and anually thereafter. Every patient responded to a survey regarding patient satisfaction.
RESULTS:
This report includes 248 combined breast and NAR in 180 patients over 5 years. Single-stage autogenous breast and NAR were done in 32% (N=58 patients) and secondary NAR in 68%(N=122 patients). Bilateral breast reconstructions were done in 38% (N=69 patients) and unilateral reconstructions in 62% ( N=111 patients). Free flaps were done in 55% (N=99 patients), including: 50% TRAM (N=90 patients), 0.5% latissimus (N=1 patient), 0.5% lateral thigh (N=1patient), 4% gluteus (N= 7 patients). Pedicled flaps were done in 45% (N=81 patients), including: 31% autogenous latissimus (N=55 patients) and 14% TRAM (N=26 patients). Mean patient age was 52 (range-24 to 67); mean follow-up was 3 yrs (range- 1 to 5years). Rating of NAR by the independent panel were recorded as: excellent-25%, good-50%, fair-15%, poor-10%. Patient satisfaction was high (85%), and dissatisfaction was low (15%). The reconstruction failed in 4 patients (1.6%) for technical reasons.
CONCLUSION:
Areolar reconstruction is equally as important as nipple reconstruction in achieving an anatomically normal appearing NAC. The additional operative time is justified by early acceptance of the new “breast shape” by patients, as evidenced by the high patient satisfaction in this study.
Postoperative photographs (6 months, 1 and 5 years)-




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