Nipple-Areolar Complex Reconstruction

A Review of the Literature and Introduction of the Rectangle-to-Cube Nipple Flap

Joshua T. Henderson, BA; Thomas J. Lee, MD; Andrew M. Swiergosz, BS; Andrea R. Hiller, BS; Joshua Choo, MD; Bradon J. Wilhelmi, MD, FACS

Disclosures

ePlasty. 2018;18(e15) 

In This Article

Operative Steps

A schematic for the flap can be seen in Figure 1 with letters corresponding to Figure 2, Figure 3, Figure 4, Figure 5 and Figure 6. Flap markings are made preoperatively. New symmetric breast meridians are approximated using distances from the sternum and mid-clavicle. An inferiorly based rectangular flap is designed inferior to the transverse scar (Figure 2). (A superiorly based rectangular flap can also be designed for a superior pedicle.) The pedicle width is 2 cm, and the length and width of the medial and lateral flaps are both 1.5 cm. The flap is incised full-thickness, and the surrounding scar is de-epithelialized (Figure 3). The medial flap is then elevated and rotated, and point A is secured to the inside corner of the lateral flap, point C, with an absorbable suture (Figure 4). This medial flap creates the base of the reconstructed nipple. The lateral flap is then elevated and approximated over the medial flap. Point H of the medial flap is sutured halfway between points C and D of the lateral flap (Figure 5). Points D and E of the lateral flap are then approximated on top of the medial flap using a permanent suture (Figure 6). A half circle is marked immediately superior to the base of the reconstructed nipple and de-epithelialized to create a stable base upon which the flap can rest (Figure 7). The base of the flap is then sutured to the edge of the de-epithelialized area with a permanent suture (Figure 8).

Figure 1.

Schematic of flap elevation and rotation. Letters A-D represent the inferior aspect of the flap, whereas letters E-H represent the superior aspect. Letters A and H represent the medial aspect of the flap for NAR of a left breast. The shaded areas are de-epithelialized. An inferiorly based rectangular flap is designed inferior to the transverse scar. The pedicle width is 2 cm, and the length and width of the medial and lateral flaps are both 1.5 cm. The flap is incised full-thickness, and the surrounding scar is de-epithelialized. The medial flap is then elevated and rotated, and point A is secured to the inside corner of the lateral flap and point C with an absorbable suture. The lateral flap is elevated and approximated over the medial flap. Point H of the medial flap is sutured halfway between points C and D of the lateral flap. Points D and E of the lateral flap are then approximated on top of the medial flap using a permanent suture.

Figure 2.

Patient markings.

Figure 3.

Flap incision and scar de-epithelialization.

Figure 4.

Medial flap rotation.

Figure 5.

Medial flap inset.

Figure 6.

Lateral flap inset.

Figure 7.

De-epithelialization of half-circle to create a base for the flap.

Figure 8.

Completed rectangle-to-cube nipple flap.

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