A Novel Technique for Single-stage Reconstruction of Nipple-Areola Complex following Central Lumpectomy

Abstract

Several oncoplastic techniques have been proposed for subareolar breast cancer, some of which may require contralateral operation for symmetry, or more than one operation for delayed reconstruction of the nipple-areola complex (NAC). We herein developed a simple and effective oncoplastic approach following central quadrantectomy, aiming to achieve the following: (1) preservation of breast shape and contour for patients who are not accepting of a notably smaller breast or bilateral operation; (2) single procedure with advantages of single anesthetic and the ability to reconstruct a breast that has not yet been affected by radiation; (3) no autologous grafts with disadvantage of an extra donor site; (4) creation of natural neo-NAC with only incision within the region of the areola complex; and (5) maintaining long-term nipple projection. In this technique, the medial and lateral peri-areolar flap was advanced and rotated to restore partial neo-NAC, and to fill the defect after central tumor and NAC resection. The whole neo-NAC margin was created using the "round block" technique. Additionally, the nipple reconstruction was performed at the mitten of the neo-areola area using the C-V nipple flaps with an internal strut of rolled dermal grafts harvested from excised skin during the round block procedures. Lastly, a purse-string suture is placed in the outer skin margin for control of areola diameter and project. Six patients with central tumors of the breast were treated in this easily achieved approach. Patient satisfaction was noted as high, and the cosmetic results were evaluated as good to excellent.

Fig. 1.

Schematic of the authors’ technique, stages I–VI. (I) Preoperative design. For illustration purpose, (a) shows proposed removal area with tumor involving the lower subareolar region and NAC; only the partial upper portion of areola is preserved (arrow head). (b) Arrows denoting 2 “crab foot shaped” medial (arrow head) and lateral (double arrow heads) peri-areolar flaps. (c) A V-C nipple flap. (d) The area of de-epithelialized or excised skin at the edge of neo-NAC. “¤” indicates tumor. (II) Central lumpectomy and flaps’ elevation. (III) NAC and tumor were removed together with central lumpectomy cavity and area of V-C and peri-areolar flaps. (IV) Appearance of advancement of glandular tissue and flaps that were mobilized and sutured to fill the central breast while creating neo-NAC. The edge of the neo-NAC was epithelialized and packed into the neo-nipple. (V) Reduction of the diameter of the outer skin margin using a purse-string suture. (VI) Final result following closure of the skin incision.

Fig. 2.

Details of the surgical procedure intraoperatively. A 64-year-old patient with subareolar invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS), 2.0 cm in size. A, a central lumpectomy cavity after removal of NAC and tumor together; medial and lateral peri-areolar flaps, V-C flap, and the area of de-epithelized at edge of areola are shown. (B) Immediate postoperative appearance of the reconstructed neo-NAC after closure of the skin incision.

Fig. 3.

The same patient as in Figure 2: lateral image of neo-NAC was obtained after 3 months, demonstrating good nipple and areolar projection.