The Modified Skate Flap: A New Technique for Nipple-Areola Complex Reconstruction in Implant-Based Breast Reconstruction

Abstract

Nipple-areola complex (NAC) reconstruction is an important part of breast reconstruction. Although several techniques for NAC reconstruction have been described in the literature, the long-term outcomes after NAC reconstruction remain less satisfactory, especially following implant-based breast reconstruction. The authors reported their newly developed technique for NAC reconstruction in implant-based breast reconstruction. The authors describe their modified skate flap, by preserving more dermal tissues from the skate flap, for NAC reconstruction, following implant-based breast reconstruction. Additional derma-fat grafts, harvested from the full-thickness skin graft site, are also added to the reconstructed nipple to ensure long-term shape, size, and projection of the reconstructed nipple. A total of 30 patients underwent such a NAC reconstruction after successful implant-based breast reconstruction by the senior author. The minimum follow-up time was 1 year. No significant surgical complications have been observed in their series of 30 patients, and only a minor office procedure was performed subsequently in 6 patients (4 unilateral and 2 bilateral) to improve the shape of the reconstructed nipple. During a minimum of a 1-year follow-up period, outcomes with the authors' technique in 30 patients are satisfactory; good size, shape, and projection of the reconstructed nipple are maintained. The long-term outcome of NAC reconstruction after implant-based breast reconstruction can be optimized with their modified skate flap by using all available flap tissue and with the addition of derma-fat grafts. The authors' technique can be used safely for NAC reconstruction after implant-based breast reconstruction with good outcome and high patient satisfaction.

Figure 1.

A schematic diagram showing the preoperative marking and design of our modified skate flap.

Figure 2.

An intraoperative view of a 59-year-old woman (Figures 2-10 are all from the same patient) showing the design of our modified skate flap. In this case, the design of the flap is based inferiorly to accommodate the location of the mastectomy scar.

Figure 3.

Completion of de-epithelialization of the inferiorly based skate flap.

Figure 4.

Completion of adjacent skin flap dissection to the designed lines and 3 triangular true adipo-cutaneous flaps elevation except for the base of the skate flap in the center before it is elevated.

Figure 5.

Completion of the elevated skate flap and approximation of the medial and lateral skin flaps.

Figure 6.

Near completion of closing the skate flap. Two corners (marked in blue) of the “excess” skin in the reconstructed nipple will be reserved.

Figure 7.

An intraoperative view showing completion of the de-epithelized skins on both corners. They are inserted into the flap to add more tissues for the nipple reconstruction.

Figure 8.

Two harvested and prepared derma-fat grafts, each about 4 × 3 × 3 mm.

Figure 9.

Completion of the reconstructed nipple after insertion of derma-fat grafts.

Figure 10.

Immediate result after completion of the nipple reconstruction and areolar skin grafting.

Figure 11.

Results at 1-year follow-up with anteroposterior (AP) (A) and oblique views (B and C) in a 39-year-old woman. The size, shape, and projection of the reconstructed nipple on each side are well maintained.

Figure 12.

Results at 10 months follow-up with AP (A) and oblique views (B and C) in a 47-year-old woman (Figures 12 and 13 are from the same patient). Good size, shape, and projection of each reconstructed nipple are well maintained.

Figure 13.

Results at 10 years follow-up with AP (A) and oblique views (B and C) in the same patient. The size, shape, and projection of each reconstructed nipple are still reasonably well maintained.

Figure 14.

(A) Results at 8 months after initial reconstruction with noted excess skin in each reconstructed nipple in a 60-year-old woman. (B) Intraoperative views show the results before and immediately after revision. (C) Results at 3 years and 4 months after revision (4 years after the initial reconstruction). The size, shape, and projection of each reconstructed nipple are still well maintained.

Figure 15.

(A-H) Schematic diagrams showing the senior author's technique when the design of the flap based superiorly.