- Email: [email protected]
Maximizing nipple graft survival after performing free nipple-areolar complex reduction mammaplasty
Correspondence and communications
971
upper lip. Therefore, the present case is the first report of a dermoid cyst of the upper lip as far as we know. Congenital midline sinus of the upper lip is very rare. Bauer et al.1 reported a dermoid in association with a pinpoint sinus opening at the base of the columella. That cyst was situated almost exactly in the same area of the upper lip as the one we describe here, but in this case, there was continuity with the skin. This may well represent initial continuity which subsequently was obliterated during the completion of development by fusion, such that no sinus remained.
References 1. Bauer BS. Benign tumors and conditions of the head and neck. In: Achauer BM, et al., editors. Plastic surgery: indications, operations, outcomes. Mosby Inc.; 2000. p. 1133e8. 2. Havlik RJ. Miscellaneous craniofacial conditons. In: Thorne CH, et al., editors. Grabb and Smith’s plastic surgery. 6th edn. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 290e2. 3. Pryor SG, Lewis JE, Weaver AL, et al. Pediatric dermoid cysts of the head and neck. Otolaryngol Head Neck Surg 2005;132:938e42. 4. Brown AP, Fogarty B, Brennen MD. A dermoid cyst presenting as an epidermoid cyst in the malar region. Br J Plast Surg 2001;54:180. 5. Samper A, Ruiz de Erenchun R, Yeste L, et al. Dermoid cyst on the auriculotemporal area. Plast Reconstr Surg 2000;106:947e8.
Kazuhiro Toriyama Yuzuru Kamei Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya 466-8560, Japan E-mail address: [email protected] Tsuyoshi Morishita Department of Plastic and Reconstructive Surgery, Chubu Rosai Hospital, Minato-ku, Nagoya 455-8530, Japan Shuhei Torii Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya 466-8560, Japan ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.011
Maximizing nipple graft survival after performing free nipple-areolar complex reduction mammaplasty
Dear Sir, Gigantomastia, characterized by massive breast enlargement during adolescence or pregnancy, is thought to be caused by an abnormal and excessive end organ response to a normal hormonal milieu. Reduction mammoplasty in patients with gigantomastia has traditionally been performed by breast reduction techniques involving free nipple grafting.1
Figure 1 Pre operative view of a 32 year old patient requesting breast reduction.
A 32 year old patient presented to our unit requesting a breast reduction (Figure 1). She was diagnosed with gigantomastia and after performing the preoperative assessment, she was submitted in a reduction mammaplasty using the Pitanguy technique.2 After removing in total, 4.250 g of breast tissue, the free nipple graft transplantation was performed. The nipple was replaced as a free, thick, split-thickness skin graft. On the right side after deepithelizing the new site of the nipple areolar complex, it was decided to perform a circular dermo-dermic round block using a 2-0 Mononylon (Ethicon Ltd., Brazil). This was based on the principle of the perioareolar ‘round block’ described by Benelli.3 On the left side, following the deepithelization, the nipple areolar graft was placed without performing the dermo-dermic round block. The grafts were sutured with 50 Mononylon (Ethicon Ltd., Brazil). The bolus tie-over ‘pressure’ dressing was used. On the seventh post-operative day after removal of the tie-over dressing, it was observed nipple epidermolysis on the left side (Figure 2A). The right nipple did not have any signs of epidermolysis (Figure 2B). There was no hematoma or signs of infection observed in either side. The preparation of both nipple grafts was done by the same surgeon and the choice to perform the ‘round block’ on the right side was randomly chosen.The left nipple graft had a total re-epithelisation 4 weeks postoperatively, but the nipple mount was not maintained and a central hypopigmentation is noticed in the nipple areolar complex (Figure 2C). The right nipple mount maintains still projection and there is no sign of central hypopigmentation (Figure 2D). The disadvantages of free nipple grafts include loss of sensation, poor nipple projection, uneven pigmentation due to partial epidermolysis, loss of lactation and total necrosis.4 The most common part of epidemolysis is the central part of the nipple, which is an expected sequela of free-nipple graft procedures.5 As a result, there is loss of the nipple mount and hypopigmentation. A possible explanation for preventing the epidermolysis and as a consequence preserving the nipple mount in the right breast could be that the deepithelized dermal bed
972
Correspondence and communications
Figure 2 A) Early post operative view of the left nipple areola complex. B) Early post operative view of the right nipple areola complex. C) Late post operative view of the left nipple areola complex. D) Late post operative view of the right nipple areola complex.
was telescoped outward by the ‘round block’, pushing against the graft and thus promoting a better contact with the free nipple areolar graft. This could have assisted in the better revascularization of the graft. Another explanation could be that the ‘round block’ possibly assisted in decreasing the tension upon the nipple-areola complex, preventing the epidermolysis of the central part of the areola. The authors believe that the ‘round block’ can possibly be an additional measure in order to maximize the survival of the nipple graft in the free nipple areolar complex reduction mammaplasty cases. A large study should be done though, in order to confirm or reject this observation.
References 1. Casas LA, Byun MY, Depoli PA. Maximizing breast projection after free-nipple-graft reduction mammaplasty. Plast Reconstr Surg 2001 Apr 1;107:955e60. 2. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 1967;20:78. 3. Benelli L. A new periareolar mammaplasty: the ‘‘round block’’ technique. Aesthetic Plast Surg 1990 Spring;14:93e100.
4. Lacerna M, Spears J, Mitra A, et al. Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia. Ann Plast Surg 2005 Jul;55:21e4 [discussion: 24]. 5. Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003 Mar;111:1102e9.
Aris Sterodimas Eugenio F. Pineda Valeria Meirelles Ivo Pitanguy Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate, Medical Institute, Rua Dona Mariana 65, 22280-020 Rio de Janeiro, Brazil E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.004
971
upper lip. Therefore, the present case is the first report of a dermoid cyst of the upper lip as far as we know. Congenital midline sinus of the upper lip is very rare. Bauer et al.1 reported a dermoid in association with a pinpoint sinus opening at the base of the columella. That cyst was situated almost exactly in the same area of the upper lip as the one we describe here, but in this case, there was continuity with the skin. This may well represent initial continuity which subsequently was obliterated during the completion of development by fusion, such that no sinus remained.
References 1. Bauer BS. Benign tumors and conditions of the head and neck. In: Achauer BM, et al., editors. Plastic surgery: indications, operations, outcomes. Mosby Inc.; 2000. p. 1133e8. 2. Havlik RJ. Miscellaneous craniofacial conditons. In: Thorne CH, et al., editors. Grabb and Smith’s plastic surgery. 6th edn. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 290e2. 3. Pryor SG, Lewis JE, Weaver AL, et al. Pediatric dermoid cysts of the head and neck. Otolaryngol Head Neck Surg 2005;132:938e42. 4. Brown AP, Fogarty B, Brennen MD. A dermoid cyst presenting as an epidermoid cyst in the malar region. Br J Plast Surg 2001;54:180. 5. Samper A, Ruiz de Erenchun R, Yeste L, et al. Dermoid cyst on the auriculotemporal area. Plast Reconstr Surg 2000;106:947e8.
Kazuhiro Toriyama Yuzuru Kamei Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya 466-8560, Japan E-mail address: [email protected] Tsuyoshi Morishita Department of Plastic and Reconstructive Surgery, Chubu Rosai Hospital, Minato-ku, Nagoya 455-8530, Japan Shuhei Torii Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya 466-8560, Japan ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.011
Maximizing nipple graft survival after performing free nipple-areolar complex reduction mammaplasty
Dear Sir, Gigantomastia, characterized by massive breast enlargement during adolescence or pregnancy, is thought to be caused by an abnormal and excessive end organ response to a normal hormonal milieu. Reduction mammoplasty in patients with gigantomastia has traditionally been performed by breast reduction techniques involving free nipple grafting.1
Figure 1 Pre operative view of a 32 year old patient requesting breast reduction.
A 32 year old patient presented to our unit requesting a breast reduction (Figure 1). She was diagnosed with gigantomastia and after performing the preoperative assessment, she was submitted in a reduction mammaplasty using the Pitanguy technique.2 After removing in total, 4.250 g of breast tissue, the free nipple graft transplantation was performed. The nipple was replaced as a free, thick, split-thickness skin graft. On the right side after deepithelizing the new site of the nipple areolar complex, it was decided to perform a circular dermo-dermic round block using a 2-0 Mononylon (Ethicon Ltd., Brazil). This was based on the principle of the perioareolar ‘round block’ described by Benelli.3 On the left side, following the deepithelization, the nipple areolar graft was placed without performing the dermo-dermic round block. The grafts were sutured with 50 Mononylon (Ethicon Ltd., Brazil). The bolus tie-over ‘pressure’ dressing was used. On the seventh post-operative day after removal of the tie-over dressing, it was observed nipple epidermolysis on the left side (Figure 2A). The right nipple did not have any signs of epidermolysis (Figure 2B). There was no hematoma or signs of infection observed in either side. The preparation of both nipple grafts was done by the same surgeon and the choice to perform the ‘round block’ on the right side was randomly chosen.The left nipple graft had a total re-epithelisation 4 weeks postoperatively, but the nipple mount was not maintained and a central hypopigmentation is noticed in the nipple areolar complex (Figure 2C). The right nipple mount maintains still projection and there is no sign of central hypopigmentation (Figure 2D). The disadvantages of free nipple grafts include loss of sensation, poor nipple projection, uneven pigmentation due to partial epidermolysis, loss of lactation and total necrosis.4 The most common part of epidemolysis is the central part of the nipple, which is an expected sequela of free-nipple graft procedures.5 As a result, there is loss of the nipple mount and hypopigmentation. A possible explanation for preventing the epidermolysis and as a consequence preserving the nipple mount in the right breast could be that the deepithelized dermal bed
972
Correspondence and communications
Figure 2 A) Early post operative view of the left nipple areola complex. B) Early post operative view of the right nipple areola complex. C) Late post operative view of the left nipple areola complex. D) Late post operative view of the right nipple areola complex.
was telescoped outward by the ‘round block’, pushing against the graft and thus promoting a better contact with the free nipple areolar graft. This could have assisted in the better revascularization of the graft. Another explanation could be that the ‘round block’ possibly assisted in decreasing the tension upon the nipple-areola complex, preventing the epidermolysis of the central part of the areola. The authors believe that the ‘round block’ can possibly be an additional measure in order to maximize the survival of the nipple graft in the free nipple areolar complex reduction mammaplasty cases. A large study should be done though, in order to confirm or reject this observation.
References 1. Casas LA, Byun MY, Depoli PA. Maximizing breast projection after free-nipple-graft reduction mammaplasty. Plast Reconstr Surg 2001 Apr 1;107:955e60. 2. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 1967;20:78. 3. Benelli L. A new periareolar mammaplasty: the ‘‘round block’’ technique. Aesthetic Plast Surg 1990 Spring;14:93e100.
4. Lacerna M, Spears J, Mitra A, et al. Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia. Ann Plast Surg 2005 Jul;55:21e4 [discussion: 24]. 5. Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003 Mar;111:1102e9.
Aris Sterodimas Eugenio F. Pineda Valeria Meirelles Ivo Pitanguy Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate, Medical Institute, Rua Dona Mariana 65, 22280-020 Rio de Janeiro, Brazil E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.004