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Modified C-V flap for nipple reconstruction: our results in 50 patients
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 991e996
Modified C-V flap for nipple reconstruction: our results in 50 patients* K. El-Ali*, M. Dalal, C.C. Kat West Midlands Regional Unit for Burns, Plastic and Reconstructive Surgery, Selly Oak Hospital, Birmingham, UK Received 23 July 2006; accepted 21 December 2007
KEYWORDS Nipple reconstruction; C-V flap; Mastectomy
Summary Various techniques have been advocated for nipple reconstruction following mastectomy, including the C-V flap. In this study, we describe a modification of the C-V flap, and present results of our first 50 patients who have had nipple reconstruction using this modified technique. Assessments were made both subjectively through a questionnaire and objectively by using a calliper to measure nipple projection. Follow up ranged from 6 to 36 months (mean 15.4 months). Three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Projection of the reconstructed nipples ranged between 0.5 and 4.99 mm (mean 2.17 mm). The difference in projection between the reconstructed and contralateral normal nipples ranged between 2 and 5.2 mm (mean 1.5 mm). Mean decrease in nipple projection was 45%. Fourteen (28%) patients reported some sensory recovery of their reconstructed nipples. Using a numerical scale of one to 10 (where one indicates worst, and 10 best possible outcomes), the reconstructed nipples were rated overall as good when compared to the opposite side [mean 6.5 (1e10)]. Patient satisfaction with this technique was rated as very good [mean 7.2 (1e10)]; and similarly improvement in body image as very good [mean 7.3 (1e10)]. The modified C-V flap in nipple reconstruction is simple, reliable, and offers an easy manoeuvre to provide connective tissue support for the reconstructed nipple. Moreover it produces good projection and has a high satisfaction rate and impact on enhancing patients’ perception of body image. Video clips (1e6) are included with the paper for demonstration of the modified C-V flap technique. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Paper presented on 5 December 2003, at the winter meeting of the British Association of Plastic Surgeons, Royal College of Surgeons of England, London, UK. * Corresponding author. Address: Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, UK. Tel.: þ44 (0) 121 627 1627; fax: þ44 (0) 121 627 8461. E-mail address: [email protected] (K. El-Ali).
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.059
992 Nipple-areola reconstruction completes breast reconstruction following mastectomy and significantly enhances its aesthetic outcome. Various techniques1e7 have been advocated for nipple reconstruction, including the C-V flap.8e10 In this study we describe a modification of the C-V flap, and present results of our first 50 patients who had nipple reconstruction using this modified technique. All the procedures were performed either by or under the direct supervision of the senior author.
Materials and methods Patients were seen at specially arranged follow up clinics, at which they completed a questionnaire before we examined them and measured nipple projection. The questions concentrated mainly on complications, nipple projection, nipple sensations, rating of reconstructed nipples in comparison to the opposite side, overall satisfaction with the technique and its impact on body image. Patients were directed to use a numerical scale of one to 10, with one as the worst outcome and 10 as the best possible outcome (<5 Z fair, 5 to 6.9 Z good, and 7 Z very good). Some questions required responses of yes or no, or giving a percentage. We used a calliper to measure nipple projection, then calculated the difference in projection between the two sides (a negative value indicates that the reconstructed nipple was less prominent than the normal one). Photographs of patients’ reconstructions were taken at the
K. El-Ali et al. medical illustration department. Statistical analysis was made using the paired t-test and a P value of less than 0.05 was considered to be significant.
Technique In the modified C-V flap technique we normally make the width of the V flaps (height of reconstructed nipple) twice the projection of the normal nipple, and we design a smaller C flap to prevent the reconstructed nipple from ‘dropping’. To provide connective tissue support (and further minimise the chance of dropping) we place the reconstructed nipple partially on a de-epithelialised base (floor) of dermis along the border of the donor incision of the C flap. The V flaps are drawn in a rectangular fashion at about 30 in relation to the base of the flap; the outer edge of the rectangle is bevelled slightly towards the inside as this helps to avoid dog ears and close the donor incision in a straight line (Figure 1aee). With reference to our diagrams, the area (N) surrounded by the dotted line represents the diameter of the new nipple being reconstructed which should match that of the opposite side. The base (B) of the flap is designed to take about one-quarter of that circle. The combined length of both V flaps when sutured together would complete the circle (though initially we design the length of each V flap at about 1.5e2 cm and then trim as necessary). As explained above the width (W) of V flaps determines the projection of the reconstructed nipple and this is usually
Figure 1 (aee) Illustration of the modified C-V flap. Markings indicate base (B) of flap, width (W) of V flaps (V), C flap (C), and strip of skin to be de-epithelialised (D). The area (N) surrounded by the dotted line represents the diameter of the new nipple being reconstructed which should match that of the opposite side. The flap is raised starting (on each side) from the upper border of the V flap and finishing at the C flap which is incised last (see text for details).
Modified C-V flap for nipple reconstruction designed to be double that of the opposite normal side. The C flap (C) is fashioned as a small crescent between the V flaps. The area to be de-epithelialised (D) is shown in Fig. 1c for demonstration only as usually this step is performed after the donor incisions are closed. The procedure is performed as a day case surgery under local anaesthesia. In consultation with the patient, and whilst she is sitting upright, the position of the new nipple is marked to match that of the opposite side. The patient is then put supine and the flap drawn on her breast mound and infiltrated with local anaesthetics (avoiding the base as usually we inject lignocaine with adrenaline using a dental syringe). The flaps are raised using a size 15 blade starting (on each side) from the upper border of the V flap and finishing at the C flap which is incised last. The V and C limbs of the flap are carefully dissected and elevated with adequate mobility and subcutaneous fat (particular caution is required near the base to protect the pedicle of the flap). Following meticulous haemostasis, the donor incision of the V flaps is closed first, in two layers, starting at the medial end on each side. The V flaps are then held against each other to judge the size of the nipple, and any excess tissue is trimmed at this stage to avoid tension. A strip of skin, a few millimetres wide, along the border of the donor incision of the C flap (between the two medial ends of the closed donor incision) is de-epithelialised, using a size15 blade, to create a firm dermal support for the reconstructed nipple. The elevated V flaps are then wrapped around (so they meet in a vertical line when opposed) and their lower ends sutured, to each other, and to the opposite edge of the donor incision using horizontal mattress stitches. The inferior margin of the V flaps will now be partially overlying and supported by the created dermal base. A similar mattress suture is used to join the upper ends of the V flaps to the most anterior part of the C flap, which then sits as a cap over the nipple. A few simple interrupted skin stitches are used to complete the securing of these flaps to each other. Absorbable sutures are used throughout the procedure. At the end Steri-Strips are applied to the donor incision and 1% chloramphenicol ointment to the nipple followed by a nonadherent dressing and protective foam. The process of nipple-areola reconstruction is usually completed by tattooing about 6 months later. The CV flap itself was originally introduced and described in detail by Bostwick8e10 as an evolution from the skate flap to eliminate the need for skin grafting of the areola.
Results Fifty patients participated in this study, and all completed their questionnaires fully. The average age was 51.5 years (range 34e68 years). Follow up ranged from 6 to 36 months (mean 15.4 months). Types of breast reconstruction were extended latissimus dorsi flap (ELD) in 30 patients, pedicled transverse rectus abdominis musculocutaneous flap (TRAM) in 14 patients, ELD with implant in five patients, and expander implant in one patient. On average, nipple reconstruction was performed about 10 months after breast reconstruction (range 1e38 months).
993 Three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Otherwise no revision surgery was performed in this series of patients. Projection of the reconstructed nipples ranged between 0.5 and 4.99 mm (mean 2.17 mm); the difference in projection between reconstructed and contralateral normal nipples ranged between 2 and 5.2 mm (mean 1.5 mm). The mean difference in nipple projection varied according to the type of breast reconstruction (1.40 mm for ELD, 3.38 mm for ELD with implant, 1.15 for pedicled TRAM, and 0.1 for expander implant), but this difference was not statically significant (P Z 0.469, Table 1). Reduction in nipple projection (as estimated by the patients) varied between 10 and 90% (mean 45%). Fourteen (28%) patients in total reported having some tactile sensation of their reconstructed nipples. Of these, nine patients had an ELD flap, four patients had a pedicled TRAM flap, and one patient had an ELD plus implant. For each subgroup, the percentage of patients reporting sensory recovery equates to 30% (nine out of 30) for ELD, 28.5% (four out of 14) for TRAM, and 20% (one out of five) for ELD plus implant. The recovered sensations were rated by our patients, in comparison to the normal side and using the numerical scale, to be between one and eight (mean 3.7); two patients (both had ELD flap) considered their sensation to be very close to the normal side and rated them with seven and eight. When compared with the opposite side, the reconstructed nipples were rated overall by our patients as good [mean 6.5 (1e10)]; 41 (82%) patients rated them as good or very good, while nine (18%) patients rated them as fair. Patient satisfaction with this technique was rated as very good [mean 7.2 (1e10)], with 40 (80%) patients rating their satisfaction as good or very good, and 10 (20%) patients rating it as fair. Similarly, improvement in body image was rated as very good [mean 7.3 (1e10)], with 41 (82%) patients rating their body image enhancement as good or very good, with nine (18%) patients rating it as fair (Table 2). Examples of our results are demonstrated in Figures 2 and 3.
Discussion The objectives of nipple reconstruction are to create a nipple which is symmetrical to the opposite side in terms
Table 1 Difference in nipple projection vs type of breast reconstructiona (n Z 50) Type of breast reconstruction
Mean difference in projection (mm)
Autologous ELD (30) ELD with implant (5) Pedicled TRAM (14) Expander implant (1) Meanb
1.40 3.38 1.15 0.1 1.5
a
The difference in nipple projection between different techniques of breast reconstruction was not statistically significant (P Z 0.469). b Mean for whole series.
994
K. El-Ali et al.
Table 2
Summary of patients’ assessments of the outcome of nipple reconstructiona (n Z 50)
Outcome
Fair
Good
Very good
Reconstructed nipple vs opposite side Overall satisfaction Improvement in body image
9 patients (18%) 10 patients (20%) 9 patients (18%)
11 patients (22%) 7 patients (14%) 9 patients (18%)
30 patients (60%) 33 patients (66%) 32 patients (64%)
a
Using numerical scale of 1e10.
of position, projection and colour, using techniques which have both patient satisfaction and compliance.1,11 A wide range of techniques1e15 has been advocated to achieve these objectives, and currently local flaps represent the favoured and most frequently chosen method for nipple reconstruction.11e15 It is well recognised that maintaining nipple projection is a challenge in nipple reconstruction.11e19 Guerra et al.14 blamed two major reasons for this, the inadequate connective tissue support to the nipple, and wound contracture with centrifugal forces acting on the new nipple mass. Shestak et al.12 stressed the role of wound healing, while Cheng et al.15 placed more emphasis on the lack of underlying support, a view that we share ourselves. To compensate for the loss of projection, most authors would ‘over build’ the reconstructed nipples,12 though the extent of this varies from 25e50%14 to 150%4,5 of the height of the contralateral normal nipple. Few et al.19 predicted that each 1 cm increase in flap length can result in a 0.16 cm increase in projection. In our experience, reconstructed nipples lose about half of their original projection, and as such our normal practice is to make the height of the reconstructed nipple (width of V-Flap) double that of the normal one (100% over built). However, if the original nipple was pretty small then one would exceed that by about 150% to achieve a more meaningful reconstruction. In
Figure 2
considering this it is important to appreciate that cutting too much tissue to make the nipple big risks distorting the reconstructed breast itself; therefore the ultimate decision remains a fine balance for the individual patient. Several techniques have been advocated to provide connective tissue support for the reconstructed nipple including using the patient’s own costal cartilage.13e15 We consider that a reasonably adequate support can be provided through the firm dermis, and as such in the modified technique we place the reconstructed nipple partially on a de-epithelialised base of dermis along its lower margin. Technically this is a simple manoeuvre and combined with fashioning a smaller C flap we believe will much reduce the chances of ‘dropping’ of the reconstructed nipple. In our study, three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Otherwise no revision surgery was performed in this series of patients. In the literature, rates of 13%12 and 16%7 have been reported for local wound problems leading to partial flap loss, and rates of 4%7,14 and 5.8%12 for total flap loss; revision surgery was reported to be between 8%5 and 20%.14 Nipple projection varied with different nipple reconstruction techniques; for example, a projection of 0.4 to
(aed) 56-year-old patient, 14 months following right nipple reconstruction.
Modified C-V flap for nipple reconstruction
Figure 3
995
(aed) 51-year-old patient, 2 years after right nipple reconstruction that was completed by tattooing.
0.83 mm was reported by Few et al.19 using the modified star flap, and 3.9 mm by Lossing7 using the modified S flap. Kroll et al.17 reported a mean projection of 2.4 mm for the modified double-opposing tab flap, and 1.9 mm for the star flap. The mean nipple projection in this series of patients was 2.17 mm (range 0.5 to 4.99 mm). In reading these results one has to take into account that ultimate projection is not only dependent on the technique but also on the initial designed height of the reconstructed nipples which in itself is determined, to a large extent, by the size of the contralateral normal nipples. The loss of nipple projection is generally believed to be about 50%18 but rates up to 59%19 and 71%18 have been reported. Several authors indicated most of the projection loss occurs during the first 3 months12 and stabilises by approximately 1 year after reconstruction.8,19 In this study, the mean reduction in nipple projection as estimated by patients was 45%, which re-emphasises data in the literature, and seems to correlate reasonably well (though subjectively) with our clinical experience and expectations. When measured by a calliper, the mean difference in projection of the reconstructed nipples as compared to normal ones was 1.5 mm (range 2 to 5.2 mm), and even though this mean varied according to the type of breast reconstruction (TRAM, ELD, ELD plus implant, and expander implant), statistically this difference was not significant (P Z 0.469, Table 1). There is still some controversy about how significant is the difference in nipple projection in relation to various techniques of breast reconstruction.11 Banducci et al.18 compared nipple projection between autologous breast reconstruction and expander implants and concluded the difference between the two groups was statistically significant. On the other hand, Few et al.19 and Rubino et al.11 compared TRAM flaps against implants, while Kroll
et al.17 compared TRAM, ELD and expander implants, and all stated that the difference in nipple projection was not significant between these subgroups. Fourteen (28%) of our patients subjectively reported having some sensory recovery of their reconstructed nipples, with two (ELD flap) patients considering these sensations to be very close to those of the normal side. Our findings concur with those of Losken et al.8 and others.20 On the other hand, Liew et al.21 indicated that TRAM flap patients usually report better sensory recovery than latissimus dorsi flap patients, but in our study these two groups showed a very similar outcome in this respect (30% sensory recovery for ELD vs 28.5% for TRAM flap patients). Patient satisfaction with nipple reconstruction was reported to be high.5e8 In our study, 40 (80%) patients rated their overall satisfaction with this technique as good or very good, and likewise 41 (82%) patients rated their body image enhancement with the same values (Table 2). Improvements in body image perception have mirrored patients’ happiness with their nipples when they compared them to the other side, while, understandably, the loss of projection was the main reason for patients’ dissatisfaction with the technique. In conclusion, we recommend the modified C-V flap in nipple reconstruction because of its simplicity, reliability, and that it offers an easy manoeuvre to provide connective tissue support for the reconstructed nipple. Moreover it produces good projection and has a high satisfaction rate and impact on enhancing patients’ perception of body image.
Acknowledgment We would like to thank the staff of the burns and plastic surgery dressing clinic, and the medical illustration
996 department at Selly Oak Hospital, Birmingham, for their help and support during this study.
Appendix. Supplementary material Supplementary data associated with this article can be found in the online version, at doi:10.1016/j.bjps.2007.12.059.
References 1. Little 3rd JW. Nipple-areola reconstruction. Clin Plast Surg 1984;11:351e64. 2. Hartrampf Jr CR, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg 1984;73:982e6. 3. Kroll SS, Hamilton S. Nipple reconstruction with the doubleopposing-tab flap. Plast Reconstr Surg 1989;84:520e5. 4. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg 1996;97:1053e6. 5. Eskenazi L. A one-stage nipple reconstruction with the ‘‘modified star’’ flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg 1993;92:671e80. 6. Hugo NE, Sultan MR, Hardy SP. Nipple-areola reconstruction with intradermal tattoo and double-opposing pennant flaps. Ann Plast Surg 1993;30:510e3. 7. Lossing C, Brongo S, Holmstrom H. Nipple reconstruction with a modified S-flap technique. Scand J Plast Reconstr Surg Hand Surg 1998;32:275e9. 8. Losken A, Mackay GJ, Bostwick III J. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:361e9. 9. Jones G, Bostwick III J. Nipple-Areola reconstruction. Oper Tech Plast Reconstr Surg 1994;1:35e8.
K. El-Ali et al. 10. Bostwick III J. Plastic and reconstructive surgery of the breast. 2nd ed. St Louis: Quality Medical Publishing; 2000. 11. Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the ‘arrow flap’. Br J Plast Surg 2003;56: 247e51. 12. Shestak KC, Gabriel A, Landecker A, et al. Assessment of longterm nipple projection: a comparison of three techniques. Plast Reconstr Surg 2002;110:780e6. 13. Yamamoto Y, Furukawa H, Oyama A, et al. Two innovations of the star-flap technique for nipple reconstruction. Br J Plast Surg 2001;54:723e6. 14. Guerra AB, Khoobehi K, Metzinger SE, et al. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg 2003; 50:31e7. 15. Cheng MH, Ho-Asjoe M, Wei FC, et al. Nipple reconstruction in Asian females using banked cartilage graft and modified top hat flap. Br J Plast Surg 2003;56:692e4. 16. Bernard RW, Beran SJ. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg 2003;112:964e8. 17. Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg 1997;99:1602e5. 18. Banducci DR, Le TK, Hughes KC. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg 1999;43:467e9 [discussion 469e70]. 19. Few JW, Marcus JR, Casas LA, et al. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg 1999;104:1321e4. 20. Place MJ, Song T, Hardesty RA, et al. Sensory reinnervation of autologous tissue TRAM flaps after breast reconstruction. Ann Plast Surg 1997;38:19. 21. Liew S, Hunt J, Pennington D. Sensory recovery following free TRAM flap for breast reconstruction. Br J Plast Surg 1996;49: 210e31.
Modified C-V flap for nipple reconstruction: our results in 50 patients* K. El-Ali*, M. Dalal, C.C. Kat West Midlands Regional Unit for Burns, Plastic and Reconstructive Surgery, Selly Oak Hospital, Birmingham, UK Received 23 July 2006; accepted 21 December 2007
KEYWORDS Nipple reconstruction; C-V flap; Mastectomy
Summary Various techniques have been advocated for nipple reconstruction following mastectomy, including the C-V flap. In this study, we describe a modification of the C-V flap, and present results of our first 50 patients who have had nipple reconstruction using this modified technique. Assessments were made both subjectively through a questionnaire and objectively by using a calliper to measure nipple projection. Follow up ranged from 6 to 36 months (mean 15.4 months). Three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Projection of the reconstructed nipples ranged between 0.5 and 4.99 mm (mean 2.17 mm). The difference in projection between the reconstructed and contralateral normal nipples ranged between 2 and 5.2 mm (mean 1.5 mm). Mean decrease in nipple projection was 45%. Fourteen (28%) patients reported some sensory recovery of their reconstructed nipples. Using a numerical scale of one to 10 (where one indicates worst, and 10 best possible outcomes), the reconstructed nipples were rated overall as good when compared to the opposite side [mean 6.5 (1e10)]. Patient satisfaction with this technique was rated as very good [mean 7.2 (1e10)]; and similarly improvement in body image as very good [mean 7.3 (1e10)]. The modified C-V flap in nipple reconstruction is simple, reliable, and offers an easy manoeuvre to provide connective tissue support for the reconstructed nipple. Moreover it produces good projection and has a high satisfaction rate and impact on enhancing patients’ perception of body image. Video clips (1e6) are included with the paper for demonstration of the modified C-V flap technique. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Paper presented on 5 December 2003, at the winter meeting of the British Association of Plastic Surgeons, Royal College of Surgeons of England, London, UK. * Corresponding author. Address: Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, UK. Tel.: þ44 (0) 121 627 1627; fax: þ44 (0) 121 627 8461. E-mail address: [email protected] (K. El-Ali).
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.059
992 Nipple-areola reconstruction completes breast reconstruction following mastectomy and significantly enhances its aesthetic outcome. Various techniques1e7 have been advocated for nipple reconstruction, including the C-V flap.8e10 In this study we describe a modification of the C-V flap, and present results of our first 50 patients who had nipple reconstruction using this modified technique. All the procedures were performed either by or under the direct supervision of the senior author.
Materials and methods Patients were seen at specially arranged follow up clinics, at which they completed a questionnaire before we examined them and measured nipple projection. The questions concentrated mainly on complications, nipple projection, nipple sensations, rating of reconstructed nipples in comparison to the opposite side, overall satisfaction with the technique and its impact on body image. Patients were directed to use a numerical scale of one to 10, with one as the worst outcome and 10 as the best possible outcome (<5 Z fair, 5 to 6.9 Z good, and 7 Z very good). Some questions required responses of yes or no, or giving a percentage. We used a calliper to measure nipple projection, then calculated the difference in projection between the two sides (a negative value indicates that the reconstructed nipple was less prominent than the normal one). Photographs of patients’ reconstructions were taken at the
K. El-Ali et al. medical illustration department. Statistical analysis was made using the paired t-test and a P value of less than 0.05 was considered to be significant.
Technique In the modified C-V flap technique we normally make the width of the V flaps (height of reconstructed nipple) twice the projection of the normal nipple, and we design a smaller C flap to prevent the reconstructed nipple from ‘dropping’. To provide connective tissue support (and further minimise the chance of dropping) we place the reconstructed nipple partially on a de-epithelialised base (floor) of dermis along the border of the donor incision of the C flap. The V flaps are drawn in a rectangular fashion at about 30 in relation to the base of the flap; the outer edge of the rectangle is bevelled slightly towards the inside as this helps to avoid dog ears and close the donor incision in a straight line (Figure 1aee). With reference to our diagrams, the area (N) surrounded by the dotted line represents the diameter of the new nipple being reconstructed which should match that of the opposite side. The base (B) of the flap is designed to take about one-quarter of that circle. The combined length of both V flaps when sutured together would complete the circle (though initially we design the length of each V flap at about 1.5e2 cm and then trim as necessary). As explained above the width (W) of V flaps determines the projection of the reconstructed nipple and this is usually
Figure 1 (aee) Illustration of the modified C-V flap. Markings indicate base (B) of flap, width (W) of V flaps (V), C flap (C), and strip of skin to be de-epithelialised (D). The area (N) surrounded by the dotted line represents the diameter of the new nipple being reconstructed which should match that of the opposite side. The flap is raised starting (on each side) from the upper border of the V flap and finishing at the C flap which is incised last (see text for details).
Modified C-V flap for nipple reconstruction designed to be double that of the opposite normal side. The C flap (C) is fashioned as a small crescent between the V flaps. The area to be de-epithelialised (D) is shown in Fig. 1c for demonstration only as usually this step is performed after the donor incisions are closed. The procedure is performed as a day case surgery under local anaesthesia. In consultation with the patient, and whilst she is sitting upright, the position of the new nipple is marked to match that of the opposite side. The patient is then put supine and the flap drawn on her breast mound and infiltrated with local anaesthetics (avoiding the base as usually we inject lignocaine with adrenaline using a dental syringe). The flaps are raised using a size 15 blade starting (on each side) from the upper border of the V flap and finishing at the C flap which is incised last. The V and C limbs of the flap are carefully dissected and elevated with adequate mobility and subcutaneous fat (particular caution is required near the base to protect the pedicle of the flap). Following meticulous haemostasis, the donor incision of the V flaps is closed first, in two layers, starting at the medial end on each side. The V flaps are then held against each other to judge the size of the nipple, and any excess tissue is trimmed at this stage to avoid tension. A strip of skin, a few millimetres wide, along the border of the donor incision of the C flap (between the two medial ends of the closed donor incision) is de-epithelialised, using a size15 blade, to create a firm dermal support for the reconstructed nipple. The elevated V flaps are then wrapped around (so they meet in a vertical line when opposed) and their lower ends sutured, to each other, and to the opposite edge of the donor incision using horizontal mattress stitches. The inferior margin of the V flaps will now be partially overlying and supported by the created dermal base. A similar mattress suture is used to join the upper ends of the V flaps to the most anterior part of the C flap, which then sits as a cap over the nipple. A few simple interrupted skin stitches are used to complete the securing of these flaps to each other. Absorbable sutures are used throughout the procedure. At the end Steri-Strips are applied to the donor incision and 1% chloramphenicol ointment to the nipple followed by a nonadherent dressing and protective foam. The process of nipple-areola reconstruction is usually completed by tattooing about 6 months later. The CV flap itself was originally introduced and described in detail by Bostwick8e10 as an evolution from the skate flap to eliminate the need for skin grafting of the areola.
Results Fifty patients participated in this study, and all completed their questionnaires fully. The average age was 51.5 years (range 34e68 years). Follow up ranged from 6 to 36 months (mean 15.4 months). Types of breast reconstruction were extended latissimus dorsi flap (ELD) in 30 patients, pedicled transverse rectus abdominis musculocutaneous flap (TRAM) in 14 patients, ELD with implant in five patients, and expander implant in one patient. On average, nipple reconstruction was performed about 10 months after breast reconstruction (range 1e38 months).
993 Three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Otherwise no revision surgery was performed in this series of patients. Projection of the reconstructed nipples ranged between 0.5 and 4.99 mm (mean 2.17 mm); the difference in projection between reconstructed and contralateral normal nipples ranged between 2 and 5.2 mm (mean 1.5 mm). The mean difference in nipple projection varied according to the type of breast reconstruction (1.40 mm for ELD, 3.38 mm for ELD with implant, 1.15 for pedicled TRAM, and 0.1 for expander implant), but this difference was not statically significant (P Z 0.469, Table 1). Reduction in nipple projection (as estimated by the patients) varied between 10 and 90% (mean 45%). Fourteen (28%) patients in total reported having some tactile sensation of their reconstructed nipples. Of these, nine patients had an ELD flap, four patients had a pedicled TRAM flap, and one patient had an ELD plus implant. For each subgroup, the percentage of patients reporting sensory recovery equates to 30% (nine out of 30) for ELD, 28.5% (four out of 14) for TRAM, and 20% (one out of five) for ELD plus implant. The recovered sensations were rated by our patients, in comparison to the normal side and using the numerical scale, to be between one and eight (mean 3.7); two patients (both had ELD flap) considered their sensation to be very close to the normal side and rated them with seven and eight. When compared with the opposite side, the reconstructed nipples were rated overall by our patients as good [mean 6.5 (1e10)]; 41 (82%) patients rated them as good or very good, while nine (18%) patients rated them as fair. Patient satisfaction with this technique was rated as very good [mean 7.2 (1e10)], with 40 (80%) patients rating their satisfaction as good or very good, and 10 (20%) patients rating it as fair. Similarly, improvement in body image was rated as very good [mean 7.3 (1e10)], with 41 (82%) patients rating their body image enhancement as good or very good, with nine (18%) patients rating it as fair (Table 2). Examples of our results are demonstrated in Figures 2 and 3.
Discussion The objectives of nipple reconstruction are to create a nipple which is symmetrical to the opposite side in terms
Table 1 Difference in nipple projection vs type of breast reconstructiona (n Z 50) Type of breast reconstruction
Mean difference in projection (mm)
Autologous ELD (30) ELD with implant (5) Pedicled TRAM (14) Expander implant (1) Meanb
1.40 3.38 1.15 0.1 1.5
a
The difference in nipple projection between different techniques of breast reconstruction was not statistically significant (P Z 0.469). b Mean for whole series.
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K. El-Ali et al.
Table 2
Summary of patients’ assessments of the outcome of nipple reconstructiona (n Z 50)
Outcome
Fair
Good
Very good
Reconstructed nipple vs opposite side Overall satisfaction Improvement in body image
9 patients (18%) 10 patients (20%) 9 patients (18%)
11 patients (22%) 7 patients (14%) 9 patients (18%)
30 patients (60%) 33 patients (66%) 32 patients (64%)
a
Using numerical scale of 1e10.
of position, projection and colour, using techniques which have both patient satisfaction and compliance.1,11 A wide range of techniques1e15 has been advocated to achieve these objectives, and currently local flaps represent the favoured and most frequently chosen method for nipple reconstruction.11e15 It is well recognised that maintaining nipple projection is a challenge in nipple reconstruction.11e19 Guerra et al.14 blamed two major reasons for this, the inadequate connective tissue support to the nipple, and wound contracture with centrifugal forces acting on the new nipple mass. Shestak et al.12 stressed the role of wound healing, while Cheng et al.15 placed more emphasis on the lack of underlying support, a view that we share ourselves. To compensate for the loss of projection, most authors would ‘over build’ the reconstructed nipples,12 though the extent of this varies from 25e50%14 to 150%4,5 of the height of the contralateral normal nipple. Few et al.19 predicted that each 1 cm increase in flap length can result in a 0.16 cm increase in projection. In our experience, reconstructed nipples lose about half of their original projection, and as such our normal practice is to make the height of the reconstructed nipple (width of V-Flap) double that of the normal one (100% over built). However, if the original nipple was pretty small then one would exceed that by about 150% to achieve a more meaningful reconstruction. In
Figure 2
considering this it is important to appreciate that cutting too much tissue to make the nipple big risks distorting the reconstructed breast itself; therefore the ultimate decision remains a fine balance for the individual patient. Several techniques have been advocated to provide connective tissue support for the reconstructed nipple including using the patient’s own costal cartilage.13e15 We consider that a reasonably adequate support can be provided through the firm dermis, and as such in the modified technique we place the reconstructed nipple partially on a de-epithelialised base of dermis along its lower margin. Technically this is a simple manoeuvre and combined with fashioning a smaller C flap we believe will much reduce the chances of ‘dropping’ of the reconstructed nipple. In our study, three (6%) patients suffered partial flap loss which settled with conservative treatment; one patient (2%) had complete flap loss due to infection and needed repeat reconstruction. Otherwise no revision surgery was performed in this series of patients. In the literature, rates of 13%12 and 16%7 have been reported for local wound problems leading to partial flap loss, and rates of 4%7,14 and 5.8%12 for total flap loss; revision surgery was reported to be between 8%5 and 20%.14 Nipple projection varied with different nipple reconstruction techniques; for example, a projection of 0.4 to
(aed) 56-year-old patient, 14 months following right nipple reconstruction.
Modified C-V flap for nipple reconstruction
Figure 3
995
(aed) 51-year-old patient, 2 years after right nipple reconstruction that was completed by tattooing.
0.83 mm was reported by Few et al.19 using the modified star flap, and 3.9 mm by Lossing7 using the modified S flap. Kroll et al.17 reported a mean projection of 2.4 mm for the modified double-opposing tab flap, and 1.9 mm for the star flap. The mean nipple projection in this series of patients was 2.17 mm (range 0.5 to 4.99 mm). In reading these results one has to take into account that ultimate projection is not only dependent on the technique but also on the initial designed height of the reconstructed nipples which in itself is determined, to a large extent, by the size of the contralateral normal nipples. The loss of nipple projection is generally believed to be about 50%18 but rates up to 59%19 and 71%18 have been reported. Several authors indicated most of the projection loss occurs during the first 3 months12 and stabilises by approximately 1 year after reconstruction.8,19 In this study, the mean reduction in nipple projection as estimated by patients was 45%, which re-emphasises data in the literature, and seems to correlate reasonably well (though subjectively) with our clinical experience and expectations. When measured by a calliper, the mean difference in projection of the reconstructed nipples as compared to normal ones was 1.5 mm (range 2 to 5.2 mm), and even though this mean varied according to the type of breast reconstruction (TRAM, ELD, ELD plus implant, and expander implant), statistically this difference was not significant (P Z 0.469, Table 1). There is still some controversy about how significant is the difference in nipple projection in relation to various techniques of breast reconstruction.11 Banducci et al.18 compared nipple projection between autologous breast reconstruction and expander implants and concluded the difference between the two groups was statistically significant. On the other hand, Few et al.19 and Rubino et al.11 compared TRAM flaps against implants, while Kroll
et al.17 compared TRAM, ELD and expander implants, and all stated that the difference in nipple projection was not significant between these subgroups. Fourteen (28%) of our patients subjectively reported having some sensory recovery of their reconstructed nipples, with two (ELD flap) patients considering these sensations to be very close to those of the normal side. Our findings concur with those of Losken et al.8 and others.20 On the other hand, Liew et al.21 indicated that TRAM flap patients usually report better sensory recovery than latissimus dorsi flap patients, but in our study these two groups showed a very similar outcome in this respect (30% sensory recovery for ELD vs 28.5% for TRAM flap patients). Patient satisfaction with nipple reconstruction was reported to be high.5e8 In our study, 40 (80%) patients rated their overall satisfaction with this technique as good or very good, and likewise 41 (82%) patients rated their body image enhancement with the same values (Table 2). Improvements in body image perception have mirrored patients’ happiness with their nipples when they compared them to the other side, while, understandably, the loss of projection was the main reason for patients’ dissatisfaction with the technique. In conclusion, we recommend the modified C-V flap in nipple reconstruction because of its simplicity, reliability, and that it offers an easy manoeuvre to provide connective tissue support for the reconstructed nipple. Moreover it produces good projection and has a high satisfaction rate and impact on enhancing patients’ perception of body image.
Acknowledgment We would like to thank the staff of the burns and plastic surgery dressing clinic, and the medical illustration
996 department at Selly Oak Hospital, Birmingham, for their help and support during this study.
Appendix. Supplementary material Supplementary data associated with this article can be found in the online version, at doi:10.1016/j.bjps.2007.12.059.
References 1. Little 3rd JW. Nipple-areola reconstruction. Clin Plast Surg 1984;11:351e64. 2. Hartrampf Jr CR, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg 1984;73:982e6. 3. Kroll SS, Hamilton S. Nipple reconstruction with the doubleopposing-tab flap. Plast Reconstr Surg 1989;84:520e5. 4. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg 1996;97:1053e6. 5. Eskenazi L. A one-stage nipple reconstruction with the ‘‘modified star’’ flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg 1993;92:671e80. 6. Hugo NE, Sultan MR, Hardy SP. Nipple-areola reconstruction with intradermal tattoo and double-opposing pennant flaps. Ann Plast Surg 1993;30:510e3. 7. Lossing C, Brongo S, Holmstrom H. Nipple reconstruction with a modified S-flap technique. Scand J Plast Reconstr Surg Hand Surg 1998;32:275e9. 8. Losken A, Mackay GJ, Bostwick III J. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:361e9. 9. Jones G, Bostwick III J. Nipple-Areola reconstruction. Oper Tech Plast Reconstr Surg 1994;1:35e8.
K. El-Ali et al. 10. Bostwick III J. Plastic and reconstructive surgery of the breast. 2nd ed. St Louis: Quality Medical Publishing; 2000. 11. Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the ‘arrow flap’. Br J Plast Surg 2003;56: 247e51. 12. Shestak KC, Gabriel A, Landecker A, et al. Assessment of longterm nipple projection: a comparison of three techniques. Plast Reconstr Surg 2002;110:780e6. 13. Yamamoto Y, Furukawa H, Oyama A, et al. Two innovations of the star-flap technique for nipple reconstruction. Br J Plast Surg 2001;54:723e6. 14. Guerra AB, Khoobehi K, Metzinger SE, et al. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg 2003; 50:31e7. 15. Cheng MH, Ho-Asjoe M, Wei FC, et al. Nipple reconstruction in Asian females using banked cartilage graft and modified top hat flap. Br J Plast Surg 2003;56:692e4. 16. Bernard RW, Beran SJ. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg 2003;112:964e8. 17. Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg 1997;99:1602e5. 18. Banducci DR, Le TK, Hughes KC. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg 1999;43:467e9 [discussion 469e70]. 19. Few JW, Marcus JR, Casas LA, et al. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg 1999;104:1321e4. 20. Place MJ, Song T, Hardesty RA, et al. Sensory reinnervation of autologous tissue TRAM flaps after breast reconstruction. Ann Plast Surg 1997;38:19. 21. Liew S, Hunt J, Pennington D. Sensory recovery following free TRAM flap for breast reconstruction. Br J Plast Surg 1996;49: 210e31.