- Email: [email protected]
Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1293e1298
Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation Luigi Valdatta*, Paolo Montemurro, Federico Tamborini, Carlo Fidanza, Alessandra Gottardi, Stefano Scamoni Plastic and Reconstructive Surgery Unit, University of Insubria, Ospedale di Circolo, Varese, Italy Received 7 December 2007; accepted 25 March 2008
KEYWORDS Nipple; Areola; Breast; Reconstruction
Summary There are several procedures available for nipple and areola reconstruction after radical mastectomy, many of them providing good results. This study presents a 1 year evaluation of nipple and areola reconstruction, using the C-V flap technique and areola tattooing. Twenty-nine patients who underwent breast reconstruction with implants in our department, between January 2006 and January 2007, were evaluated and asked to return to conduct a follow-up control. They all completed a questionnaire focusing on patient satisfaction using a 1e10 point visual scale. Nipple measurements were taken with a calliper: the average nipple projection of the reconstructed nipple after 1 year was 3.52 mm, compared to 4.96 mm for the native nipple. The fading of colour of the tattooed areola and the match with the native areola were estimated with computer software (Adobe Photoshop). The technique results were simple, reliable and safe; overall patient satisfaction with the procedure was good. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The reconstruction of the nipple-areola complex represents the final step in breast reconstruction in women who underwent radical mastectomy after breast cancer. This procedure has both physical and psychological implications and needs therefore to be easy, painless and reliable. There are several methods available for this procedure1e8; nipple projection and areola pigmentation are critical
* Corresponding author. Tel./fax: þ39 332 278615. E-mail address: [email protected] (L. Valdatta).
elements of a successful reconstruction and good patient satisfaction.9 Our experience is based on the C-V flap technique, giving an easy procedure performed in the outpatient clinic, using local tissue.10 Although tattooing the areola does not allow texture and projection to be re-gained, it is quick and effective and eliminates the creation of additional donor and recipient incisions from skin grafting.11,12 The purpose of this study was to evaluate both the objective final result (projection of the nipple and colour of the areola) and the subjective patient’s satisfaction, after 1 year.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.03.064
1294
L. Valdatta et al.
Figure 3
Figure 1 Electrocardiogram disposable foam electrode positioned on the reconstructed breast (frontal view).
Patients and methods Patients who underwent breast reconstruction with implants in our department, at Circolo Hospital, between January 2006 and January 2007, were evaluated. A retrospective review was performed contacting each patient and arranging a follow-up visit. There were no exclusion criteria.
Figure 2 Electrocardiogram disposable foam electrode positioned on the reconstructed breast (lateral view).
Preoperative marks of the C-V flap (frontal view).
Measurements of the both the reconstructed and the native breast were taken with a calliper, focusing on the nipple diameter and projection. We thus calculated the nipple volume and statistically evaluated the patterns of the reconstructed nipple compared with the native one. Pictures were taken both in the immediate postoperative time and after 1 year. All the shots were taken using the same digital camera and under the same lighting conditions. Assessments were made by using computer software (Adobe Photoshop), to estimate the fading of colour of the tattooed areola and the match with the native areola. We evaluated the colour intensity using the HSB model (hue-saturation-brightness).13 In an attempt to estimate their satisfaction, patients were then asked to complete a questionnaire, considering different parameters (nipple projection, sensation, pigmentation, position and symmetry) with a 1e10 point visual scale.14 This allowed an evaluation of 29 nipple-areola reconstructions after 1 year. The average age of the patients was 56, ranging from 37 to 68 years.
Figure 4
Preoperative marks of the C-V flap (lateral view).
Nipple reconstruction using the C-V flap technique
1295
Figure 5 The margins of the C-V flap are incised through the subcutaneous fat.
Figure 7 Nipple reconstruction: immediate postoperative (lateral) view.
Surgical technique We usually perform nipple reconstruction about 3 months after breast reconstruction (range 2e4 months) and areola tattooing after another 3 months. The location of the new nipple is determined by measurements taken with the patient in the upright position; patients were actively involved in choosing nipple position giving them an electrocardiogram disposable foam electrode and asking them to place it on the reconstructed breast in front of a mirror (Figures 1 and 2). The widths of the flaps are detected according to the opposite nipple shape and dimension, generally slightly larger to allow for loss of projection. The outline of the flaps is thus drawn with a 1 mm tip surgical skin marker (Figures 3 and 4). We perform this procedure under local anaesthesia (mepivacaine hydrochloride 10 mg/ml) in an outpatient clinic. We usually do not use epinephrine due to the increased risk of necrosis in these small flaps. The flaps are then elevated and the subcutaneous tissue is thinned depending on requirements for fullness of the nipple (Figure 5).
The donor sites are closed primarily, by a 4/0 subcutaneous interrupted suture and a 4/0 intradermal continuous nylon. The V flaps are wrapped around, and the C flap is used as a cap (Figure 6); the flaps are sutured together with 4/0 interrupted nylon (Figures 7 and 8). After the procedure, a protective dressing is prepared using the bottom of a 50 cc syringe as a splint protector and a non-adhering gauze is laid underneath it (Figure 9). Stitches are removed after 15e20 days. Intradermal areolar tattooing is also performed in an outpatient clinic, under local anaesthesia (Figure 10a). We use mepivacaine hydrochloride and epinephrine in order to reduce bleeding, which would make the procedure more difficult and might therefore affect the aesthetic final result (Figure 10b). The colours are chosen and mixed together manually, in order to obtain the best match with the native areola. A darker intensity is made on purpose, to allow for subsequent fading. The tattooed areola is dressed with a non-adherent dressing, applying an antibiotic ointment over the skin. We reported no complications such as allergic reaction to local anaesthesia or to pigments, local infections or local flap necrosis.
Figure 6 The V flaps are elevated and wrapped around; the C flap is used as a cap.
Figure 8 Nipple reconstruction: immediate postoperative (frontal) view.
1296
L. Valdatta et al. Nipple measurements 16
Immediate
14
Native nipple One year follow up
12
mm
10 8 6 4 2
Figure 9 Protective dressing prepared using the bottom of a 50 cc syringe as a splint protector and a non-adhering gauze.
Results Measurements The average projection of the nipple in the immediate postoperative period was 5.18 0.42 mm (standard deviation), compared with 4.96 1.49 mm for the opposite
0
Figure 11 projection.
Radius
Diameter
Projection
Nipple measurements: radius, diameter and
nipple. After 1 year, the average projection of the reconstructed nipple was 3.52 0.95 mm (Figure 11). The average diameter of the reconstructed nipple in the immediate postoperative period was 12.2 1.0 mm, compared with 12.5 1.2 mm for the opposite nipple. After 1 year, the average diameter was 14.7 1.1 mm. The average volume of the nipple was then calculated: 598.21 mm3 in the immediate postoperative period and 608.34 mm3 for the opposite side. The average volume was 597.09 mm3 after 1 year (Figure 12). Considering that the areola is not a perfect circle, we measured the average length of both its major and its minor diameter, in the immediate postoperative period and after 1 year: these data were then compared with the native areola (Table 1). The average areolar area was calculated thus: 1600 mm2 in the immediate postoperative period and 1695 mm2 for the native areola. After 1 year, the average value was 1650 mm2. Similar comparisons showed no statistically significant differences. When tattooing the areola, a darker colour intensity is chosen on purpose: þ12.7% on average, compared to the native areola. After 1 year, the intensity of the colour faded to a value of 6.5% compared to the native areola. These data show that the fading of the colour after 1 year can be estimated to be an average value of 19.2%.
Patients’ satisfaction after 1 year
Figure 10 (a) Areolar tattooing: intraoperative. (b) Areolar tattooing: immediately postoperative.
All 29 patients completed a simple questionnaire, considering and estimating five parameters with a 1e10 point visual scale (with 1 as the worst outcome and 10 as the best possible outcome). The average patient satisfaction regarding nipple projection was 6.28, sensation of the nipple 5.57, colour of the areola 6.14, position of the reconstructed nipple-areola complex 7.85, symmetry compared with the opposite nipple-areola complex 7.42. Overall patient satisfaction was 6.65 (Table 2; Figure 13).
Nipple reconstruction using the C-V flap technique
1297 Nipple volume
1800
1800
1600
1600
1400
1400
1200
1200
mm3
mm2
Nipple and areola measurements
1000 800
800
600
600
400
400
200
200
0
Nipple area Immediate
Native nipple
0
Areola area One year follow-up
Figure 12
There are several techniques available for the reconstruction of the nipple-areola complex, with results varying depending on the chosen procedure; the C-V flap has been the standard method of nipple reconstruction for the last few years and the tattooing of the areola was a very common procedure. We have presented a 1 year evaluation of 29 patients, who underwent C-V flap nipple reconstruction and areola tattooing after breast reconstruction with implants. Reconstructing a nipple with adequate long-term projection and creating an areola with long-lasting colour intensity, is a major challenge for the reconstructive surgeon and the primary criteria that influence the patient’s satisfaction. Despite projecting a nipple slightly larger than the native nipple, the loss of projection is a constant in this procedure. Comparing the reconstructed nipple in the immediate postoperative period and after 1 year, there was a loss of projection of 32%. Comparing the native with the reconstructed nipple after 1 year, we reported a difference in projection of 29%. We reported an increase of 17% in the diameter of the reconstructed nipple after 1 year, compared with the nipple in the immediate postoperative period. We thus reported that Nipple and areola measurements Immediate Native Nipple Radius (mm) Diameter (mm) Projection (mm) Area (mm2) Volume (mm3) Areola Major Diameter (mm) Minor Diameter (mm) Area (mm2) D color (96)
6.10 12.2 5.18 116.83 598.21 48.5 42.0 1600 þ12.7
Immediate
Native nipple
One year follow-up
Nipple and areola measurements.
Discussion
Table 1
1000
One year follow-up
6.25 7.35 12.50 14.7 4.96 3.52 122.65 169.63 608.34 597.09 49.7 49.0 43.4 42.8 1695 1650 0 6.5
the diameter of the reconstructed nipple after 1 year was 15% larger than the diameter of the native nipple. It is known, in fact, that the expanded skin tends to be thinner and to atrophy with a great amount of nipple projection loss. Considering these two parameters (loss of projection and increase in diameter), we found no significant difference between the volume of the reconstructed nipple in the immediate postoperative period and after 1 year (0.2%). We only reported a slight difference between the volume of the native and the reconstructed nipple after 1 year, estimated at 1.9%. As far as the areola is concerned, the long-term fading of the colour intensity after tattooing is a constant too; this is clearly related to the healing and maturing of the area. After 1 year, we thus reported fading estimated at 19.2%: patients may then require one or more touch-up tattoos in the forthcoming months. Despite tattooing the areola with a darker colour intensity, after 1 year we calculated that the intensity of the neo-areola was 6.5% compared with the native areola. Nevertheless, according to the increase of the diameter length in the reconstructed nipple, we reported also a slight increase in the areola area after 1 year (3.1%). The most important matter after any surgical procedure is patient satisfaction: it is important to discuss preoperatively the expected outcomes, informing the patient exhaustively. Despite loss of projection of the reconstructed nipple and fading of the colour of the tattooed
Table 2 scale
Patient satisfaction as measured by the visual
Parameters
Average value
Nipple projection Sensation Color of the areola Position Symmetry Overall satisfaction
6.28 5.57 6.14 7.85 7.42 6.65
1298
L. Valdatta et al. Patient satisfaction
Symmetry
Overall satisfaction
2
Position
4
Areola colour
6
Sensation
8
Nipple projection
Visual scale
10
0 1
2
3
4
5
6
Figure 13 Patients’ satisfaction measured by the 0e10 point visual scale.
areola,15e18 the average patient satisfaction regarding these two parameters was passable. Sensation is an important matter too, but despite the fact that the C-V flap technique uses native skin to reconstruct the nipple, the return of sensation after 1 year was not totally satisfactory. The position of the reconstructed nipple and the symmetry of the nipple-areola complex compared with the opposite breast, are the factors that patients were generally most satisfied with during the procedure. The overall satisfaction after 1 year, considering these five subjective parameters, was good (Figures 14 and 15). In conclusion, we have presented an evaluation of 29 patients who underwent nipple reconstruction with the C-V flap technique and areola tattooing. Loss of nipple projection and colour fading of the tattooed areola are always experienced; however, symmetry with the opposite breast can be achieved with an overreconstruction of the nipple and tattooing the areola with a darker colour intensity. The presence of a reconstructed nipple-areola complex is capable of restoring the patient’s self-esteem and completes the reconstructive process. This certainly greatly contributes to overall satisfaction, despite the patients’ lower ratings on projection, colour of the areola and sensation. Patients are thus generally satisfied with their results and would undergo the procedure again.
Figure 14
Tatooed areola and nipple e front view.
Figure 15
Tatooed areola and nipple e lateral view.
References 1. Farhadi Jioan, Maksvytyte Giedra K, Schaefer Dirk J, et al. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg 2006;59:40e53. 2. Kroll SS, Hamilton S. Nipple reconstruction with the doubleopposing tab-flap. Plast Reconstr Surg 1989;84:520. 3. Weiss J, Herman O, Rosenberg L, et al. The S nipple-areolar reconstruction. Plast Reconstr Surg 1989;83:904. 4. Chang WHJ. Nipple reconstruction with a T-flap. Plast Reconstr Surg 1984;73:140. 5. Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg 1996;97:1053. 6. Schoeller T, Schubert HM, Pu ¨lzl P, et al. Nipple reconstruction using a modified arrow flap technique. Breast 2006;15:762. 7. Little JW, Munasifi T, McCulloch DT. One stage reconstruction of a projecting nipple: the quadripod flap. Plast Reconstr Surg 1983;71:126. 8. Hartrampf Jr CR, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg 1984;73:982. 9. Jabor MA, Shayani P, Collins Jr DR, et al. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 2002 Aug;110:457e63. 10. Losken A, Mackay GJ, Bostwick 3rd J. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 2001 Aug;108:361e9. 11. Spear SL, Convit R, Little JW. Intradermal tattoo as an adjunct to nipple-areola reconstruction. Plast Reconstr Surg 1989;83:907. 12. Becker H. Nipple-areola reconstruction using intradermal tattoo. Plast Reconstr Surg 1988;81:450. 13. El-Ali K, Dalal M, Kat CC. Tattooing of the nipple-areola complex: review of outcome in 40 patients. J Plast Reconstr Aesthet Surg 2006;59:1052e7. 14. Spear SL, Arias J. Long-term experience with nipple-areolar tattooing. Ann Plast Surg 1995;35:232. 15. Banducci DR, Le TK, Hughes KC. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg 1999;43:467. 16. Few JW, Markus JR, Casa LA, et al. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg 1999;104:1321. 17. Eskenazi L. A one stage nipple reconstruction with the ‘‘modified star’’ flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg 1993;92:671. 18. Nahabedian MY. Nipple reconstruction. Clin Plast Surg 2007 Jan;34:131e7.
Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation Luigi Valdatta*, Paolo Montemurro, Federico Tamborini, Carlo Fidanza, Alessandra Gottardi, Stefano Scamoni Plastic and Reconstructive Surgery Unit, University of Insubria, Ospedale di Circolo, Varese, Italy Received 7 December 2007; accepted 25 March 2008
KEYWORDS Nipple; Areola; Breast; Reconstruction
Summary There are several procedures available for nipple and areola reconstruction after radical mastectomy, many of them providing good results. This study presents a 1 year evaluation of nipple and areola reconstruction, using the C-V flap technique and areola tattooing. Twenty-nine patients who underwent breast reconstruction with implants in our department, between January 2006 and January 2007, were evaluated and asked to return to conduct a follow-up control. They all completed a questionnaire focusing on patient satisfaction using a 1e10 point visual scale. Nipple measurements were taken with a calliper: the average nipple projection of the reconstructed nipple after 1 year was 3.52 mm, compared to 4.96 mm for the native nipple. The fading of colour of the tattooed areola and the match with the native areola were estimated with computer software (Adobe Photoshop). The technique results were simple, reliable and safe; overall patient satisfaction with the procedure was good. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The reconstruction of the nipple-areola complex represents the final step in breast reconstruction in women who underwent radical mastectomy after breast cancer. This procedure has both physical and psychological implications and needs therefore to be easy, painless and reliable. There are several methods available for this procedure1e8; nipple projection and areola pigmentation are critical
* Corresponding author. Tel./fax: þ39 332 278615. E-mail address: [email protected] (L. Valdatta).
elements of a successful reconstruction and good patient satisfaction.9 Our experience is based on the C-V flap technique, giving an easy procedure performed in the outpatient clinic, using local tissue.10 Although tattooing the areola does not allow texture and projection to be re-gained, it is quick and effective and eliminates the creation of additional donor and recipient incisions from skin grafting.11,12 The purpose of this study was to evaluate both the objective final result (projection of the nipple and colour of the areola) and the subjective patient’s satisfaction, after 1 year.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.03.064
1294
L. Valdatta et al.
Figure 3
Figure 1 Electrocardiogram disposable foam electrode positioned on the reconstructed breast (frontal view).
Patients and methods Patients who underwent breast reconstruction with implants in our department, at Circolo Hospital, between January 2006 and January 2007, were evaluated. A retrospective review was performed contacting each patient and arranging a follow-up visit. There were no exclusion criteria.
Figure 2 Electrocardiogram disposable foam electrode positioned on the reconstructed breast (lateral view).
Preoperative marks of the C-V flap (frontal view).
Measurements of the both the reconstructed and the native breast were taken with a calliper, focusing on the nipple diameter and projection. We thus calculated the nipple volume and statistically evaluated the patterns of the reconstructed nipple compared with the native one. Pictures were taken both in the immediate postoperative time and after 1 year. All the shots were taken using the same digital camera and under the same lighting conditions. Assessments were made by using computer software (Adobe Photoshop), to estimate the fading of colour of the tattooed areola and the match with the native areola. We evaluated the colour intensity using the HSB model (hue-saturation-brightness).13 In an attempt to estimate their satisfaction, patients were then asked to complete a questionnaire, considering different parameters (nipple projection, sensation, pigmentation, position and symmetry) with a 1e10 point visual scale.14 This allowed an evaluation of 29 nipple-areola reconstructions after 1 year. The average age of the patients was 56, ranging from 37 to 68 years.
Figure 4
Preoperative marks of the C-V flap (lateral view).
Nipple reconstruction using the C-V flap technique
1295
Figure 5 The margins of the C-V flap are incised through the subcutaneous fat.
Figure 7 Nipple reconstruction: immediate postoperative (lateral) view.
Surgical technique We usually perform nipple reconstruction about 3 months after breast reconstruction (range 2e4 months) and areola tattooing after another 3 months. The location of the new nipple is determined by measurements taken with the patient in the upright position; patients were actively involved in choosing nipple position giving them an electrocardiogram disposable foam electrode and asking them to place it on the reconstructed breast in front of a mirror (Figures 1 and 2). The widths of the flaps are detected according to the opposite nipple shape and dimension, generally slightly larger to allow for loss of projection. The outline of the flaps is thus drawn with a 1 mm tip surgical skin marker (Figures 3 and 4). We perform this procedure under local anaesthesia (mepivacaine hydrochloride 10 mg/ml) in an outpatient clinic. We usually do not use epinephrine due to the increased risk of necrosis in these small flaps. The flaps are then elevated and the subcutaneous tissue is thinned depending on requirements for fullness of the nipple (Figure 5).
The donor sites are closed primarily, by a 4/0 subcutaneous interrupted suture and a 4/0 intradermal continuous nylon. The V flaps are wrapped around, and the C flap is used as a cap (Figure 6); the flaps are sutured together with 4/0 interrupted nylon (Figures 7 and 8). After the procedure, a protective dressing is prepared using the bottom of a 50 cc syringe as a splint protector and a non-adhering gauze is laid underneath it (Figure 9). Stitches are removed after 15e20 days. Intradermal areolar tattooing is also performed in an outpatient clinic, under local anaesthesia (Figure 10a). We use mepivacaine hydrochloride and epinephrine in order to reduce bleeding, which would make the procedure more difficult and might therefore affect the aesthetic final result (Figure 10b). The colours are chosen and mixed together manually, in order to obtain the best match with the native areola. A darker intensity is made on purpose, to allow for subsequent fading. The tattooed areola is dressed with a non-adherent dressing, applying an antibiotic ointment over the skin. We reported no complications such as allergic reaction to local anaesthesia or to pigments, local infections or local flap necrosis.
Figure 6 The V flaps are elevated and wrapped around; the C flap is used as a cap.
Figure 8 Nipple reconstruction: immediate postoperative (frontal) view.
1296
L. Valdatta et al. Nipple measurements 16
Immediate
14
Native nipple One year follow up
12
mm
10 8 6 4 2
Figure 9 Protective dressing prepared using the bottom of a 50 cc syringe as a splint protector and a non-adhering gauze.
Results Measurements The average projection of the nipple in the immediate postoperative period was 5.18 0.42 mm (standard deviation), compared with 4.96 1.49 mm for the opposite
0
Figure 11 projection.
Radius
Diameter
Projection
Nipple measurements: radius, diameter and
nipple. After 1 year, the average projection of the reconstructed nipple was 3.52 0.95 mm (Figure 11). The average diameter of the reconstructed nipple in the immediate postoperative period was 12.2 1.0 mm, compared with 12.5 1.2 mm for the opposite nipple. After 1 year, the average diameter was 14.7 1.1 mm. The average volume of the nipple was then calculated: 598.21 mm3 in the immediate postoperative period and 608.34 mm3 for the opposite side. The average volume was 597.09 mm3 after 1 year (Figure 12). Considering that the areola is not a perfect circle, we measured the average length of both its major and its minor diameter, in the immediate postoperative period and after 1 year: these data were then compared with the native areola (Table 1). The average areolar area was calculated thus: 1600 mm2 in the immediate postoperative period and 1695 mm2 for the native areola. After 1 year, the average value was 1650 mm2. Similar comparisons showed no statistically significant differences. When tattooing the areola, a darker colour intensity is chosen on purpose: þ12.7% on average, compared to the native areola. After 1 year, the intensity of the colour faded to a value of 6.5% compared to the native areola. These data show that the fading of the colour after 1 year can be estimated to be an average value of 19.2%.
Patients’ satisfaction after 1 year
Figure 10 (a) Areolar tattooing: intraoperative. (b) Areolar tattooing: immediately postoperative.
All 29 patients completed a simple questionnaire, considering and estimating five parameters with a 1e10 point visual scale (with 1 as the worst outcome and 10 as the best possible outcome). The average patient satisfaction regarding nipple projection was 6.28, sensation of the nipple 5.57, colour of the areola 6.14, position of the reconstructed nipple-areola complex 7.85, symmetry compared with the opposite nipple-areola complex 7.42. Overall patient satisfaction was 6.65 (Table 2; Figure 13).
Nipple reconstruction using the C-V flap technique
1297 Nipple volume
1800
1800
1600
1600
1400
1400
1200
1200
mm3
mm2
Nipple and areola measurements
1000 800
800
600
600
400
400
200
200
0
Nipple area Immediate
Native nipple
0
Areola area One year follow-up
Figure 12
There are several techniques available for the reconstruction of the nipple-areola complex, with results varying depending on the chosen procedure; the C-V flap has been the standard method of nipple reconstruction for the last few years and the tattooing of the areola was a very common procedure. We have presented a 1 year evaluation of 29 patients, who underwent C-V flap nipple reconstruction and areola tattooing after breast reconstruction with implants. Reconstructing a nipple with adequate long-term projection and creating an areola with long-lasting colour intensity, is a major challenge for the reconstructive surgeon and the primary criteria that influence the patient’s satisfaction. Despite projecting a nipple slightly larger than the native nipple, the loss of projection is a constant in this procedure. Comparing the reconstructed nipple in the immediate postoperative period and after 1 year, there was a loss of projection of 32%. Comparing the native with the reconstructed nipple after 1 year, we reported a difference in projection of 29%. We reported an increase of 17% in the diameter of the reconstructed nipple after 1 year, compared with the nipple in the immediate postoperative period. We thus reported that Nipple and areola measurements Immediate Native Nipple Radius (mm) Diameter (mm) Projection (mm) Area (mm2) Volume (mm3) Areola Major Diameter (mm) Minor Diameter (mm) Area (mm2) D color (96)
6.10 12.2 5.18 116.83 598.21 48.5 42.0 1600 þ12.7
Immediate
Native nipple
One year follow-up
Nipple and areola measurements.
Discussion
Table 1
1000
One year follow-up
6.25 7.35 12.50 14.7 4.96 3.52 122.65 169.63 608.34 597.09 49.7 49.0 43.4 42.8 1695 1650 0 6.5
the diameter of the reconstructed nipple after 1 year was 15% larger than the diameter of the native nipple. It is known, in fact, that the expanded skin tends to be thinner and to atrophy with a great amount of nipple projection loss. Considering these two parameters (loss of projection and increase in diameter), we found no significant difference between the volume of the reconstructed nipple in the immediate postoperative period and after 1 year (0.2%). We only reported a slight difference between the volume of the native and the reconstructed nipple after 1 year, estimated at 1.9%. As far as the areola is concerned, the long-term fading of the colour intensity after tattooing is a constant too; this is clearly related to the healing and maturing of the area. After 1 year, we thus reported fading estimated at 19.2%: patients may then require one or more touch-up tattoos in the forthcoming months. Despite tattooing the areola with a darker colour intensity, after 1 year we calculated that the intensity of the neo-areola was 6.5% compared with the native areola. Nevertheless, according to the increase of the diameter length in the reconstructed nipple, we reported also a slight increase in the areola area after 1 year (3.1%). The most important matter after any surgical procedure is patient satisfaction: it is important to discuss preoperatively the expected outcomes, informing the patient exhaustively. Despite loss of projection of the reconstructed nipple and fading of the colour of the tattooed
Table 2 scale
Patient satisfaction as measured by the visual
Parameters
Average value
Nipple projection Sensation Color of the areola Position Symmetry Overall satisfaction
6.28 5.57 6.14 7.85 7.42 6.65
1298
L. Valdatta et al. Patient satisfaction
Symmetry
Overall satisfaction
2
Position
4
Areola colour
6
Sensation
8
Nipple projection
Visual scale
10
0 1
2
3
4
5
6
Figure 13 Patients’ satisfaction measured by the 0e10 point visual scale.
areola,15e18 the average patient satisfaction regarding these two parameters was passable. Sensation is an important matter too, but despite the fact that the C-V flap technique uses native skin to reconstruct the nipple, the return of sensation after 1 year was not totally satisfactory. The position of the reconstructed nipple and the symmetry of the nipple-areola complex compared with the opposite breast, are the factors that patients were generally most satisfied with during the procedure. The overall satisfaction after 1 year, considering these five subjective parameters, was good (Figures 14 and 15). In conclusion, we have presented an evaluation of 29 patients who underwent nipple reconstruction with the C-V flap technique and areola tattooing. Loss of nipple projection and colour fading of the tattooed areola are always experienced; however, symmetry with the opposite breast can be achieved with an overreconstruction of the nipple and tattooing the areola with a darker colour intensity. The presence of a reconstructed nipple-areola complex is capable of restoring the patient’s self-esteem and completes the reconstructive process. This certainly greatly contributes to overall satisfaction, despite the patients’ lower ratings on projection, colour of the areola and sensation. Patients are thus generally satisfied with their results and would undergo the procedure again.
Figure 14
Tatooed areola and nipple e front view.
Figure 15
Tatooed areola and nipple e lateral view.
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