- Email: [email protected]
Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons
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Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons Han Gyu Cha M.D. , Jin Geun Kwon M.D. , Eun Key Kim M.D., Ph.D. , Hwa Jeong Lee R.N. PII: DOI: Reference:
S1748-6815(19)30499-1 https://doi.org/10.1016/j.bjps.2019.11.011 PRAS 6315
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
18 February 2019 22 November 2019
Please cite this article as: Han Gyu Cha M.D. , Jin Geun Kwon M.D. , Eun Key Kim M.D., Ph.D. , Hwa Jeong Lee R.N. , Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.11.011
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons
Han Gyu Cha, M.D.1; Jin Geun Kwon, M.D.1; Eun Key Kim, M.D., Ph.D.1; Hwa Jeong Lee, R.N.2
1
Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul,
Republic of Korea 2
Department of Nursing, Asan Medical Center, Seoul, Republic of Korea
Corresponding author: Eun Key Kim Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel.: 82-2-3010-3600; Fax: 82-2-476-7471 Email: [email protected]
1
Summary
Background: Total breast reconstruction involves a long process consisting of mastectomy, breast reconstruction, and adjuvant therapy. For various reasons, some patients refuse the final step of nipple-areola reconstruction. Some patients have potential risk factors for poor outcome after undergoing conventional techniques. We have performed tattoo-only nipple-areola complex reconstruction in these situations and accomplished satisfactory results for both patients and surgeons. Methods: Ninety-five patients who underwent nipple-areola complex reconstruction between October 2017 and June 2018 were included. We retrospectively evaluated the breast reconstruction timing and type, history of a secondary breast procedure or other operations, history of adjuvant therapy, reasons for performing a tattoo-only procedure, and average operative time. Overall patient satisfaction was assessed and compared. Results: Twenty patients (21%) underwent tattoo-only nipple-areola complex reconstruction. The main reasons for performing the tattoo-only technique were patient reluctance to undergo another operation, thin and/or tight breast skin in patients with implant-based reconstruction, radiation therapy after implant-based reconstruction, adverse chemotherapy effects, scar across the central breast mound, and smoking habit. The average time for tattooing was 29 min (range, 15–45 min). The average overall satisfaction score was 8.1 on a 10-point scale, which was significantly the highest compared with that of other techniques. Conclusion: The tattoo-only nipple-areola complex reconstruction technique is an essential option to consider and utilize in selected patients who refuse another operation for nipple reconstruction for various reasons. Moreover, tattoo-only nipple-areola complex reconstruction has distinct advantages for patients with potential risk factors for poor outcome after conventional nipple-areola complex reconstruction.
Keywords: nipple-areola complex reconstruction, NAC reconstruction, breast reconstruction, nipple reconstruction, tattoo
2
Introduction Nipple-areola complex (NAC) reconstruction, the final step after skin-sparing mastectomy, is an essential procedure to complete total breast reconstruction. This reconstruction procedure is crucial to achieve not only symmetrical natural breasts but also psychological and emotional satisfaction of patients. Although many different techniques, including local flaps, nipple sharing, full-thickness skin graft, and tattooing, have been used to reconstruct a new NAC, none of them have been established as the gold standard because no single technique guarantees long-term nipple projection.1-4 Generally, an interval of 3–5 months is needed to reconstruct the nipple after breast reconstruction and another 6–8 weeks are required for areola tattooing. However, owing to the long process of total breast reconstruction, which consists of mastectomy, breast reconstruction, and adjuvant therapy, some patients become impatient and refuse the final reconstruction step. Some patients become exhausted after multiple operations on the breast, especially in the presence of complications, and other parts of the body. For surgeons, nipple reconstruction after implant-based reconstruction in patients with thin skin flaps is a challenging situation. Moreover, surgeons hesitate to perform the procedure in patients with a history of radiotherapy on the breast mounds. Sometimes, the mastectomy scar across the breast mound interferes with adequate reconstruction of the new NAC. In these situations, we perform the tattoo-only NAC reconstruction in patients and have attained satisfactory results for both patients and surgeons. Herein, we present the clinical results obtained using the tattoo-only NAC reconstruction technique that reproduces realistic nipple and areola.
Patients and methods A total of 95 patients who underwent NAC reconstruction performed by a single surgeon after oncological mastectomy and breast reconstruction from October 2017 to June 2018 were included in this study. Among them, 20 patients (21%) who underwent tattoo-only NAC reconstruction were retrospectively reviewed based on a prospectively maintained database to evaluate the breast reconstruction timing and type, history of a secondary breast procedure or other operations, history of adjuvant therapy, reasons for performing the tattoo-only procedure, and average operative time for tattoo-only NAC reconstruction. Tattooing was performed without anesthesia except in patients who had some sensory function recovery owing to a delayed interval because of adjuvant therapies. No prophylactic antibiotics were used, and only oral antibiotics were administered for 2 days 3
postoperatively. Patient satisfaction was assessed using a 10-point-scale questionnaire with written consent form. The questionnaire contained questions about overall patient satisfaction with NAC reconstruction, including tattooonly and other techniques, at 6 months postoperatively.
Surgical procedure The procedure was generally performed 2–3 months after the final operative procedure or adjuvant therapy on an outpatient basis. The patients were evaluated in the upright position, and the new NAC position was collaboratively determined using an electrocardiographic lead with the patient standing in front of a mirror. The new nipple was designed according to the size of the contralateral nipple. The Amiea Linelle Supreme permanent makeup device system (MT.DERM GmbH, Berlin, Germany) with sterile prepackaged 9-magnum needle cartridges and pigments (Permark pigment; PMT/Permark, Chanhassen, MN, USA) was used for tattooing. After color preparation by matching the colors of tattoo pigments to the color of the contralateral areola, tattooing was started from the outside border of the areola using light brown shades. Dark brown and yellow toners were used for the areola depending on the color of the contralateral areola. The nipple was created with a lighter flesh-colored pigment frequently mixed with a red toner bounded with dark brown and black pigments. Finally, white color pigment was used to make Montgomery glands sparsely distributed over the areola. (Video 1)
Statistical analysis We compared the patient satisfaction score of three different patient groups according to the NAC reconstruction method. All data were analyzed through a Kruskal-Wallis test (post hoc Mann-Whitney test) in SPSS version 21.0 for Windows (IBM Corp., Armonk, NY, USA). Statistical significance was defined as P < 0.05.
Results NAC reconstruction was performed using three different methods: single-stage nipple sharing and tattooing (44 patients, 46%), two-stage C-R flap and tattooing (31 patients, 33%), and tattoo-only technique (20 patients, 21%). Among 20 patients who underwent tattoo-only NAC reconstruction, 15 had undergone immediate breast 4
reconstruction (including two cases of two-stage reconstruction after mastectomy) and 5 had undergone delayed breast reconstruction after modified radical mastectomy (Table 1). With respect to the breast reconstruction type, a silicone implant was used in eight patients, including in two patients who underwent two-stage tissue expander/implant reconstruction. The pedicled latissimus dorsi myocutaneous flap was used in five patients, a pedicled transverse rectus abdominis myocutaneous (TRAM) flap in four patients, and a free TRAM flap in three patients. Among the 15 patients in the immediate reconstruction group, 9 received adjuvant chemotherapy or radiotherapy. Three patients in the delayed group had a history of chemotherapy or radiotherapy. Other histories of major operation and secondary procedures for breast reconstruction in each patient are presented in Table 1. The main reasons for performing the tattoo-only technique were reluctance of the patient to undergo another operation, thin and/or tight breast skin in patients with implant-based reconstruction, radiotherapy after implant-based reconstruction, adverse effects of chemotherapy, mastectomy scar across the central portion of the breast mound, and smoking habit. The average time required for tattooing was 29 min (range, 15–45 min). Only one patient underwent re-tattooing owing to fading out at 3 months after the primary procedure, and no other complications have been reported (Figures 1–3). The mean overall satisfaction score of tattoo-only NAC reconstruction was 8.1 on a 10-point scale, compared with 7.4 in single-stage nipple sharing and tattooing NAC reconstruction and 5.8 in two-stage C-R flap and tattooing reconstruction (Table 2 and Figure 4).
Discussion Tattooing has been used in the medical field mainly to camouflage various scars. Hypopigmented or hairless traumatic scars that are not suitable for surgical revision or laser treatment have been successfully improved with tattooing.5,6 Recently, as tattoos are becoming socially more acceptable and even used as tools of selfexpression and individuality, the demand for tattooing to camouflage surgical scars has increased. Especially in women, tattoos are used for scars after abdominoplasty, for flap donor sites, and in breast reconstruction not only as a tool for camouflaging but also for enhancing aesthetic appearance.7,8 In breast reconstruction, tattooing is used mainly for areola reconstruction after nipple reconstruction. However, at our institution, tattooing has been successfully applied to camouflage the loss of nipple projection after nipple reconstruction with a local flap.6 With the insights gained from this experience, we started to apply the tattoo-only technique for NAC reconstruction in selected patients. 5
Tattoo-only NAC reconstruction was recommended and performed in (i) patients who refused to undergo another surgery for various reasons, (ii) patients with very thin and/or tight breast skin in which nipple reconstruction may result in mound distortion, and (iii) patients not suitable for local skin flap elevation owing to insufficient dimension of the skin paddle or a mastectomy scar across the central portion of the breast mound. After performing this technique in 20 patients, we now strongly believe that tattoo-only NAC reconstruction has a distinct advantage for patients with potential risk factors for poor outcome after undergoing the conventional techniques and that many candidates can benefit from tattoo-only NAC reconstruction. From the patient perspective, the main advantage of this technique is the termination of surgery. Patients may undergo multiple operations because of complications of primary breast reconstructive surgery. For example, similar to the patients in our study, patients with histories of infection and implant change are common in implant-based reconstruction. Patients with a history of cancer in other parts of the body may also not be willing to undergo another surgery. Furthermore, a patient with a history of breast cancer on the contralateral side may not be willing to undergo nipple reconstruction. In these patients, the fear of lying on the operation bed is avoided, and the additional time for wound healing and subsequent hospital visits for dressings after nipple reconstruction can be eliminated by the tattoo-only technique. Only 30 min is required for “tattooing.” Another meaningful benefit of the tattoo-only technique is the shortened total reconstruction period. Owing to the long process of total breast reconstruction and multiple operative procedures, many patients become exhausted and even more if adjuvant chemotherapy or radiotherapy is added. In this situation, waiting for another 3–5 months, and sometimes even longer, to undergo nipple reconstruction becomes intolerable for the patients. Tattoo-only NAC reconstruction may provide psychological consolation and satisfaction by shortening the reconstruction period. Consequently, in our survey, this resulted in a high satisfaction score compared with the two-stage technique. The tattoo-only technique is also a useful option for surgeons. Nipples reconstructed using local skin flaps are known to lose their initial projection regardless of the flap type. Both skate and star flaps were reported to have a projection loss rate of >40%, and other flaps such as the C-V, arrow, and bell flaps also resulted in a 45–73% projection loss.3,9,10 The modified top hat flap (also known as the C-R flap), which is the workhorse technique of our senior author, also resulted in a 59% projection loss in our previous study. 11 Therefore, surgeons tend to overcorrect the nipple to address the expected projection loss. Maintenance of projection was better achieved using the thicker skin from the back after latissimus dorsi reconstruction rather than the thinner skin from the 6
abdomen; however, a nipple made of back skin tends to have frequent necrosis due to hardness and thickness.12 Especially in irradiated breasts, the postoperative complication rates after nipple reconstruction have been proved to significantly increase in many studies,13,14 and the tattoo-only technique would be a good alternative without loss of projection and nipple necrosis. Patients with an extremely thin skin flap after implant-based reconstruction can also be good candidates for tattoo-only NAC reconstruction without using adjacent skin tissue for local flaps. Moreover, if radiotherapy is performed in these patients, the tattoo-only technique may be the only option to reproduce the NAC unless the contralateral nipple is sufficiently large for sharing and the patient agree to the sharing procedure. The most important and difficult step in tattoo-only NAC reconstruction is making a projected nipple. Similar to our previous experience of camouflaging nipple projection, dark colors were used to make a thickened border mainly on the inferior part for gradation, and light flesh colors mixed with red toner were used in the central portion of the nipple. To reconstruct a natural areola, the outside borders were pigmented with light brown and flesh colors to reproduce the blurred margin. Moreover, applying a white pigment sparsely in the area of the areola can replicate the Montgomery glands. Another technical difficulty that many surgeons encounter is fading out of colors in a few weeks to months. The key factor for preventing fading out and for permanent micropigmentation is the depth of pigment deposition, and the upper and mid-papillary dermis is the optimal target. Pigments that do not reach the upper papillary dermis would be pushed out in a few weeks, whereas pigments that are located too deep below the papillary dermis are carried away by macrophages after a few months.15 In cases of skin-sparing mastectomy, the NAC is reconstructed using the breast skin, abdominal skin, or back skin according to the breast reconstruction method. Because the skin thickness differs by anatomical site, surgeons should recognize the skin thickness of patients before tattooing. According to previous studies, the thickness of breast skin is reported to be 1.50–1.80 mm in middle-aged women.16 Furthermore, the abdominal skin thickness is 1.51–1.62 mm and the back skin thickness is 2.18–2.47 mm.17 Therefore, the length of needle cartridges should be adjusted before tattooing according to the skin type and thickness, followed by perpendicular insertion of the needle to achieve permanent micropigmentation. The limitation of this tattoo-only technique is the absence of a true nipple projection. Although threedimensional tattooing makes a projected nipple in frontal view, it is difficult to create projection in the lateral view. In fact, long-term nipple projection was the most important factor for patient satisfaction in some studies.18,19 However, patients are informed about the absence of nipple projection before tattooing, and most 7
patients primarily do not want to undergo NAC reconstruction. Therefore, nipple projection would not have a significant impact on these patients, as the other studies had shown.20 Paradoxically, although patients claim to not want a reconstructed nipple, tattooing should be strongly recommended to these patients, considering the highest satisfaction score of this technique in our study. A concern may be raised that this study was designed to have a comparison only with the C-R flap among the various local flap techniques; however, we believe that the type of flap would not have an impact on the high satisfaction score of the tattoo-only technique. There are some limitations regarding the satisfaction score evaluation. First, we have used our 10-point scale protocol to evaluate patient satisfaction rather than the Breast-Q which is the most popular validated questionnaire. In fact, there is only one question (“How natural your reconstructed nipple look?”) regarding the nipple reconstruction in Breast-Q and also the score is only from 1 to 4. We think it is better to refine the score from 1 to 10 and that is the only point differs from Breast-Q. Second, the surgeon’s satisfaction score was not evaluated according to various NAC reconstruction techniques. Thus, the next challenge should be the analysis of patient factors that is associated with tattoo-only technique selection and evaluation of surgeon’s satisfaction with more cases. It will help many surgeons to recommend this technique in adequate situation and eventually help the patients in certain condition. Until now, surgeons have not given much attention to the basic principles of intradermal tattooing and have been dependent on tattoo artists or micropigmentationists. However, many patients consider nipple and areola tattooing as the final course of breast reconstruction and prefer to undergo tattooing performed by a surgeon in a medical facility. Furthermore, in some countries in Asia, tattooing is only permitted if performed by surgeons, who have the obligation to meet the increasing demand of patients who undergo breast reconstruction. A recent collaboration of plastic surgeons and tattoo artists has shown the potential to improve the aesthetic outcomes of NAC reconstruction by applying a three-dimensional reconstruction technique.21,22 Our study proves the applications and results of tattoo-only NAC reconstruction with aesthetic potential and high patient satisfaction. As more surgeons become interested in tattooing, more evolutionary aesthetic outcomes can be achieved.
Conclusions The tattoo-only NAC reconstruction technique is an essential option that surgeons should be prepared to consider and utilize in selected patients. This technique can be introduced to patients who refuse another operation for nipple reconstruction for various reasons and those who become impatient after the long period of 8
breast reconstruction procedures. Moreover, surgeons can apply this technique in patients who have potential risk factors for poor outcome after undergoing conventional NAC reconstruction, including those with irradiated breasts and extremely thin and/or tight breast skin after implant-based reconstruction, as well as patients who are not suitable for local skin flap elevation. By adopting simple technical skills for creating realistic nipple and areola, the patient will have a satisfactory NAC without any burden.
Acknowledgment None
Conflict of interest statement None of the authors have commercial associations or financial interests to disclose.
9
References 1.
Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009;62(5):591-595.
2.
Kim YC, Yun JY, Lee HC, Yim JH, Eom JS. Nipple reconstruction with combination of modified CV flap and contralateral nipple composite graft. J Plast Reconstr Aesthet Surg. 2017;70(2):243-247.
3.
Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the 'arrow flap'. Br J Plast Surg. 2003;56(3):247-251.
4.
Cha HG, Kwon JG, Kim EK. Simultaneous Nipple-Areola Complex Reconstruction Technique: Combination Nipple Sharing and Tattooing. Aesthetic Plast Surg. 2019;43(1):76-82.
5.
Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented scars. Plast
Reconstr Surg. 1995;95(3):575-579. 6.
Kim EK, Chang TJ, Hong JP, Koh KS. Use of tattooing to camouflage various scars.
Aesthetic Plast Surg. 2011;35(3):392-395. 7.
Allen D. Moving the Needle on Recovery From Breast Cancer: The Healing Role of Postmastectomy Tattoos. JAMA. 2017;317(7):672-674.
8.
Spyropoulou GA, Fatah F. Decorative tattooing for scar camouflage: patient innovation. J
Plast Reconstr Aesthet Surg. 2009;62(10):e353-355. 9.
Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110(3):780786.
10.
El-Ali K, Dalal M, Kat CC. Modified C-V flap for nipple reconstruction: our results in 50 patients. J Plast Reconstr Aesthet Surg. 2009;62(8):991-996.
11.
Lee HC, Eom JS, Kim EK, Lee TJ. Does the Sequence of Tattooing and Nipple Reconstruction Affect Nipple Projection? Ann Plast Surg. 2017;79(5):430-432.
12.
Mihara R, Mori H, Okazaki M. Nipple Reconstruction with Dorsal Skin Provides Better Projection than Reconstruction with Abdominal or Breast Skin with Cartilage Grafting.
Aesthetic Plast Surg. 2017;41(1):31-35. 13.
Momeni A, Ghaly M, Gupta D, et al. Nipple reconstruction after implant-based breast reconstruction: a "matched-pair" outcome analysis focusing on the effects of radiotherapy.
J Plast Reconstr Aesthet Surg. 2013;66(9):1202-1205. 14.
Momeni A, Ghaly M, Gupta D, et al. Nipple Reconstruction: Risk Factors and Complications after 189 Procedures. Eur J Plast Surg. 2013;36(10):633-638.
15.
Garg G, Thami GP. Micropigmentation: tattooing for medical purposes. Dermatol Surg. 2005;31(8 Pt 1):928-931; discussion 931.
16.
Coltman CE, Steele JR, McGhee DE. Effect of aging on breast skin thickness and elasticity: implications for breast support. Skin Res Technol. 2017;23(3):303-311. 10
17.
Nedelec B, Forget NJ, Hurtubise T, et al. Skin characteristics: normative data for elasticity, erythema, melanin, and thickness at 16 different anatomical locations. Skin Res Technol. 2016;22(3):263-275.
18.
Goh SC, Martin NA, Pandya AN, Cutress RI. Patient satisfaction following nipple-areolar complex reconstruction and tattooing. J Plast Reconstr Aesthet Surg. 2011;64(3):360-363.
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Jabor MA, Shayani P, Collins DR, Jr., Karas T, Cohen BE. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110(2):457-463; discussion 464-455.
20.
Sisti A, Grimaldi L, Tassinari J, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol. 2016;42(4):441-465.
21.
Carney MJ, Weissler JM, Sauler M, Serletti JM. Looking Beyond the Knife: Establishing a Framework for Micropigmentation following Breast Reconstruction. Plast Reconstr Surg. 2017;140(1):243e-244e.
22.
Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing:
a new technique with superior results. Plast Reconstr Surg. 2014;133(5):1073-1075. Figure legends
11
Figure 1. Postoperative photograph at 6 months of a 47-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer, followed by immediate reconstruction with a silicone implant. She also had a history of subtotal thyroidectomy for thyroid cancer before breast cancer and did not want to undergo an additional operation. Her breast skin was extremely thin, and she was recommended to undergo tattoo-only nipple-areola complex reconstruction.
12
Figure 2. Postoperative photograph at 7 months of a 33-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer, followed by immediate reconstruction with a silicone implant and vertical reduction mammaplasty on the right breast. She had thin and tight breast skin with a transverse mastectomy scar across the middle of the breast mound.
13
ge
Reconstruction timing
Reconstruction method
History of other major operation or secondary breast procedure
Adjuvant therapy
Reasons for applying tattoo-only technique
Figure 3. Postoperative photograph at 6 months of a 53-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer followed by immediate reconstruction with a silicone implant. She also had a history of breast-conserving surgery for right breast cancer and refused to undergo an additional operation.
Figure 4. Photographs of nipples reconstructed using three different techniques: (A) C-R flap and tattooing, (B) nipple sharing and tattooing, and (C) tattoo-only techniques.
Table 1. Patient details 14
4
Immediate
7
Immediate
4
1
8
0
8
0
3
2
0
3
Pedicled LD
-
Implant One-stage nipple Subtotal thyroidectomy (Thyroid cancer) sharing Two-stage C-R flap and and tattooing tattooing Immediate Implant - (n = 31) (n = 44) Satisfaction score Immediate Pedicled LD - 5.8 ± 1.5 7.4 ± 1.2 (mean ± SD) Immediate Pedicled LD One-stage nipple sharing Two-stage C-R flap and and tattooing tattooing Immediate Pedicled LD Revision (breast infection) (n = 44) (n = 31) Total thyroidectomy (Thyoid cancer) Immediate Pedicled Satisfaction score TRAM 7.4 ± 1.2 Secondary free fat 5.8injection ± 1.5 (mean ± SD) Immediate Implant One-stage nipple sharing Two-stage C-R flap and and tattooing tattooing (n = 44) Immediate Implant - (n = 31) Satisfaction score 7.4 ± 1.2 Immediate Pedicled LD - 5.8 ± 1.5 (mean ± SD) One-stage nipple sharing(nipple Two-stage and Immediate Pedicled TRAM Revision necrosisC-R afterflap NSM) and tattooing tattooing Breast conserving surgery (n = 44) (n = 31) Immediate Implant (contralateral breast cancer) Satisfaction score 7.4 ± 1.2 5.8 ± 1.5
CTx Tattoo-only technique (n =CTx 20) 8.1 ± -1.2 RTx Tattoo-only technique (n = 20) CTx, RTx 8.1 ± 1.2 CTx Tattoo-only technique (n = 20) 8.1 ± -1.2 RTx Tattoo-only technique (n = 20) CTx, RTx 8.1 ± 1.2
9
Immediate
Implant
-
CTx, RTx
4
Two-stage
Expander to Implant
-
CTx, RTx
0 9 6 0 0
Two-stage Delayed Delayed Delayed Delayed
Expander to Implant Free TRAM Pedicled TRAM Pedicled TRAM Free TRAM
Refuse additional operation History of adverse effect (CTx) Refuse additional operation Thin skin P-value Refuse additional operation History of adverse effect (CTx) Refuse additional operation < 0.05 Irradiated breast Heavy smoker P-value Refuse additional operation Refuse additional operation Irradiated < 0.05 breast Refuse additional operation Thin skin P-value Scar across the breast mound Thin and tight skin < 0.05 Refuse additional operation Refuse additional operation Irradiated breast P-value Refuse additional operation Irradiated breast < 0.05 Thin and tight skin Irradiated breast Smoker Thin and tight skin Irradiated breast Thin and tight skin Refuse additional operation Refuse additional operation Refuse additional operation Refuse additional operation
Prior CTx Prior CTx, RTx Prior CTx Revision (infection on contralateral breast after 8 Delayed Free TRAM Refuse additional operation reduction mammaplasty) simus dorsi; TRAM, transverse rectus abdominis myocutaneous; CTx, chemotherapy; RTx, radiotherapy; NSM, nipple-sparing mastectomy
Table 2. Patient satisfaction score assessed by a 10-point-scale questionnaire
15
(mean ± SD)
Satisfaction score (mean ± SD)
One-stage nipple sharing and tattooing (n = 44)
Two-stage C-R flap and tattooing (n = 31)
Tattoo-only technique (n = 20)
P-value
7.4 ± 1.2
5.8 ± 1.5
8.1 ± 1.2
< 0.05
16
Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons Han Gyu Cha M.D. , Jin Geun Kwon M.D. , Eun Key Kim M.D., Ph.D. , Hwa Jeong Lee R.N. PII: DOI: Reference:
S1748-6815(19)30499-1 https://doi.org/10.1016/j.bjps.2019.11.011 PRAS 6315
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
18 February 2019 22 November 2019
Please cite this article as: Han Gyu Cha M.D. , Jin Geun Kwon M.D. , Eun Key Kim M.D., Ph.D. , Hwa Jeong Lee R.N. , Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.11.011
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Tattoo-only nipple-areola complex reconstruction: Another option for plastic surgeons
Han Gyu Cha, M.D.1; Jin Geun Kwon, M.D.1; Eun Key Kim, M.D., Ph.D.1; Hwa Jeong Lee, R.N.2
1
Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul,
Republic of Korea 2
Department of Nursing, Asan Medical Center, Seoul, Republic of Korea
Corresponding author: Eun Key Kim Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel.: 82-2-3010-3600; Fax: 82-2-476-7471 Email: [email protected]
1
Summary
Background: Total breast reconstruction involves a long process consisting of mastectomy, breast reconstruction, and adjuvant therapy. For various reasons, some patients refuse the final step of nipple-areola reconstruction. Some patients have potential risk factors for poor outcome after undergoing conventional techniques. We have performed tattoo-only nipple-areola complex reconstruction in these situations and accomplished satisfactory results for both patients and surgeons. Methods: Ninety-five patients who underwent nipple-areola complex reconstruction between October 2017 and June 2018 were included. We retrospectively evaluated the breast reconstruction timing and type, history of a secondary breast procedure or other operations, history of adjuvant therapy, reasons for performing a tattoo-only procedure, and average operative time. Overall patient satisfaction was assessed and compared. Results: Twenty patients (21%) underwent tattoo-only nipple-areola complex reconstruction. The main reasons for performing the tattoo-only technique were patient reluctance to undergo another operation, thin and/or tight breast skin in patients with implant-based reconstruction, radiation therapy after implant-based reconstruction, adverse chemotherapy effects, scar across the central breast mound, and smoking habit. The average time for tattooing was 29 min (range, 15–45 min). The average overall satisfaction score was 8.1 on a 10-point scale, which was significantly the highest compared with that of other techniques. Conclusion: The tattoo-only nipple-areola complex reconstruction technique is an essential option to consider and utilize in selected patients who refuse another operation for nipple reconstruction for various reasons. Moreover, tattoo-only nipple-areola complex reconstruction has distinct advantages for patients with potential risk factors for poor outcome after conventional nipple-areola complex reconstruction.
Keywords: nipple-areola complex reconstruction, NAC reconstruction, breast reconstruction, nipple reconstruction, tattoo
2
Introduction Nipple-areola complex (NAC) reconstruction, the final step after skin-sparing mastectomy, is an essential procedure to complete total breast reconstruction. This reconstruction procedure is crucial to achieve not only symmetrical natural breasts but also psychological and emotional satisfaction of patients. Although many different techniques, including local flaps, nipple sharing, full-thickness skin graft, and tattooing, have been used to reconstruct a new NAC, none of them have been established as the gold standard because no single technique guarantees long-term nipple projection.1-4 Generally, an interval of 3–5 months is needed to reconstruct the nipple after breast reconstruction and another 6–8 weeks are required for areola tattooing. However, owing to the long process of total breast reconstruction, which consists of mastectomy, breast reconstruction, and adjuvant therapy, some patients become impatient and refuse the final reconstruction step. Some patients become exhausted after multiple operations on the breast, especially in the presence of complications, and other parts of the body. For surgeons, nipple reconstruction after implant-based reconstruction in patients with thin skin flaps is a challenging situation. Moreover, surgeons hesitate to perform the procedure in patients with a history of radiotherapy on the breast mounds. Sometimes, the mastectomy scar across the breast mound interferes with adequate reconstruction of the new NAC. In these situations, we perform the tattoo-only NAC reconstruction in patients and have attained satisfactory results for both patients and surgeons. Herein, we present the clinical results obtained using the tattoo-only NAC reconstruction technique that reproduces realistic nipple and areola.
Patients and methods A total of 95 patients who underwent NAC reconstruction performed by a single surgeon after oncological mastectomy and breast reconstruction from October 2017 to June 2018 were included in this study. Among them, 20 patients (21%) who underwent tattoo-only NAC reconstruction were retrospectively reviewed based on a prospectively maintained database to evaluate the breast reconstruction timing and type, history of a secondary breast procedure or other operations, history of adjuvant therapy, reasons for performing the tattoo-only procedure, and average operative time for tattoo-only NAC reconstruction. Tattooing was performed without anesthesia except in patients who had some sensory function recovery owing to a delayed interval because of adjuvant therapies. No prophylactic antibiotics were used, and only oral antibiotics were administered for 2 days 3
postoperatively. Patient satisfaction was assessed using a 10-point-scale questionnaire with written consent form. The questionnaire contained questions about overall patient satisfaction with NAC reconstruction, including tattooonly and other techniques, at 6 months postoperatively.
Surgical procedure The procedure was generally performed 2–3 months after the final operative procedure or adjuvant therapy on an outpatient basis. The patients were evaluated in the upright position, and the new NAC position was collaboratively determined using an electrocardiographic lead with the patient standing in front of a mirror. The new nipple was designed according to the size of the contralateral nipple. The Amiea Linelle Supreme permanent makeup device system (MT.DERM GmbH, Berlin, Germany) with sterile prepackaged 9-magnum needle cartridges and pigments (Permark pigment; PMT/Permark, Chanhassen, MN, USA) was used for tattooing. After color preparation by matching the colors of tattoo pigments to the color of the contralateral areola, tattooing was started from the outside border of the areola using light brown shades. Dark brown and yellow toners were used for the areola depending on the color of the contralateral areola. The nipple was created with a lighter flesh-colored pigment frequently mixed with a red toner bounded with dark brown and black pigments. Finally, white color pigment was used to make Montgomery glands sparsely distributed over the areola. (Video 1)
Statistical analysis We compared the patient satisfaction score of three different patient groups according to the NAC reconstruction method. All data were analyzed through a Kruskal-Wallis test (post hoc Mann-Whitney test) in SPSS version 21.0 for Windows (IBM Corp., Armonk, NY, USA). Statistical significance was defined as P < 0.05.
Results NAC reconstruction was performed using three different methods: single-stage nipple sharing and tattooing (44 patients, 46%), two-stage C-R flap and tattooing (31 patients, 33%), and tattoo-only technique (20 patients, 21%). Among 20 patients who underwent tattoo-only NAC reconstruction, 15 had undergone immediate breast 4
reconstruction (including two cases of two-stage reconstruction after mastectomy) and 5 had undergone delayed breast reconstruction after modified radical mastectomy (Table 1). With respect to the breast reconstruction type, a silicone implant was used in eight patients, including in two patients who underwent two-stage tissue expander/implant reconstruction. The pedicled latissimus dorsi myocutaneous flap was used in five patients, a pedicled transverse rectus abdominis myocutaneous (TRAM) flap in four patients, and a free TRAM flap in three patients. Among the 15 patients in the immediate reconstruction group, 9 received adjuvant chemotherapy or radiotherapy. Three patients in the delayed group had a history of chemotherapy or radiotherapy. Other histories of major operation and secondary procedures for breast reconstruction in each patient are presented in Table 1. The main reasons for performing the tattoo-only technique were reluctance of the patient to undergo another operation, thin and/or tight breast skin in patients with implant-based reconstruction, radiotherapy after implant-based reconstruction, adverse effects of chemotherapy, mastectomy scar across the central portion of the breast mound, and smoking habit. The average time required for tattooing was 29 min (range, 15–45 min). Only one patient underwent re-tattooing owing to fading out at 3 months after the primary procedure, and no other complications have been reported (Figures 1–3). The mean overall satisfaction score of tattoo-only NAC reconstruction was 8.1 on a 10-point scale, compared with 7.4 in single-stage nipple sharing and tattooing NAC reconstruction and 5.8 in two-stage C-R flap and tattooing reconstruction (Table 2 and Figure 4).
Discussion Tattooing has been used in the medical field mainly to camouflage various scars. Hypopigmented or hairless traumatic scars that are not suitable for surgical revision or laser treatment have been successfully improved with tattooing.5,6 Recently, as tattoos are becoming socially more acceptable and even used as tools of selfexpression and individuality, the demand for tattooing to camouflage surgical scars has increased. Especially in women, tattoos are used for scars after abdominoplasty, for flap donor sites, and in breast reconstruction not only as a tool for camouflaging but also for enhancing aesthetic appearance.7,8 In breast reconstruction, tattooing is used mainly for areola reconstruction after nipple reconstruction. However, at our institution, tattooing has been successfully applied to camouflage the loss of nipple projection after nipple reconstruction with a local flap.6 With the insights gained from this experience, we started to apply the tattoo-only technique for NAC reconstruction in selected patients. 5
Tattoo-only NAC reconstruction was recommended and performed in (i) patients who refused to undergo another surgery for various reasons, (ii) patients with very thin and/or tight breast skin in which nipple reconstruction may result in mound distortion, and (iii) patients not suitable for local skin flap elevation owing to insufficient dimension of the skin paddle or a mastectomy scar across the central portion of the breast mound. After performing this technique in 20 patients, we now strongly believe that tattoo-only NAC reconstruction has a distinct advantage for patients with potential risk factors for poor outcome after undergoing the conventional techniques and that many candidates can benefit from tattoo-only NAC reconstruction. From the patient perspective, the main advantage of this technique is the termination of surgery. Patients may undergo multiple operations because of complications of primary breast reconstructive surgery. For example, similar to the patients in our study, patients with histories of infection and implant change are common in implant-based reconstruction. Patients with a history of cancer in other parts of the body may also not be willing to undergo another surgery. Furthermore, a patient with a history of breast cancer on the contralateral side may not be willing to undergo nipple reconstruction. In these patients, the fear of lying on the operation bed is avoided, and the additional time for wound healing and subsequent hospital visits for dressings after nipple reconstruction can be eliminated by the tattoo-only technique. Only 30 min is required for “tattooing.” Another meaningful benefit of the tattoo-only technique is the shortened total reconstruction period. Owing to the long process of total breast reconstruction and multiple operative procedures, many patients become exhausted and even more if adjuvant chemotherapy or radiotherapy is added. In this situation, waiting for another 3–5 months, and sometimes even longer, to undergo nipple reconstruction becomes intolerable for the patients. Tattoo-only NAC reconstruction may provide psychological consolation and satisfaction by shortening the reconstruction period. Consequently, in our survey, this resulted in a high satisfaction score compared with the two-stage technique. The tattoo-only technique is also a useful option for surgeons. Nipples reconstructed using local skin flaps are known to lose their initial projection regardless of the flap type. Both skate and star flaps were reported to have a projection loss rate of >40%, and other flaps such as the C-V, arrow, and bell flaps also resulted in a 45–73% projection loss.3,9,10 The modified top hat flap (also known as the C-R flap), which is the workhorse technique of our senior author, also resulted in a 59% projection loss in our previous study. 11 Therefore, surgeons tend to overcorrect the nipple to address the expected projection loss. Maintenance of projection was better achieved using the thicker skin from the back after latissimus dorsi reconstruction rather than the thinner skin from the 6
abdomen; however, a nipple made of back skin tends to have frequent necrosis due to hardness and thickness.12 Especially in irradiated breasts, the postoperative complication rates after nipple reconstruction have been proved to significantly increase in many studies,13,14 and the tattoo-only technique would be a good alternative without loss of projection and nipple necrosis. Patients with an extremely thin skin flap after implant-based reconstruction can also be good candidates for tattoo-only NAC reconstruction without using adjacent skin tissue for local flaps. Moreover, if radiotherapy is performed in these patients, the tattoo-only technique may be the only option to reproduce the NAC unless the contralateral nipple is sufficiently large for sharing and the patient agree to the sharing procedure. The most important and difficult step in tattoo-only NAC reconstruction is making a projected nipple. Similar to our previous experience of camouflaging nipple projection, dark colors were used to make a thickened border mainly on the inferior part for gradation, and light flesh colors mixed with red toner were used in the central portion of the nipple. To reconstruct a natural areola, the outside borders were pigmented with light brown and flesh colors to reproduce the blurred margin. Moreover, applying a white pigment sparsely in the area of the areola can replicate the Montgomery glands. Another technical difficulty that many surgeons encounter is fading out of colors in a few weeks to months. The key factor for preventing fading out and for permanent micropigmentation is the depth of pigment deposition, and the upper and mid-papillary dermis is the optimal target. Pigments that do not reach the upper papillary dermis would be pushed out in a few weeks, whereas pigments that are located too deep below the papillary dermis are carried away by macrophages after a few months.15 In cases of skin-sparing mastectomy, the NAC is reconstructed using the breast skin, abdominal skin, or back skin according to the breast reconstruction method. Because the skin thickness differs by anatomical site, surgeons should recognize the skin thickness of patients before tattooing. According to previous studies, the thickness of breast skin is reported to be 1.50–1.80 mm in middle-aged women.16 Furthermore, the abdominal skin thickness is 1.51–1.62 mm and the back skin thickness is 2.18–2.47 mm.17 Therefore, the length of needle cartridges should be adjusted before tattooing according to the skin type and thickness, followed by perpendicular insertion of the needle to achieve permanent micropigmentation. The limitation of this tattoo-only technique is the absence of a true nipple projection. Although threedimensional tattooing makes a projected nipple in frontal view, it is difficult to create projection in the lateral view. In fact, long-term nipple projection was the most important factor for patient satisfaction in some studies.18,19 However, patients are informed about the absence of nipple projection before tattooing, and most 7
patients primarily do not want to undergo NAC reconstruction. Therefore, nipple projection would not have a significant impact on these patients, as the other studies had shown.20 Paradoxically, although patients claim to not want a reconstructed nipple, tattooing should be strongly recommended to these patients, considering the highest satisfaction score of this technique in our study. A concern may be raised that this study was designed to have a comparison only with the C-R flap among the various local flap techniques; however, we believe that the type of flap would not have an impact on the high satisfaction score of the tattoo-only technique. There are some limitations regarding the satisfaction score evaluation. First, we have used our 10-point scale protocol to evaluate patient satisfaction rather than the Breast-Q which is the most popular validated questionnaire. In fact, there is only one question (“How natural your reconstructed nipple look?”) regarding the nipple reconstruction in Breast-Q and also the score is only from 1 to 4. We think it is better to refine the score from 1 to 10 and that is the only point differs from Breast-Q. Second, the surgeon’s satisfaction score was not evaluated according to various NAC reconstruction techniques. Thus, the next challenge should be the analysis of patient factors that is associated with tattoo-only technique selection and evaluation of surgeon’s satisfaction with more cases. It will help many surgeons to recommend this technique in adequate situation and eventually help the patients in certain condition. Until now, surgeons have not given much attention to the basic principles of intradermal tattooing and have been dependent on tattoo artists or micropigmentationists. However, many patients consider nipple and areola tattooing as the final course of breast reconstruction and prefer to undergo tattooing performed by a surgeon in a medical facility. Furthermore, in some countries in Asia, tattooing is only permitted if performed by surgeons, who have the obligation to meet the increasing demand of patients who undergo breast reconstruction. A recent collaboration of plastic surgeons and tattoo artists has shown the potential to improve the aesthetic outcomes of NAC reconstruction by applying a three-dimensional reconstruction technique.21,22 Our study proves the applications and results of tattoo-only NAC reconstruction with aesthetic potential and high patient satisfaction. As more surgeons become interested in tattooing, more evolutionary aesthetic outcomes can be achieved.
Conclusions The tattoo-only NAC reconstruction technique is an essential option that surgeons should be prepared to consider and utilize in selected patients. This technique can be introduced to patients who refuse another operation for nipple reconstruction for various reasons and those who become impatient after the long period of 8
breast reconstruction procedures. Moreover, surgeons can apply this technique in patients who have potential risk factors for poor outcome after undergoing conventional NAC reconstruction, including those with irradiated breasts and extremely thin and/or tight breast skin after implant-based reconstruction, as well as patients who are not suitable for local skin flap elevation. By adopting simple technical skills for creating realistic nipple and areola, the patient will have a satisfactory NAC without any burden.
Acknowledgment None
Conflict of interest statement None of the authors have commercial associations or financial interests to disclose.
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References 1.
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Kim YC, Yun JY, Lee HC, Yim JH, Eom JS. Nipple reconstruction with combination of modified CV flap and contralateral nipple composite graft. J Plast Reconstr Aesthet Surg. 2017;70(2):243-247.
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Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the 'arrow flap'. Br J Plast Surg. 2003;56(3):247-251.
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Cha HG, Kwon JG, Kim EK. Simultaneous Nipple-Areola Complex Reconstruction Technique: Combination Nipple Sharing and Tattooing. Aesthetic Plast Surg. 2019;43(1):76-82.
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Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented scars. Plast
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Kim EK, Chang TJ, Hong JP, Koh KS. Use of tattooing to camouflage various scars.
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Allen D. Moving the Needle on Recovery From Breast Cancer: The Healing Role of Postmastectomy Tattoos. JAMA. 2017;317(7):672-674.
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Spyropoulou GA, Fatah F. Decorative tattooing for scar camouflage: patient innovation. J
Plast Reconstr Aesthet Surg. 2009;62(10):e353-355. 9.
Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110(3):780786.
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El-Ali K, Dalal M, Kat CC. Modified C-V flap for nipple reconstruction: our results in 50 patients. J Plast Reconstr Aesthet Surg. 2009;62(8):991-996.
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Lee HC, Eom JS, Kim EK, Lee TJ. Does the Sequence of Tattooing and Nipple Reconstruction Affect Nipple Projection? Ann Plast Surg. 2017;79(5):430-432.
12.
Mihara R, Mori H, Okazaki M. Nipple Reconstruction with Dorsal Skin Provides Better Projection than Reconstruction with Abdominal or Breast Skin with Cartilage Grafting.
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Momeni A, Ghaly M, Gupta D, et al. Nipple reconstruction after implant-based breast reconstruction: a "matched-pair" outcome analysis focusing on the effects of radiotherapy.
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Momeni A, Ghaly M, Gupta D, et al. Nipple Reconstruction: Risk Factors and Complications after 189 Procedures. Eur J Plast Surg. 2013;36(10):633-638.
15.
Garg G, Thami GP. Micropigmentation: tattooing for medical purposes. Dermatol Surg. 2005;31(8 Pt 1):928-931; discussion 931.
16.
Coltman CE, Steele JR, McGhee DE. Effect of aging on breast skin thickness and elasticity: implications for breast support. Skin Res Technol. 2017;23(3):303-311. 10
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Nedelec B, Forget NJ, Hurtubise T, et al. Skin characteristics: normative data for elasticity, erythema, melanin, and thickness at 16 different anatomical locations. Skin Res Technol. 2016;22(3):263-275.
18.
Goh SC, Martin NA, Pandya AN, Cutress RI. Patient satisfaction following nipple-areolar complex reconstruction and tattooing. J Plast Reconstr Aesthet Surg. 2011;64(3):360-363.
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Jabor MA, Shayani P, Collins DR, Jr., Karas T, Cohen BE. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110(2):457-463; discussion 464-455.
20.
Sisti A, Grimaldi L, Tassinari J, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol. 2016;42(4):441-465.
21.
Carney MJ, Weissler JM, Sauler M, Serletti JM. Looking Beyond the Knife: Establishing a Framework for Micropigmentation following Breast Reconstruction. Plast Reconstr Surg. 2017;140(1):243e-244e.
22.
Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing:
a new technique with superior results. Plast Reconstr Surg. 2014;133(5):1073-1075. Figure legends
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Figure 1. Postoperative photograph at 6 months of a 47-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer, followed by immediate reconstruction with a silicone implant. She also had a history of subtotal thyroidectomy for thyroid cancer before breast cancer and did not want to undergo an additional operation. Her breast skin was extremely thin, and she was recommended to undergo tattoo-only nipple-areola complex reconstruction.
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Figure 2. Postoperative photograph at 7 months of a 33-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer, followed by immediate reconstruction with a silicone implant and vertical reduction mammaplasty on the right breast. She had thin and tight breast skin with a transverse mastectomy scar across the middle of the breast mound.
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ge
Reconstruction timing
Reconstruction method
History of other major operation or secondary breast procedure
Adjuvant therapy
Reasons for applying tattoo-only technique
Figure 3. Postoperative photograph at 6 months of a 53-year-old patient who underwent tattoo-only nippleareola complex reconstruction. This patient had a history of skin-sparing mastectomy for left breast cancer followed by immediate reconstruction with a silicone implant. She also had a history of breast-conserving surgery for right breast cancer and refused to undergo an additional operation.
Figure 4. Photographs of nipples reconstructed using three different techniques: (A) C-R flap and tattooing, (B) nipple sharing and tattooing, and (C) tattoo-only techniques.
Table 1. Patient details 14
4
Immediate
7
Immediate
4
1
8
0
8
0
3
2
0
3
Pedicled LD
-
Implant One-stage nipple Subtotal thyroidectomy (Thyroid cancer) sharing Two-stage C-R flap and and tattooing tattooing Immediate Implant - (n = 31) (n = 44) Satisfaction score Immediate Pedicled LD - 5.8 ± 1.5 7.4 ± 1.2 (mean ± SD) Immediate Pedicled LD One-stage nipple sharing Two-stage C-R flap and and tattooing tattooing Immediate Pedicled LD Revision (breast infection) (n = 44) (n = 31) Total thyroidectomy (Thyoid cancer) Immediate Pedicled Satisfaction score TRAM 7.4 ± 1.2 Secondary free fat 5.8injection ± 1.5 (mean ± SD) Immediate Implant One-stage nipple sharing Two-stage C-R flap and and tattooing tattooing (n = 44) Immediate Implant - (n = 31) Satisfaction score 7.4 ± 1.2 Immediate Pedicled LD - 5.8 ± 1.5 (mean ± SD) One-stage nipple sharing(nipple Two-stage and Immediate Pedicled TRAM Revision necrosisC-R afterflap NSM) and tattooing tattooing Breast conserving surgery (n = 44) (n = 31) Immediate Implant (contralateral breast cancer) Satisfaction score 7.4 ± 1.2 5.8 ± 1.5
CTx Tattoo-only technique (n =CTx 20) 8.1 ± -1.2 RTx Tattoo-only technique (n = 20) CTx, RTx 8.1 ± 1.2 CTx Tattoo-only technique (n = 20) 8.1 ± -1.2 RTx Tattoo-only technique (n = 20) CTx, RTx 8.1 ± 1.2
9
Immediate
Implant
-
CTx, RTx
4
Two-stage
Expander to Implant
-
CTx, RTx
0 9 6 0 0
Two-stage Delayed Delayed Delayed Delayed
Expander to Implant Free TRAM Pedicled TRAM Pedicled TRAM Free TRAM
Refuse additional operation History of adverse effect (CTx) Refuse additional operation Thin skin P-value Refuse additional operation History of adverse effect (CTx) Refuse additional operation < 0.05 Irradiated breast Heavy smoker P-value Refuse additional operation Refuse additional operation Irradiated < 0.05 breast Refuse additional operation Thin skin P-value Scar across the breast mound Thin and tight skin < 0.05 Refuse additional operation Refuse additional operation Irradiated breast P-value Refuse additional operation Irradiated breast < 0.05 Thin and tight skin Irradiated breast Smoker Thin and tight skin Irradiated breast Thin and tight skin Refuse additional operation Refuse additional operation Refuse additional operation Refuse additional operation
Prior CTx Prior CTx, RTx Prior CTx Revision (infection on contralateral breast after 8 Delayed Free TRAM Refuse additional operation reduction mammaplasty) simus dorsi; TRAM, transverse rectus abdominis myocutaneous; CTx, chemotherapy; RTx, radiotherapy; NSM, nipple-sparing mastectomy
Table 2. Patient satisfaction score assessed by a 10-point-scale questionnaire
15
(mean ± SD)
Satisfaction score (mean ± SD)
One-stage nipple sharing and tattooing (n = 44)
Two-stage C-R flap and tattooing (n = 31)
Tattoo-only technique (n = 20)
P-value
7.4 ± 1.2
5.8 ± 1.5
8.1 ± 1.2
< 0.05
16