- Email: [email protected]
The use of custom-made external nipple-areolar prostheses following breast cancer reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, e103ee105
CORRESPONDENCE AND COMMUNICATION The use of custom-made external nipple-areolar prostheses following breast cancer reconstruction* Introduction Restoration of the nipple-areolar complex (NAC) usually represents the completion of breast reconstruction and helps restore the patient’s body image.1 The goals of any technique to recreate a nipple-areolar complex are to achieve symmetry in appearance and position. Many surgical techniques exist2,3 and achieve these goals to varying degrees but there is little in the literature relating to the use of custom-made external “stick-on” silicone nipple-areolar prostheses. These have been in use since the 1970s but were initially only available commercially as “offthe-shelf” items. There was little scope to modify these to cater for individual variations in anatomical detail and patient satisfaction was low. As techniques and materials were developed around the 1980s to create custom-made prostheses that were much more realistic, interest in their use began again.4,5 However, the service and expertise required is still not universally available in all breast reconstruction units. The Royal Derby Hospital has run a custom-made prosthetic nipple-areolar service since 1997, provided by 2 maxillofacial laboratory prosthetists. The prostheses are made from silicone, using the contralateral nipple as a template. The patient attends for 2 outpatient visits that last approximately 1 hour in total. Vaseline or a weak medical adhesive is used for attachment and the patient is advised to remove the prosthesis at least daily for hygiene reasons. The aim of this study is to quantify levels of patient satisfaction with the use of these following breast cancer reconstruction. * This work was presented to the British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 1e3 July 2009 as a poster.
Patients and methods Manufacture of a prosthetic NAC The prostheses are made from silicone, using the contralateral nipple as a template. At the first appointment, photographs are taken and areolar shade is matched using colour swatches. Negative impressions using Crystacal R plaster (British Gypsum) are taken from both the contralateral nipple and the ipsilateral breast mound. A positive wax mould of the nipple is sealed to a positive plaster mould of the mound and a full plaster negative impression taken of this. Once cured, this is split into two halves, the wax boiled away and the chosen coloured silicone positioned into the moulds. The two halves are then closed and cured for just over 1 hour at 110 C. The resultant prosthesis is then trimmed to size. Figure 1, taken from our study, demonstrates the final cosmetic result that can be achieved with an external prosthesis.
Study We conducted a retrospective postal survey of all breast cancer reconstruction patients who had been referred to the prosthetic nipple-areolar service between April 2002 and April 2007. A standard questionnaire was posted to all
Figure 1 Use of a nipple-areolar prosthesis on the reconstructed right breast.
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.12.016
e104 Table 1 (IQR)
Correspondence and communication Aggregated responses expressed as percentage scoring favourably (4 or more), median score and interquartile range
Question
% scoring 4 or more
Median s core
IQR
Happy with appearance Good match for contralateral nipple Comfortable to wear Convenient to use Feel happier or more confident when wearing nipple Wear nipple most of the time Satisfaction with service provided
85% 81% 72% 61% 50%
5 5 5 5 4
5e6 5e6 4e6 3e6 2e5
34% 80%
2.5 6
1e5 5e6
eligible patients. Questions were answered on a Likert Scale, with responses rated from 1 (strongly disagree) to 6 (strongly agree). A score of 4 or more was taken to indicate a positive or favourable response. Results are expressed as median and interquartile range (IQR).
Results From a total of 92 eligible patients we got a response from 74 (80%) patients in total after 2 postings of the questionnaire. The mean age was 54.6 years (range 35.9e83.0). Aggregated responses are presented in Table 1. A total of 59% indicated that they were still using their prosthetic nipple after a period of up to 6 years. Regarding other (surgical) nipple-areolar reconstruction techniques, 28% of respondents had considered their use, 16% had discussed these options with their breast care team, but only 1 patient (1%) had pursued a surgical alternative following use of a prosthetic NAC. Additional positive comments received included the advantages of avoiding further surgery or scarring and the convenience and flexibility of use offered by the prostheses, often stating that they didn’t always feel the need to use the prostheses and would only do so when they were wearing very light clothing or during social occasions. A small number felt that the prosthetic NAC could provide additional volume to a reconstructed breast that was otherwise felt to be marginally on the small side. A small number expressed concerns regarding the glue becoming loose or runny resulting in movement or loss of the prosthesis, or regarding the degree and persistence of projection and erectness. The most common reason for requesting a replacement was due to loss, only a very limited minority reported that they had requested revision prostheses due to dissatisfaction with appearance. Only one person reported an adverse skin reaction to either the adhesive or silicone material.
Discussion The patients in this study reported high levels of satisfaction with the appearances and ease of use of the prostheses and the standards and convenience of the out patient service provided. Custom-made external prostheses can
provide an almost identical match to the contralateral nipple without the need for further surgery and scarring. Positional adjustments are readily made to maintain symmetry, which can be of particular importance in the early post-operative phase following breast reconstruction.5 The entire process of fitting and producing an external prosthetic NAC is performed on an outpatient basis and takes between 3e4 hours of time. This benefits the patient who is minimally inconvenienced and avoids any further surgical episodes and could offer cost savings for the NHS.
Conclusions Custom-made external NAC prostheses can offer a satisfactory and acceptable alternative to surgical nipple reconstruction for many people. They should be readily available and offered as an alternative to surgical reconstruction to all breast reconstruction patients where nipple loss has occurred.
Acknowledgements None.
Conflicts of interest None.
References 1. Wellisch DK, Schain WS, Noone RB, Little JW. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987;80:699e704. 2. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple areolar complex: an update. J Plast Reconstr Aesthet Surg 2006;59:40e53. 3. Jabor MA, Shayani P, Collins DR, Karas T, Cohen BE. Nippleareolar reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 2002;110:457e63. 4. Roberts AC, Coleman DJ, Sharpe DT. Custom-made nippleareolar prostheses in breast reconstruction. Br J Plast Surg 1988;41:586e7. 5. Ward CM. The uses of external nipple-areolar prostheses following reconstruction of a breast mound after mastectomy. Br J Plast Surg 1985;38:51e4.
Correspondence and communication D.J. Clarkson Department of Plastic & Reconstructive Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom Department of Plastic & Reconstructive Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom. E-mail address: [email protected]
e105 P.M. Smith Maxillofacial Laboratory, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom R.J. Thorpe Maxillofacial Laboratory, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom J.C. Daly Department of Plastic & Reconstructive Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom
CORRESPONDENCE AND COMMUNICATION The use of custom-made external nipple-areolar prostheses following breast cancer reconstruction* Introduction Restoration of the nipple-areolar complex (NAC) usually represents the completion of breast reconstruction and helps restore the patient’s body image.1 The goals of any technique to recreate a nipple-areolar complex are to achieve symmetry in appearance and position. Many surgical techniques exist2,3 and achieve these goals to varying degrees but there is little in the literature relating to the use of custom-made external “stick-on” silicone nipple-areolar prostheses. These have been in use since the 1970s but were initially only available commercially as “offthe-shelf” items. There was little scope to modify these to cater for individual variations in anatomical detail and patient satisfaction was low. As techniques and materials were developed around the 1980s to create custom-made prostheses that were much more realistic, interest in their use began again.4,5 However, the service and expertise required is still not universally available in all breast reconstruction units. The Royal Derby Hospital has run a custom-made prosthetic nipple-areolar service since 1997, provided by 2 maxillofacial laboratory prosthetists. The prostheses are made from silicone, using the contralateral nipple as a template. The patient attends for 2 outpatient visits that last approximately 1 hour in total. Vaseline or a weak medical adhesive is used for attachment and the patient is advised to remove the prosthesis at least daily for hygiene reasons. The aim of this study is to quantify levels of patient satisfaction with the use of these following breast cancer reconstruction. * This work was presented to the British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 1e3 July 2009 as a poster.
Patients and methods Manufacture of a prosthetic NAC The prostheses are made from silicone, using the contralateral nipple as a template. At the first appointment, photographs are taken and areolar shade is matched using colour swatches. Negative impressions using Crystacal R plaster (British Gypsum) are taken from both the contralateral nipple and the ipsilateral breast mound. A positive wax mould of the nipple is sealed to a positive plaster mould of the mound and a full plaster negative impression taken of this. Once cured, this is split into two halves, the wax boiled away and the chosen coloured silicone positioned into the moulds. The two halves are then closed and cured for just over 1 hour at 110 C. The resultant prosthesis is then trimmed to size. Figure 1, taken from our study, demonstrates the final cosmetic result that can be achieved with an external prosthesis.
Study We conducted a retrospective postal survey of all breast cancer reconstruction patients who had been referred to the prosthetic nipple-areolar service between April 2002 and April 2007. A standard questionnaire was posted to all
Figure 1 Use of a nipple-areolar prosthesis on the reconstructed right breast.
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.12.016
e104 Table 1 (IQR)
Correspondence and communication Aggregated responses expressed as percentage scoring favourably (4 or more), median score and interquartile range
Question
% scoring 4 or more
Median s core
IQR
Happy with appearance Good match for contralateral nipple Comfortable to wear Convenient to use Feel happier or more confident when wearing nipple Wear nipple most of the time Satisfaction with service provided
85% 81% 72% 61% 50%
5 5 5 5 4
5e6 5e6 4e6 3e6 2e5
34% 80%
2.5 6
1e5 5e6
eligible patients. Questions were answered on a Likert Scale, with responses rated from 1 (strongly disagree) to 6 (strongly agree). A score of 4 or more was taken to indicate a positive or favourable response. Results are expressed as median and interquartile range (IQR).
Results From a total of 92 eligible patients we got a response from 74 (80%) patients in total after 2 postings of the questionnaire. The mean age was 54.6 years (range 35.9e83.0). Aggregated responses are presented in Table 1. A total of 59% indicated that they were still using their prosthetic nipple after a period of up to 6 years. Regarding other (surgical) nipple-areolar reconstruction techniques, 28% of respondents had considered their use, 16% had discussed these options with their breast care team, but only 1 patient (1%) had pursued a surgical alternative following use of a prosthetic NAC. Additional positive comments received included the advantages of avoiding further surgery or scarring and the convenience and flexibility of use offered by the prostheses, often stating that they didn’t always feel the need to use the prostheses and would only do so when they were wearing very light clothing or during social occasions. A small number felt that the prosthetic NAC could provide additional volume to a reconstructed breast that was otherwise felt to be marginally on the small side. A small number expressed concerns regarding the glue becoming loose or runny resulting in movement or loss of the prosthesis, or regarding the degree and persistence of projection and erectness. The most common reason for requesting a replacement was due to loss, only a very limited minority reported that they had requested revision prostheses due to dissatisfaction with appearance. Only one person reported an adverse skin reaction to either the adhesive or silicone material.
Discussion The patients in this study reported high levels of satisfaction with the appearances and ease of use of the prostheses and the standards and convenience of the out patient service provided. Custom-made external prostheses can
provide an almost identical match to the contralateral nipple without the need for further surgery and scarring. Positional adjustments are readily made to maintain symmetry, which can be of particular importance in the early post-operative phase following breast reconstruction.5 The entire process of fitting and producing an external prosthetic NAC is performed on an outpatient basis and takes between 3e4 hours of time. This benefits the patient who is minimally inconvenienced and avoids any further surgical episodes and could offer cost savings for the NHS.
Conclusions Custom-made external NAC prostheses can offer a satisfactory and acceptable alternative to surgical nipple reconstruction for many people. They should be readily available and offered as an alternative to surgical reconstruction to all breast reconstruction patients where nipple loss has occurred.
Acknowledgements None.
Conflicts of interest None.
References 1. Wellisch DK, Schain WS, Noone RB, Little JW. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg 1987;80:699e704. 2. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple areolar complex: an update. J Plast Reconstr Aesthet Surg 2006;59:40e53. 3. Jabor MA, Shayani P, Collins DR, Karas T, Cohen BE. Nippleareolar reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 2002;110:457e63. 4. Roberts AC, Coleman DJ, Sharpe DT. Custom-made nippleareolar prostheses in breast reconstruction. Br J Plast Surg 1988;41:586e7. 5. Ward CM. The uses of external nipple-areolar prostheses following reconstruction of a breast mound after mastectomy. Br J Plast Surg 1985;38:51e4.
Correspondence and communication D.J. Clarkson Department of Plastic & Reconstructive Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom Department of Plastic & Reconstructive Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom. E-mail address: [email protected]
e105 P.M. Smith Maxillofacial Laboratory, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom R.J. Thorpe Maxillofacial Laboratory, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom J.C. Daly Department of Plastic & Reconstructive Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, United Kingdom