Ideas and Innovations

Secondary Nipple Reconstruction Using LocalFlaps and AlloDermMaurice Y. Nahabedian, M.D.Baltimore, Md.

Over the years, a variety of techniques toreconstruct the nipple following mastectomyand reconstruction have been described. Themost commonly used techniques involve theuse of local flaps that include the star, bell,skate, double-opposing tab, and C-V.1–3 All ofthese methods require a series of incisions onthe breast mound, creation of local flaps withrandom blood supply, and rearrangement ofthese flaps to reconstruct the nipple. Althoughthe initial projection is excellent, all will flattento some degree over time. Shestak et al. havecompared the skate, star, and bell flaps anddemonstrated flattening by 30 to 75 percentwithin 2 years.1 Losken et al. have analyzedlong-term nipple projection using the C-V flapand demonstrated an average projection of3.77 mm with a patient satisfaction of 42 per-cent at an average follow-up of 5.3 years.2 Krollet al. have compared the double-opposing taband star flaps and found that the mean 2-yearprojection was 2.42 mm and 1.97 mm, respec-tively.3 In a survey assessing patient satisfactionfollowing nipple reconstruction, Jabor et al.have demonstrated that excessive flattening ofthe nipple was the principal area of dissatisfac-tion in over 50 percent of the womenquestioned.4

To overcome the tendency of reconstructednipples to flatten, a variety of materials havebeen used to augment nipple projection thatincludes subcutaneous fat, bone, cartilage, andsilicone.5–8 These materials have been used forprimary and secondary nipple reconstructionand sometimes result in improved long-termprojection; however, a disadvantage of thesemethods is that they rely on foreign material or

autologous material harvested from remote ar-eas of the body. This can occasionally result indonor-site morbidity such as scars, pain, anddistortion.

AlloDerm (LifeCell Corporation, Branch-burg, N.J.) is an acellular dermal graft that hasbeen demonstrated to revascularize and be-come incorporated into recipient tissues withminimal morbidity.9,10 It has been successfullyused in a variety of clinical and experimentalsettings9,11,12; however, its use to increase pro-jection of the nipple following reconstructionhas not been previously described. The pur-pose of this study was to review my initial ex-perience and outcome with AlloDerm for sec-ondary and tertiary nipple reconstruction.

PATIENTS AND METHODS

Over a 6-year period, the author has per-formed 383 primary nipple reconstructions. Ofthese, 35 nipples (9.1 percent) required sec-ondary reconstruction because of excessiveflattening. AlloDerm was used in eight of thesenipples (four women) to increase projection.The secondary nipple reconstruction was bilat-eral in three women, unilateral in one woman,and repeated in one breast, totaling eight nip-ples. This cohort of patients was not comparedwith a control group. The type of breast recon-struction was an implant in four breasts andautologous tissue in three breasts. Nipple pro-jection was assessed and measured in the oper-ating room and the clinic. The mean age ofthese four women was 40.5 years (range, 25 to54 years). Minimum follow-up was 6 monthsafter the final nipple reconstruction.

From the Division of Plastic and Reconstructive Surgery, The Johns Hopkins University. Received for publication June 29, 2004; revisedSeptember 14, 2004.

DOI: 10.1097/01.PRS.0000164490.99581.F9

2056

Technique of Nipple Reconstruction Using AlloDerm

The use of AlloDerm for nipple recon-struction is possible using a variety of localflaps. The method described reflects the au-thor’s preferred technique for nipple recon-struction. The local flaps used for this studyinclude the elongated C flap and the C-V flap(Fig. 1, above and center). The elongated Cflap was usually used for primary nipple re-construction and the C-V flap was usuallyused for secondary nipple reconstruction.The dimensions of the elongated C flap are 3to 4 cm in width and 1 to 1.5 cm in length.The base of the flap is usually 1 to 1.5 cm inlength to allow for adequate blood supply.Projection of the nipple is usually 9 to 10 mmat completion. Advantages of the elongatedC flap include orientation along a scar, ori-entation in any direction, and ease of eleva-tion. The reason for use of the C-V flap forsecondary nipple reconstruction was that theV segment included the residual nipple andscar from the prior reconstruction.

The technical aspects of the secondary nip-ple reconstruction using AlloDerm are de-scribed. The operation is usually performedunder local anesthesia using lidocaine with-out epinephrine. The C-V flap is outlined,incised, and elevated in the subcutaneousplane, incorporating some fat (Fig. 1, below).The donor site created by the right and leftwings of the C flap is reapproximated usingan absorbable suture. A trifurcation suture isthen used to suture the right and left dermalapices of the C flap to the dermal midline ofthe donor site created by elevation of the Vflap. A 1 � 2-cm precut portion of AlloDermwas obtained and prepared according to themanufacturer’s instructions (Fig. 2, above). Asmall portion of the AlloDerm measuringbetween 4 and 6 mm in each direction wasfolded in half and sutured using an absorb-able suture. The dimension of the AlloDermto be inserted was usually 2 � 6 mm andbased on the dimensions of the C-V flap (Fig.2, below). The AlloDerm was inserted into thepocket created by the approximated lateralapices of the C flap and oriented vertically toserve as a strut to maintain projection (Fig. 3,above). The V flap was then draped over theAlloDerm and the skin incisions were closedusing a permanent monofilament suture(Fig. 3, center). Using this technique, nipple

projection on immediate completion rangedfrom 7 to 8 mm (Fig. 3, below). Figure 4demonstrates a secondary nipple reconstruc-tion using AlloDerm at 1-year follow-up.

FIG. 1. (Above) A secondary nipple reconstruction using aC-V flap is outlined on a breast following excessive flatteningof the nipple. (Center) A primary nipple reconstruction usingthe elongated C flap is outlined. (Below) The elevated C-V flapis depicted. Note the bleeding from the distal margins, dem-onstrating good blood supply.

Vol. 115, No. 7 / NIPPLE RECONSTRUCTION 2057

RESULTS

The pre-AlloDerm and post-AlloDerm pro-jection of the nipple and the time for finalprojection height of the nipple are provided inTable I. In no breast was preoperative or post-operative radiation therapy necessary. In allnipples, the wound healing was uneventfulwithout skin flap necrosis or local infection. Inthe breast that required a secondary and ter-tiary nipple reconstruction using AlloDerm, atransverse rectus abdominis musculocutaneousflap had been performed.

In all seven breasts in which secondary nip-ple reconstruction using AlloDerm was per-formed, the preoperative nipple projectionranged from 0 to 2 mm. Secondary nipplereconstruction was completed in all breasts ofwhich AlloDerm was used in five and not in two(Table I). Of the five nipples in which Allo-Derm was used, four (80 percent) demon-strated acceptable projection (4 to 5 mm) andone did not. In this breast, a tertiary nipplereconstruction using AlloDerm for a second

time resulted in acceptable projection (4 mm).Operative findings at the time of this tertiarynipple reconstruction demonstrated some re-sidual scar tissue that may have been from theAlloDerm. No histologic analysis was per-formed. Of the two secondary nipple recon-

FIG. 2. (Above) A 1 � 2-cm prepackaged portion of Allo-Derm. (Below) The AlloDerm is cut, folded, and suturedbased on the dimensions of the local flaps.

FIG. 3. (Above) The AlloDerm is inserted vertically be-tween the local flaps. (Center) The AlloDerm is completelycovered by the C and V flaps. (Below) The immediate pro-jection of the nipple is demonstrated.

2058 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2005

structions in which AlloDerm was not used,excessive flattening was observed (2 mm). Ter-tiary nipple reconstruction using AlloDerm re-sulted in a final projection of 4 and 5 mm,respectively. The success of AlloDerm did notappear to be related to the type of breast re-construction (autologous tissue or implant).

DISCUSSION

One of the principal goals of breast recon-struction is to create a three-dimensional nip-ple from a two-dimensional surface. To accom-plish this goal, it is important to realize thatthere is a natural tendency for the recon-structed nipple to flatten and for the skin sur-face to return to its normal contour. The causeof nipple flattening is multifactorial and in-cludes inadequate subcutaneous fat, internalpressure, external pressure, poor flap design,delayed healing, and tissue memory. The nat-ural elements required for a nipple recon-structed with local flaps include epidermis, der-mis, and subcutaneous fat. The ratio of theseelements is variable and dependent on thequality of skin, type of breast reconstruction,and surgical technique. In some women thathave had breast reconstruction with implants,the skin is very thin and contains minimal sub-cutaneous fat. In addition, there is internalpressure that is applied to the surface of thebreast that tends to stretch and flatten thesurface over time. This may predispose to pre-

FIG. 4. A lateral view of a breast demonstrating good nip-ple projection at 1-year follow-up. AlloDerm was used duringthe secondary reconstruction.

TA

BL

EI

Res

ult

sof

Pri

mar

y,Se

con

dar

y,an

dT

erti

ary

Nip

ple

Rec

onst

ruct

ion

Pati

ent

Age

(yr)

Proc

edur

e

Prim

ary

Nip

ple

Rec

onst

ruct

ion

Seco

nda

ryN

ippl

eR

econ

stru

ctio

nT

erti

ary

Nip

ple

Rec

onst

ruct

ion

Init

ial

Proj

ecti

on(m

m)

Fin

alPr

ojec

tion

(mm

)T

ime

Init

ial

Proj

ecti

on(m

m)

Fin

alPr

ojec

tion

(mm

)T

ime

Init

ial

Proj

ecti

on(m

m)

Fin

alPr

ojec

tion

(mm

)T

ime

154

Rig

ht

TR

AM

101

4m

o8

26

mo

84

(Allo

Der

m)

6m

oL

eft

TR

AM

101

4m

o8

26

mo

85

(Allo

Der

m)

6m

o2

25L

eft

impl

ant

101

3m

o9

4(A

lloD

erm

)1

yrN

AN

AN

AR

igh

tim

plan

t10

14

mo

81

(Allo

Der

m)

9m

o8

4(A

lloD

erm

)8

mo

344

Lef

tT

RA

M10

24

mo

94

(Allo

Der

m)

9m

oN

AN

AN

AR

igh

tim

plan

t10

15

yr8

5(A

lloD

erm

)6

mo

NA

NA

NA

439

Lef

tim

plan

t10

15

yr8

4(A

lloD

erm

)6

mo

NA

NA

NA

NA

,n

otap

plic

able

;T

RA

M,

tran

sver

sere

ctu

sm

yocu

tan

eou

s.

Vol. 115, No. 7 / NIPPLE RECONSTRUCTION 2059

mature or excessive flattening of the recon-structed nipple. Wearing a bra may result inexternal pressure on the surface of the breastand may predispose to nipple flattening. Otherfactors such as local infection, previous radia-tion, and poor flap design can compromise thecirculation within the local flaps, resulting indelayed healing and eventual flattening. Thus,the principal challenge with nipple reconstruc-tion is to reconstruct a nipple that will be ableto overcome these local obstacles and naturaltendencies.

Methods to improve nipple projection andminimize flattening include secondary nipplereconstruction and/or use of remote material.Secondary nipple reconstruction without theuse of remote material has included the use ofa purse-string suture, local flaps, and skingrafts.13,14 Remote materials that have beenused to augment nipple projection include au-tologous homografts such as cartilage6,8 andfat,5 biological heterografts such as artificialbone7 and tissue-engineered cartilage,15 andsynthetic materials such as polyurethanecoated silicone.16 These techniques have allbeen used with variable success and some havebeen limited by donor-site morbidity, availabil-ity, tissue reactivity, and cost.

AlloDerm was used in this series of womenfor secondary nipple reconstruction primar-ily based on our current understanding of itsphysiology and that it was readily available. Ithas been used in a variety of clinical settingsthat have included abdominal wall recon-struction,11,12 urogynecologic procedures17,18

and, most recently, breast reconstruction.19,20

This limited experience has demonstratedthat AlloDerm can be successfully used toaugment nipple projection in the secondaryand tertiary settings. Although histologicanalysis was not performed in this study, itappears that the AlloDerm was well toleratedand incorporated into the normal host tis-sue, resulting in improved nipple projection.Although shrinkage of the nipple did occur,ranging from 38 to 50 percent, the final pro-jection observed at 6 months was greaterthan that of the historical controls (4 to 5mm versus 1.97 to 3.77 mm). These resultscan be partially attributed to the fact thatthere was some residual tissue (scar and skin)from the primary nipple reconstruction thatwas incorporated into the secondary nipplereconstruction. However, it is the author’s

belief that the AlloDerm did contribute tothe stability and longevity of the secondarynipple reconstructions. Further prospectivestudies using AlloDerm for primary and sec-ondary nipple reconstruction are warranted.

SUMMARY

Secondary nipple reconstruction using Allo-Derm results in improved nipple projection.This was demonstrated in seven of eight nipplereconstructions (88 percent). In the only nip-ple that flattened, a tertiary reconstructionagain using AlloDerm resulted in good projec-tion. This limited experience has demon-strated that AlloDerm is simple to use, welltolerated, and has the potential for improvedlong-term nipple projection. Further studiesare warranted.

Maurice Y. Nahabedian, M.D.Georgetown University Hospital3800 Reservoir Road, N.W.Washington, D.C. 20007moandanissa@aol.com

REFERENCES

1. Shestak, K. C., Gabriel, A., Landecker, A., Peters, S.,Shestak, A., and Kim, J. Assessment of long-term nip-ple projection: A comparison of three techniques.Plast. Reconstr. Surg. 110: 780, 2002.

2. Kroll, S. S., Reece, G. P., Miller, M. J., et al. Comparison ofnipple projection with the modified double apposingtab and star flaps. Plast. Reconstr. Surg. 99: 1602, 1997.

3. Losken, A., Mackay, G. J., and Bostwick, J. Nipplereconstruction using the C-V flap technique: A long-term evaluation. Plast. Reconstr. Surg. 108: 361, 2001.

4. Jabor, M. A., Shayani, P., Collins, D. R., Karas, T., andCohen, B. E. Nipple-areolar reconstruction: Satisfac-tion and clinical determinants. Plast. Reconstr. Surg.110: 457, 2002.

5. Bernard, R. W., and Beran, S. J. Autologous fat graft innipple reconstruction. Plast. Reconstr. Surg. 112: 964,2003.

6. Guerra, A. B., Khoobehi, K., Metzinger, S. E., andAllen, R. J. New technique for nipple areola recon-struction: Arrow flap and rib cartilage graft for longlasting nipple reconstruction. Ann. Plast. Surg. 50:31, 2003.

7. Yanaga, H. Nipple-areola reconstruction with a dermal-fat flap: Technical improvement from rolled auricularcartilage to artificial bone. Plast. Reconstr. Surg. 112:1863, 2003.

8. Tanabe, H. Y., Ti, Y., Kiyokawa, W., and Yamauchi, T.Nipple-areola reconstruction with a dermal-fat flapand rolled auricular cartilage. Plast. Reconstr. Surg. 100:431, 1997.

9. Menon, N. G., Rodriguez, E. D., Byrnes, C. K., Girotto,J. A., Goldberg, N. H., and Silverman, R. P. Revas-

2060 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2005

cularization of human acellular dermis in full-thick-ness abdominal wall reconstruction in the rabbitmodel. Ann. Plast. Surg. 50: 523, 2003.

10. Eppley, B. L. Revascularization of acellular human der-mis (AlloDerm) in subcutaneous implantation. Aes-thetic Surg. J. 20: 291, 2000.

11. Buinewicz, B., and Rosen, B. Acellular cadaveric dermis(AlloDerm): A new alternative for abdominal herniarepair. Ann. Plast. Surg. 52: 188, 2004.

12. Silverman, R. P., Singh, N. K., Li, E. N., et al. Restoringabdominal wall integrity in contaminated tissue defi-cient wounds using autologous fascia grafts. Plast. Re-constr. Surg. 113: 673, 2004.

13. Peled, I. J. Purse string suture for nipple projection.Plast. Reconstr. Surg. 103: 1480, 1999.

14. Vecchione, T. R. Reconstruction and/or salvage of nippleprojection. Plast. Reconstr. Surg. 78: 679, 1986.

15. Cao, Y. L., Lach, E., Kim, T. H., Rodriguez, A., Arevalo,C., and Vacanti, C. Tissue engineered nipple recon-struction. Plast. Reconstr. Surg. 102: 2239, 1997.

16. Hallock, G. G. Polyurethane nipple prosthesis. Ann.Plast. Surg. 24: 80, 1990.

17. Lemer, M. L., Chaikin, D. C., and Blaivas, J. G. Tissuestrength analysis of autologous and cadaveric allografts forthe pubovaginal sling. Neurourol. Urodyn. 18: 497, 1999.

18. Choe, J. M., Kothandapani, R., James, L., and Bowling, D.Autologous, cadaveric, and synthetic materials used insling surgery: Comparative biomechanical analysis.Urology 58: 482, 2001.

19. Baxter, R. A. Intracapsular allogenic dermal grafts forbreast implant-related problems. Plast. Reconstr. Surg.112: 1692, 2003.

20. Duncan, D. I. Correction of implant rippling usingallograft dermis. Aesthetic Surg. J. 21: 81, 2001.

Vol. 115, No. 7 / NIPPLE RECONSTRUCTION 2061