Secondary nipple reconstruction using local flaps and AlloDerm

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Over the years, a variety of techniques to reconstruct the nipple following mastectomy and reconstruction have been described. The most commonly used techniques involve the use of local flaps that include the star, bell, skate, double-opposing tab, and C-V.1–3 All of these methods require a series of incisions on the breast mound, creation of local flaps with random blood supply, and rearrangement of these flaps to reconstruct the nipple. Although the initial projection is excellent, all will flatten to some degree over time. Shestak et al. have compared the skate, star, and bell flaps and demonstrated flattening by 30 to 75 percent within 2 years. Losken et al. have analyzed long-term nipple projection using the C-V flap and demonstrated an average projection of 3.77 mm with a patient satisfaction of 42 percent at an average follow-up of 5.3 years. Kroll et al. have compared the double-opposing tab and star flaps and found that the mean 2-year projection was 2.42 mm and 1.97 mm, respectively. In a survey assessing patient satisfaction following nipple reconstruction, Jabor et al. have demonstrated that excessive flattening of the nipple was the principal area of dissatisfaction in over 50 percent of the women questioned.

To overcome the tendency of reconstructed nipples to flatten, a variety of materials have been used to augment nipple projection that includes subcutaneous fat, bone, cartilage, and silicone. These materials have been used for primary and secondary nipple reconstruction and sometimes result in improved long-term projection; however, a disadvantage of these methods is that they rely on foreign material or autologous material harvested from remote areas of the body. This can occasionally result in donor-site morbidity such as scars, pain, and distortion.

AlloDerm (LifeCell Corporation, Branchburg, N.J.) is an acellular dermal graft that has been demonstrated to revascularize and become incorporated into recipient tissues with minimal morbidity. It has been successfully used in a variety of clinical and experimental settings; however, its use to increase projection of the nipple following reconstruction has not been previously described. The purpose of this study was to review my initial experience and outcome with AlloDerm for secondary and tertiary nipple reconstruction.

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Maurice Nahabedian

Plastic Surgeon, National center for plastic surgery

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