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PubMed2002

Intraepidermal cytokeratin 7 immunoreactive cells in the non-neoplastic nipple may represent interepithelial extension of lactiferous duct cells.

AIMS: The interpretation of cytokeratin 7 (CK7)-positive cells in the epidermis of the nipple has been controversial. These cells have been described in Paget's disease of the nipple, and they have also been cited as benign 'Toker' cells or as Merkel cells. Having observed CK7+ cells in histologically unremarkable nipple biopsies, we sought to assess the distribution of CK7+ cells in Paget's disease of the nipple and in histologically unremarkable nipple. METHODS AND RESULTS: Representative sections from 37 cases of Paget's disease of the nipple and 32 cases of histologically unremarkable nipple were obtained. The histologically unremarkable nipple sections were taken from prophylactic mastectomies (n=17) and from autopsies of patients who did not have breast cancer (n=15). CK7 immunostaining was performed on sections from formalin-fixed paraffin blocks. Sequential sections were immunostained with antibodies to low-molecular weight cytokeratin-CAM 5.2 and HER-2/neu. CK7+ cells were present in the epidermis around the opening of the lactiferous ducts in Paget's disease (95%) and in histologically unremarkable nipple (45%) cases. CK7+ cells diminished in number with increasing distance from the orifice of the lactiferous ducts. The lactiferous duct epithelium in Paget's disease and in histologically unremarkable nipple was CK7+ in all specimens when this element was present. CAM5.2 immunostaining had a similar but weaker pattern of reactivity. HER-2/neu reactivity was seen in 68% cases of Paget's disease and was negative in all cases of histologically unremarkable nipple. Tumour cells in two cases of Paget's disease were CK7-. In one of these, the underlying breast carcinoma was also CK7-, the only CK7- tumour in this series. In the other case, the normal lactiferous duct was CK7+ and no underlying carcinomatous tissue was available to study. CONCLUSIONS: The presence of CK7+ cells does not equate to Paget's disease of the nipple. Intraepidermal CK7+ cells in the non-neoplastic nipple can be a manifestation of interepithelial extension of benign lactiferous duct cells. The increased presence of CK7+ cells in Paget's disease probably results either from neoplastic transformation of native intraepithelial lactiferous duct cells or form direct extension/migration of neoplastic cells into the nipple. The distribution of CK7 immunoreactive cells in the nipple epidermis can be helpful in the diagnosis of Paget's disease of the nipple.

Biomarkers↗
PubMed2005

Correction of inverted nipple: an alternative method using continuous elastic outside distraction.

Inverted nipple, which is defined as a nipple located on a plane lower than the areola, presents both functional and cosmetic problems. It is a source of repeated irritation and inflammation and interferes with nursing. In addition, its abnormal appearance may cause psychologic distress. With consideration of its underlying pathophysiologic components and severity, a number of techniques have been introduced for correction of this anomaly. Most of these techniques involve extensive skin incision around the nipple that may jeopardize the blood and nerve supply to the nipple or create much scar tissue that is esthetically objectionable. For correcting the inverted nipple, the authors introduce an alternative, simple method using continuous elastic outside distraction. Compared with other methods using outside distraction, the authors used an adjustable elastic instrument made of steel wire, spring, and plastic syringe; continuous distraction of the inverted nipples; and sustaining 3 to 6 months. From August 2002 to December 2003, 14 patients (26 nipples) were treated. 12 patients had bilateral inverted nipples. Patient age at operation ranged from 14 to 40 years (mean age, 24 years). All nipples were congenital, and they had no previous operation. Six nipples were grade I, 9 nipples were grade II, and 11 nipples were grade III according to the classification of inverted nipple by Han and Hong. The mean follow-up period was 7.3 months (range, 3-12 months). Follow-up examinations revealed no evidence of recurrence of inversion. There was no complication associated with surgery, such as infection, hematoma, permanent sensory disturbance, or nipple necrosis. All patients were satisfied with their results. The authors conclude that their procedure is reliable, a simple, safe, and effective method for correction inverted nipple. But a long-term follow-up is needed. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

Adult↗
PubMed2002

Early experience with the artificial nipple.

The present study examined the newborn pup's responsiveness to artificial nipples that differed in length and width. In a series of experiments, pups were: exposed to a long (5.0 mm), thin (1.0 mm) nipple or a short (2.0 mm), fat (2.5 mm) nipple and their immediate behavioral responses including oral grasping were recorded and quantified (Experiment 1); preexposed to one artificial nipple and then reexposed to another artificial nipple to determine how early nipple experience affected subsequent responding to the artificial nipple (Experiment 2); videotaped to characterize details of oral grasping and to develop a technique for measuring depth of nipple entry into the pup's mouth (Experiment 3a); provided early nipple experience to see how depth of nipple entry into the pup's mouth changed when pups were reexposed to another artificial nipple (Experiment 3b); and exposed to an artificial nipple to determine how early nipple experience changed the pattern of oral grasping and ingestion of milk from a surrogate nipple (Experiment 4).

Analysis of Variance↗
PubMed1986

Afferent projections from the mammary glands to the spinal cord in the lactating rat--II. Electrophysiological responses of spinal neurons during stimulation of the nipples, including suckling.

In lactating rats, the milk ejection reflex is evoked and maintained by stimulation of the nipples by the suckling young. In order to understand the processing of the suckling stimulus within the spinal cord, urethane-anaesthetized lactating rats were prepared for electrophysiological recording from the thoraco-lumbar spinal cord during stimulation of the nipples. Single shocks to inguinal or abdominal nipples evoked a cord dorsum potential, consisting of an early (2.6 ms) afferent volley followed by a negative wave (100-200 microV; latency 5-7 ms, duration 5-10 ms). Evoked potentials were also recorded at various depths within the spinal cord, with a maximum amplitude (200-400 microV) at a depth of 400-800 microns, 400-800 microns lateral to the mid-line. At a given recording site, the response was maximal for one particular nipple but submaximal potentials could be evoked from adjacent nipples. Simultaneous stimulation of adjacent nipples caused summation of the response. Unit recordings were made from 35 spinal neurons. Upon electrical stimulation of the nipples, the cells responded with an early train of spikes (latency 5-15 ms), and in 6 cells, a later response (140-180 ms), with a higher stimulation threshold, was also observed. All cells examined showed convergence and summation from different nipples. Twenty out of 27 cells were also activated by stretching of the nipples, which evoked a rapidly adapting response; rhythmical stretching produced a more sustained increase in activity. The cells also responded to other natural stimuli such as touch and pressure or stroking the hair around the nipple and had large receptive fields. Six cells were tested with the suckling stimulus. There was a brisk increase in firing as the pup grasped the nipple and then intermittent (every 18-30 s) episodes of enhanced activity, which directly correlated with the suckling movements. These episodes continued for the duration of the suckling test and were enhanced when a second pup was placed on an adjacent nipple. Finally, from a few experiments when a stimulating electrode was placed within the contralateral antero-lateral funiculus at the level of C2-C3 for antidromic identification, it was seen that some of the cells activated from the nipples projected to higher levels. The short latency responses to nipple stimulation, including suckling, suggest that the suckling stimulus reaches the spinal cord ungated.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed2002

Nipple-areola reconstruction: satisfaction and clinical determinants.

After performing a chart review, the authors identified 120 patients who underwent breast cancer-related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple-areola reconstruction type, the interval between breast mound and nipple-areola reconstruction, the number of procedures needed to achieve nipple-areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple-areola reconstruction; what the patient disliked most about the nipple-areola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction.A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nipple-areola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S-flap (8 percent), a full-thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple-areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis. Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nipple-areola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple-areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple-areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple-areola reconstruction (p = 0.0001).

Breast Implants↗
PubMed2006

Nipple reduction using the modified top hat flap.

BACKGROUND: Large nipples, disproportionate to the small areola and breast size, are an ethnic characteristic frequently encountered among Asian female patients. Patients seek correction to improve cosmesis and alleviate psychological and physical discomfort. The authors present a new technique of nipple reduction and describe its potential advantages over other techniques. METHODS: Between March of 2003 and April of 2005, 34 nipple reductions were performed in 19 female patients (mean age, 40.5 +/- 5.6 years) using the modified top hat flap. The neonipple is designed to reduce the nipple diameter at the superior pole of the nipple while preserving the subdermal plexus. A crescent-shaped section of nipple skin below the proposed neonipple is excised, maintaining the integrity of the neonipple and the central nipple core. Two lateral wing flaps are elevated and trimmed to reduce both nipple height and diameter at the lateral walls of the nipple. The flaps of the neonipple are then sutured to the areola. RESULTS: Postoperative recovery was rapid and uneventful and no complications were encountered. The mean diameter of the hypertrophic nipple was 16.3 +/- 2.6 mm (range, 16 to 30 mm). The mean diameter of the neonipple was 7.9 +/- 1.7 mm (range, 5 to 11 mm), with an average reduction of 8.4 +/- 1.6 mm (range, 5 to 20 mm). At 17.2 +/- 2.9 months of follow-up, the neonipple had a natural appearance, with less projection and an inconspicuous scar. There was no statistically significant difference on monofilament sensation testing (p = 0.5829) between reduction nipple and areola in 11 nipples of seven patients. CONCLUSIONS: The modified top hat flap requires minimal preoperative planning, is easy to perform, and yields reproducible results. This technique decreases both the diameter and height of any size nipple and can be modified to meet patient preferences. Because the continuity of the neonipple with the subdermal arterial plexus is maintained and the majority of the parenchymal elements are preserved, nipple sensation and circulation remain largely unaffected.

Adult↗
PubMed2003

Correction of inverted nipple: an alternative method using two triangular areolar dermal flaps.

Inverted nipple, which is defined as a nipple located on a plane lower than the areola, presents both functional and cosmetic problems. It is a source of repeated irritation and inflammation, and interferes with nursing. In addition, its abnormal appearance may cause psychological distress. Inverted nipples are congenital or acquired, and are classified as the umbilicated and invaginated types or divided into 3 groups (grades 1, 2, and 3). With consideration of its underlying pathophysiologic components and severity, various surgical procedures have been proposed. For correcting the inverted nipple, the authors introduce an alternative, simple method using 2 triangular areolar dermal flaps. Compared with other methods using triangular areolar dermal flaps, each triangle is approximately 1 mm shorter than the diameter of the nipple, and the deepithelialized areolar dermal flaps are lodged at the slit in the bundle of the lactiferous ducts in the grade 2 inverted nipple. From August 2000 to December 2001, 11 patients (16 nipples) were treated. Five patients had bilateral inverted nipples. Patient age at operation ranged from 18 to 31 years (mean age, 27 years). All nipples were congenital and they had no previous operation. Thirteen nipples were grade 2 and 3 were grade 3 according to the classification of inverted nipple by Han and Hong. The mean follow-up period was 8.7 months (range, 3-12 months). Follow-up examinations revealed no evidence of recurrence of inversion. There was no complication associated with surgery, such as infection, hematoma, permanent sensory disturbance, or nipple necrosis. The resulting scars were minimal. All patients were satisfied with their results. The authors conclude that their procedure is reliable, preserves the lactiferous ducts in grade 2 inverted nipple, requires no special postoperative care, and leaves minimal scars and no recurrence of inversion. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

Adolescent↗
PubMed1992

Monoclonal antibodies specific for rat relaxin. VII. Passive immunization with monoclonal antibodies throughout the second half of pregnancy prevents development of normal mammary nipple morphology and function in rats.

We recently demonstrated that relaxin-dependent development of the mammary nipples during the second half of pregnancy is required for pup survival during lactation in the rat. The two related objectives of this investigation were to 1) characterize the effects of endogenous relaxin on the histological modifications that normally occur in the mammary nipples, and 2) test the hypothesis that the cause of lactational failure in relaxin-deficient rats is attributable to failure of the nipples to grow and develop during the second half of pregnancy. Endogenous relaxin was neutralized by daily iv injection of a highly purified monoclonal antibody specific for rat relaxin (MCA1) to intact rats from days 12-22 of pregnancy. Mammary nipples were collected on day 22 of pregnancy and routinely prepared for light microscopy. Tissue cross-sections (6 microns) obtained from the midpoint of mammary nipples were stained with either Gomori's trichrome stain (to visualize collagen) or orcein (to visualize elastin). Nipple size as well as histological characteristics of nipple cross sections were determined by morphometric analysis. MCA1-treated rats were significantly different from controls with the following parameters: shorter length of the nipples; smaller cross-sectional areas of the entire nipple, lactiferous duct lumen, and blood vessels; greater percentage of the analysis field composed of collagen; lower percentage of the analysis field composed of amorphous ground substance; and longer elastin fibers. To test the hypothesis that the cause of lactational failure in relaxin-deficient rats is attributable to the failure of nipples to grow and develop, MCA1 and control rats were cesarean sectioned between 2100-2400 h on day 22 of pregnancy, and lactation was examined using normal foster pups from intact donor females. Unlike pups fostered to controls, pups fostered to MCA1-treated dams failed to grasp the nipples, stimulate PRL release, or have milk in their abdomens. This study demonstrates that endogenous relaxin promotes not only growth, but also modifications of the histological characteristics of the nipple that are consistent with relaxin's effects on the cervix and mammary glands. Additionally, this study provides evidence that lactational failure in relaxin-deficient rats is attributable to the small size and different histology of the mammary nipples, which results in the inability of the pups to attach to the nipple, stimulate PRL release, and obtain milk from the dams.

Animals↗
PubMed2007

Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications.

BACKGROUND: The anatomy of the nipple has become clinically relevant. Diagnostic techniques access the breast through nipple ducts and surgeons offer nipple-sparing mastectomy. There is variation in the number of ducts reported and little is known about the spatial location of ducts, their size, and their relationship to orifices on the surface. METHODS: Nipple specimens were taken from 129 consecutive mastectomies. Each was sectioned coronally into 3 mm blocks and one section was prepared from each block. The number of ducts and cross-sectional areas of nipple and duct 'bundle' were recorded. Three nipples were sectioned at 50 mum intervals and digitally reconstructed in three dimensions. RESULTS: The median number of ducts was 23 (interquartile range 19-28). Reconstructions and summary data from 25 nipples show a central duct bundle narrowing to form a 'waist' as the ducts enter breast parenchyma. A three-dimensional reconstruction focusing on one nipple tip demonstrated 29 ducts arising from 15 orifices. Beneath the skin, most ducts are very narrow, gradually becoming larger deeper within the nipple. CONCLUSIONS: This work demonstrates that many ducts share a few common openings onto the surface of the nipple, explaining the observed discrepancy between number of ducts and of orifices. Neither duct diameter nor position predicts whether a duct system will terminate close to the nipple or pass deeper into the breast. These new insights into nipple anatomy will be of use in considering the reliability of a ductal approach to diagnosis and in planning nipple-sparing mastectomy.

Adult↗
PubMed2003

Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast.

If a patient's nipple-areola complex is available for grafting after mastectomy, it is the best material to use for nipple-areola reconstruction. The authors performed delayed autologous nipple-areola complex transfer to reconstructed breasts in 10 patients (mean age, 47 years; range, 40 to 53 years). The nipple-areola complex was cryopreserved with a programmed freezer after mastectomy. Histological examination of the tissue surrounding the nipple and areola eliminated the possibility of cancer invasion. At the time of transfer, the cryopreserved nipple-areola complex was thawed in 37 degrees C water and grafted on a projection made by a denuded dermal flap on the reconstructed breast. Each patient underwent immediate breast reconstruction using an innervated pedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The patients' postoperative courses were uneventful. The timing of transfer ranged from 3 months to 1 year (mean, 5.8 months) after breast reconstruction. Nipple projection was made by the "four" dermal flap in five cases, a round dermal flap in three cases, a double dermal flap in one case, and a denuded skate flap in one case. The follow-up period ranged from 5 to 36 months (mean, 21.8 months). All grafts were adapted. The final evaluation of nipple-areola complex adaptation was good in four cases, fair in four cases, and poor in two cases. Histological examination of the hematoxylin and eosin stains showed no remarkable destruction of the skin of the nipple and areola, and electron microscopic examination of the areola skin revealed no significant change. However, electron microscopic examination of the nipple skin showed serious damage to skin components, including elongation of the desmosome, widening of the intercellular space at the prickle cell and basal layers, and shrinking of prickle and basal cells. Although further development of the freezing process and cryopreservation technique is needed to prevent depigmentation of the nipple and areola, cryopreserved nipple-areola complex transfer to a reconstructed breast could be an alternative method of nipple-areola reconstruction.

Adult↗
PubMed2005

Visible male nipple shadows in chest radiographs.

OBJECTIVE: Annual company employee physical examinations are performed in Japan and include a chest X-ray. Among nodular shadows observed in the lower lung field, nipple shadow is a normal structure to be differentiated, and understanding its characteristics in chest X-rays aids in the interpretation of solitary nodular shadows. METHODOLOGY: Chest X-rays from male employees over 35 years of age at two different companies were analysed for anatomical location, morphology, and size of nipple shadows. If unilateral or bilateral solitary nodular shadows in the lower lung field coincided with the lead nipple marker, we defined it as 'definitive' nipple shadow. If the nodular shadow was observed to be stable for at least 2 years at the typical nipple position, we defined it as 'possible' nipple shadow without confirmation with nipple marking. RESULTS: Typical nipple position, from the analyses of definitive nipple shadows (n = 15), was between the ninth and tenth posterior ribs and within 60 mm from the inner margin of the rib. The nipple was oval or round and did not exceed 15 mm in size. Incidence of definitive and possible (n = 25) nipple shadows was estimated as 3.5% of examined males (n = 1150). Thoracic computed tomography scanning was conducted in four cases, of which three cases involved solitary nodular shadows that did not coincide with the nipple marker, and one was for a newly formed nodular lesion not detected in previous chest X-rays. CONCLUSION: Visible male nipple shadows are not rare and need to be differentiated among the solitary nodular shadows in the lower lung field.

Adult↗
PubMed1998

Histological and morphometrical studies on the rat nipple during the reproductive cycle.

Histological changes in the rat nipple during the reproductive cycle were observed. In virgin and the first half (days 5 and 10) of pregnancy, the nipple had a dull conical shape and the germinative layer of epidermis, thicker than that of the skin surrounding the nipple, deeply ingrew into the dermis in the basal region. From the second half (days 15 and 20) of pregnancy to the post-weaning period, the nipple appeared columnar in shape and many wrinkles were observed in the nipple wall especially during the lactating period. Collagen fibers longitudinally running in the nipple wall mainly comprised the dermis of the nipple and became loose during lactation. Small numbers of elastic fibers running parallel with smooth muscles were also observed in the nipple wall, and these increased in number and thickness from the second half of pregnancy, and most became frizzy structures during lactation. Around the lactiferous sinus, smooth muscle cells were arranged longitudinally but a few muscle cells were seen in a concentric layer, but during the lactating period the sinus was distended and many epithelial folds were observed. Morphometrical analysis indicated that the length of the nipple increased from the second half of pregnancy and reached the maximum on day 15 of lactation, approximately 3.7 times that in the virgin period. The outer diameter of the nipple and thickness of the nipple wall during lactation also reached approximately twice that in virgin. The size of the nipple decreased gradually after weaning. These observations suggest that the histological changes in the rat nipple during the reproductive cycle were mainly characterized by hyperplasia of the epidermis and hypertrophy of connective tissue in the dermis from the second half of pregnancy.

Animals↗
PubMed1995

Relaxin acts directly on rat mammary nipples to stimulate their growth.

Previously, we demonstrated that endogenous circulating relaxin promotes growth of the mammary nipples during the second half of pregnancy in the rat. The objective of this study was to determine whether relaxin acts directly on rat nipples to promote their growth. Initially, specific relaxin-binding cells were identified to assure that relaxin binds to the same cell types in the nipples of nonpregnant rats as those we previously described in pregnant rats. To examine relaxin-induced growth of the mammary nipples, 5 days after ovariectomy, 48 nonpregnant rats were assigned (12 rats/group) to 1 of the following 4 treatment groups: ovariectomized controls, estrogen treated, relaxin treated, and estrogen plus relaxin treated. Estrogen (0.05 micrograms 17 beta-estradiol) or estradiol vehicle (0.1 ml stripped corn oil) was administered sc on the dorsal side of the neck daily for the entire 10-day treatment period. Porcine relaxin (12.5 micrograms) or relaxin vehicle (0.05 ml 5% beeswax in corn oil) was administered sc at the base of the left abdominal nipple daily for the last 5 days of the 10-day treatment period. After hormone treatments, the lengths and wet weights of the left (relaxin-treated) and right (untreated) abdominal nipples were measured. There were three findings. First, the presence of specific relaxin binding in the epithelial cells of the lactiferous duct, smooth muscle cells, and skin of the nipples in nonpregnant rats was identical to the sites of specific relaxin binding in the nipples of pregnant rats. Second, relaxin-induced increases in nipple length and wet weight were mediated at least in part by the direct effects of relaxin in the nipple. Third, estrogen was not required for relaxin-induced increases in nipple length and wet weight. We conclude that relaxin stimulates the growth of rat mammary nipples at least in part through direct actions in the nipples, and that estrogen is not required for these actions.

Animals↗
PubMed1994

Imaging evaluation of artificial nipples during bottle feeding.

OBJECTIVES: To determine whether real-time ultrasonography can be used to directly visualize artificial nipples in vivo while an infant is sucking, to compare deformation differences of the artificial nipple with the human nipple during sucking, and to compare the suck mechanism used by the infant with four types of artificial nipples. DESIGN: Nonrandomized clinical study with a control group. SETTING: University-affiliated teaching hospital in Iowa City, Iowa. PARTICIPANTS: A volunteer sample of 35 healthy infants 6 to 12 weeks of age. INTERVENTION: None. MEASUREMENTS/MAIN RESULTS: Images produced by real-time ultrasound of infants during sucking using artificial nipples were measured to determine the percentage lengthening, the percentage lateral compression, and the percentage flattening of nipples. These results were compared with data obtained from studies using breast-fed infants. None of the artificial nipples lengthened like the human nipple. One artificial nipple was significantly more compressible than the human nipple and the remaining three artificial nipples. CONCLUSION: Real-time ultrasonography can be used to visualize artificial nipples in vivo during sucking.

Bottle Feeding↗
PubMed1999

Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction.

This study was performed to determine the degree of shrinkage over time in nipple projection after reconstruction. Nipple-areolar reconstruction was performed using the modified Anton-Hartrampf technique, and pigmentation was achieved with tattooing. This study looked at 28 consecutive patients with nipple reconstruction performed at The Milton S. Hershey Medical Center of the Penn State Geisinger Health Systems between September 1989 and November 1993. Two patients were lost to follow-up and 3 patients died of breast cancer. Thus, 23 patients and a total of 32 nipples were investigated. Initial measurements of nipple projection were taken 2 weeks postoperatively. Patients were followed an average of 38.7 months (range, 11-66 months). Ten patients (18 nipples) had tissue expansion and implantation for breast mound reconstruction. Thirteen patients (14 nipples) had autologous breast mound reconstruction. The mean decrease in projection of the tissue expansion and implantation group was 76.7+/-9.7%. The mean decrease in projection of the autologous reconstruction group was 64.3+/-12.1%. The mean decrease in projection for the entire group was 71.3+/-21.9%. Comparison between the two groups using a two-sample t-test showed p = 0.0047. The authors concluded that there is a significant reduction in nipple projection over time using the modified Anton-Hartrampf technique regardless of the type of breast mound reconstruction. In addition, their results also indicated that nipple projection on the breast mound reconstructed with an autologous musculocutaneous flap technique achieved a better long-term outcome. This study is potentially helpful in planning the initial size of the reconstructed nipple papule to match the opposite normal nipple. Additional studies need to be performed on other types of nipple-areolar reconstruction.

Breast Implants↗
PubMed2001

Maximizing breast projection after free-nipple-graft reduction mammaplasty.

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.

Adult↗
PubMed2002

Assessment of long-term nipple projection: a comparison of three techniques.

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.

Female↗
PubMed2006

Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction.

BACKGROUND: Creation of the nipple-areola complex is the final step in surgical restoration of the breast. Often considered as a secondary complement to breast reconstruction, nipple-areola reconstruction is usually done after an interval of several months and makes use of composite graft techniques involving the opposite nipple or local flaps. METHODS: Because the position of the nipple-areola complex is defined from the outset in skin-sparing mastectomy and because of the disappointing results obtained by classic nipple reconstruction techniques, the authors propose immediate nipple reconstruction using the skin paddle of the latissimus dorsi flap. Once the flap has been raised and placed in the skin-sparing mastectomy site, its paddle is folded back onto itself to form a cone. Two dermal-fat flaps are lifted at the top of the cone and sutured together to form the new nipple. RESULTS: Thirty patients (mean age, 49 years; range, 43 to 60 years) underwent immediate nipple reconstruction between May of 1999 and December of 2001. A retrospective study of the 30 cases was conducted with a mean follow-up of 16.5 months (range, 2 to 31 months). Mean residual projection was 7.8 mm after 1 year in 20 patients and 6.8 mm after 2 years in eight patients. Patient satisfaction with nipple projection was studied by means of a questionnaire. Seventy percent of patients considered the result very good, 23.3 percent considered it good, 6.6 percent considered it medium, and none considered it poor. CONCLUSIONS: On a psychological level, immediate nipple reconstruction seems to help assimilation of the reconstructed breast in the body image and leads to considerable patient satisfaction. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction. From the patient's viewpoint, the nipple appears to be an essential component of breast reconstruction.

Adult↗