Long-term predicatable nipple projection following reconstruction

The creation of the nipple-areola complex is often the final step in the su rgical treatment of breast cancer patients, and it consequently has importa nt symbolic and aesthetic implications. Patient expectations and the need f or symmetry make nipple projection a crucial aesthetic determinant of nippl e reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fa t flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 4 9 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month posto perative care regimen was observed in all patients. Nipple projection was a ssessed by the same observer at each follow-up examination. The average len gth of follow-up was 730 days (745 for TRAM reconstructions and 713 for imp lants). Consistently, an average of 41 percent of the intraoperative projec tion remained intact in both groups at final evaluation (SD 12 percent). Th e total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 t o 9.0 cm, and in a linear correlation, resulted in intraoperative projectio n of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 c m, respectively. Based on the linear relationship, every 1-cm increase in f lap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was n o difference between TRAM and implant nipple reconstruction in predicting p ostoperative nipple projection. Intraoperative planning and execution are c ritical to achieve predictable nipple shape, size, and projection. The dime nsions of the star dermal fat flap can be strategically modified to allow t he surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM. and implant patients at 2 years.