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A Novel Technique for Single-stage Reconstruction of Nipple-Areola Complex following Central Lumpectomy

Summary Several oncoplastic techniques have been proposed for subareolar breast cancer, some of which may require contralateral operation for symmetry, or more than one operation for delayed reconstruction of the nipple-areola complex (NAC). We herein developed a simple and effective oncoplastic approach following central quadrantectomy, aiming to achieve the following: (1) preservation of breast shape and contour for patients who are not accepting of a notably smaller breast or bilateral operation; (2) single procedure with advantages of single anesthetic and the ability to reconstruct a breast that has not yet been affected by radiation; (3) no autologous grafts with disadvantage of an extra donor site; (4) creation of natural neo-NAC with only incision within the region of the areola complex; and (5) maintaining long-term nipple projection. In this technique, the medial and lateral peri-areolar flap was advanced and rotated to restore partial neo-NAC, and to fill the defect after central tumor and NAC resection. The whole neo-NAC margin was created using the “round block” technique. Additionally, the nipple reconstruction was performed at the mitten of the neo-areola area using the C-V nipple flaps with an internal strut of rolled dermal grafts harvested from excised skin during the round block procedures. Lastly, a purse-string suture is placed in the outer skin margin for control of areola diameter and project. Six patients with central tumors of the breast were treated in this easily achieved approach. Patient satisfaction was noted as high, and the cosmetic results were evaluated as good to excellent.


INTRODUCTION
Simple closure of defects after central tumor and nipple-areola complex (NAC) resection gave cosmetic outcomes so poor that mastectomy was traditionally considered. 1,2 Several oncoplastic techniques have been proposed for patients with subareolar breast cancer, some of which may require more than one operation. [3][4][5] There are also immediate breast and NAC reconstruction techniques using volume displacement or replacement, such as latissimus dorsi myocutaneous flap, anterior intercostal artery perforator flap, keyhole-shaped flap, and Grisotti's flap. [6][7][8][9] However, these approaches require recruitment of additional tissue in the used flaps. To overcome these problems, we developed an immediate neo-NAC reconstruction technique aiming to improve the cosmesis after central lumpectomy. Our technique involved double opposing rotational peri-areolar flaps, C-V nipple flap 10 with inner dermal core, and the "round block" procedure. 11

PATIENTS AND METHODS
Six patients with subareolar breast cancer, aged 36-76 years, were treated with breast-conserving and NAC resection followed by immediate neo-NAC reconstruction. Axillary lymph node dissection was performed if indicated. All patients underwent preoperative imaging examination, and surface markers were applied for location and range of breast tumor.
Yinglai Huang, MD, PhD Karin Jogeland, BSN Mariya Ivanova, BSN Summary: Several oncoplastic techniques have been proposed for subareolar breast cancer, some of which may require contralateral operation for symmetry, or more than one operation for delayed reconstruction of the nipple-areola complex (NAC). We herein developed a simple and effective oncoplastic approach following central quadrantectomy, aiming to achieve the following: (1) preservation of breast shape and contour for patients who are not accepting of a notably smaller breast or bilateral operation; (2) single procedure with advantages of single anesthetic and the ability to reconstruct a breast that has not yet been affected by radiation; (3) no autologous grafts with disadvantage of an extra donor site; (4) creation of natural neo-NAC with only incision within the region of the areola complex; and (5) maintaining long-term nipple projection. In this technique, the medial and lateral peri-areolar flap was advanced and rotated to restore partial neo-NAC, and to fill the defect after central tumor and NAC resection. The whole neo-NAC margin was created using the "round block" technique. Additionally, the nipple reconstruction was performed at the mitten of the neo-areola area using the C-V nipple flaps with an internal strut of rolled dermal grafts harvested from excised skin during the round block procedures. Lastly, a purse-string suture is placed in the outer skin margin for control of areola diameter and project. Six patients with central tumors of the breast were treated in this easily achieved approach. Patient satisfaction was noted as high, and the cosmetic results were evaluated as good to excellent.

PRS Global Open • 2021
Suitability This technique can be used for small-volume breasts with minimal or little ptosis.

Surgical Strategy
The surgical strategy is composed of central quadrantectomy, including NAC and tumor, 2 medial and lateral peri-areolar flaps, a C-V flap, and the round block procedures. Figure 1 shows detailed schematic stages I-VI of the developed neo-NAC reconstruction technique. Stage I (preoperative design): An eccentric ellipse is drawn around the proposed central quadrantectomy area with 2 "crab claw shaped" peri-areolar flaps (b) and the NAC located in the inferior pole. The ellipse is extended superiorly to encompass the neo-NAC position with the neonipple located on the edge of remaining local skin after nipple-areolar excision. A parallel hemi-circumferential ring is marked around the upper half of ellipse outline for the round block procedures. Stage II and III: Perform central quadrantectomy, including NAC and tumor, with a column of tissue from the subcutaneous layer down to the pectoral, then bring the defect together with 2 or 3 layers of glandular suture using the purse-string technique to obtain a central projection of the mammary cone. 12,13 The operation is continued with management of designed 2 medial and lateral peri-areolar flaps. The medial and lateral borders of the flap are performed extending from the medial and lateral margins of the neo-NAC to give a "crab claw" shaped appearance skin and subcutaneous tissue flap. Stage IV and V: The flaps are advanced and rotated in opposite directions toward each other to cover the large part of defect after central quadrantectomy, and the opposite poles are closed in a hemi-circumferential fashion. Flap edges are sutured with interrupted, nonabsorbable sutures. In this way, the lower portion of neo-NAC is created simultaneously. The skin between the 2 rings around the upper portion of neo-NAC is carefully de-epithelialized during the round block procedures. The dermal graft harvested from de-epithelialization is rolled tightly and held in place with a 3/0 Vicryl suture so that a cylindrical central pillar of the nipple reconstruction (d) is formed. The designed C-V flap is elevated from the underlying subcutaneous tissue, and the donor sites are closed with interrupted nonabsorbable sutures. The "V" flaps are rolled and sutured together in a ying-yang fashion, and the cylindrical compacted graft is placed in its erect position into the trough formed by the V flaps so that the core volume of nipple is augmented with axial rigidity. The C flap is folded over and sutured to the V flaps to complete the nipple reconstruction. 14,15 Stage VI: Lastly, the round skin defects along the edge of the NAC are closed by a continuous running stitch technique using purse-string sutures for control of neo-areola diameter, shape, and project. 16 Figure 2 shows the surgical procedure intraoperatively.

RESULTS
With this novel approach, we successfully achieved satisfactory results for 6 patients. All central breast cancers were completely excised with negative margins. The neo-NAC positions were well centered, and the neonipple remained conspicuous (Fig. 3 The patients were well pleased with the cosmetic results that were maintained over the long term. But notably, the breast of one 52-year-old patient showed mild central depression deformities after postoperative radiation, and the breast of one 73-year-old patient had small surface necrosis at the edge between the peri-areolar flaps, which delayed wound healing.

DISCUSSION
The surgical options for NAC involved central tumors include simple or modified ellipse excisions, round block purse-string excisions with poor cosmetic outcomes, volume displacement, and volume replacement techniques with more ideal cosmetic outcomes. Patients with large ptotic breasts are good candidates for volume displacement procedures, such as wedge excision and Grisotti flap. The procedure is usually bilateral for symmetry. 17 Volume replacement techniques using local flap to correct partial breast defects and restore NAC are preferable in patients with smaller, non-ptotic breasts. However, these sophisticated approaches require recruitment of additional tissue in the used flaps, which increases the risk of adjacent tissue distortion, resulting in alteration of the final breast contour. Moreover, postoperative radiotherapy  can result in retraction of scar outside the region of the NAC at breast and dislocate the neo-NAC position. 8,9 Our approach fulfilled patients' desire to have a one-stage procedure in which the double rotational peri-areolar flaps, C-V flap, and round block technique can create neo-NAC that has adequate long-term projection and provides satisfactory results. This technique is ideal for patients with small central breast cancers that involve the NAC or are located close to the NAC. It is also beneficial to operate on patients with larger subareolar tumors or Paget's disease. However, one disadvantage of our technique is the high-riding of the neo-NAC location. Care should be taken in designing the neo-NAC position and areolar excision to avoid malposition.

CONCLUSION
We describe our new approach for immediate reconstruction of the NAC after central lumpectomy, with excellent results in patients who are not accepting of a notably smaller breast or bilateral operation.