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Repair of the deflated nipple following nipple‐sparing mastectomy utilizing the skate flap technique

To the Editor: The esthetic outcome of the nipple-areola complex (NAC) is a critical aspect of reconstruction after oncologic surgery. Multiple techniques for creation of an NAC that looks and feels like the native NAC have been proposed but all suffer from loss of projection over time, with some studies quoting 50-70% over the first year. Skate, C-V, star and bell flaps, and the utilization of cartilage or bioprosthetic implants to achieve nipple projection have been described. The skate flap is popular because it provides better longterm projection compared to other methodologies. Shestak et al. found a statistically significant loss of projection when the bell flap was compared to the star or skate flaps at 3, 6, or 12 months. Between 12-24 months, both bell and star flaps had increased loss of projection while the skate flaps remained essentially unchanged from the 6 month period onwards. The skate flap lost a mean of 42% 14% initial projection by 24 months, compared to 71% 24% for the bell flap. Garramone et al. use an AlloDerm core supporting a modified star flap, allowing maintenance of projection of 56% at 1 year in patients with autologous reconstructions and 47% with tissue-expanders. Craft inserts a disc of Surgimend at the time of initial mastectomy and allows it to integrate into the remaining tissues for several months to provide a thicker substrate for a delayed skate flap which demonstrated only a 25% loss of projection at 6 months. Guerra et al. use an arrow-style flap supported by cartilage, which is routinely resected from the sternochondral joint of the third rib during autologous flap reconstruction when accessing the vessels for microvascular anastomosis. The authors note excellent maintenance of projection over 7 years of follow-up. Nipple-sparing mastectomy (NSM) has emerged as an alternative for patients who wish to remove all of the breast tissue but want to preserve the esthetic appearance of the natural nipple. Although large series with long-term follow-up are not yet available, several studies have indicated that NSM can be safe and oncologically sound. Preservation of the nipple is predicated on the ability to ensure that there is no cancer remaining in the NAC. Some surgeons choose to send an intraoperative frozen section of a biopsy from the areolar disc but preserve some amount of ductal tissue, while others choose to “core” the nipple in its entirety. Removal of the ductal tissue contributes to postoperative loss of projection due to loss of connective tissue support for the skin. This has prompted the need for reconstructive procedures to augment postoperative projection of the native NAC. We propose an adaptation of the skate flap incorporating the native NAC to address flattening of the nipple after NSM. This procedure is performed first by marking out a circular area centered on the deflated NAC. One half is thinly de-epithelialized. On the other half, consisting of the native flattened nipple and the remainder of the areola, two complementary skin flaps are raised and sutured together to create a mound which projects from the surface of the breast. The de-epithelialized area is covered with a skin graft to