Topographic Analysis of the Nipple-Areolar Complex Sensation in Superomedial Pedicle Breast Reduction.

BACKGROUND: Surgeons meticulously perform breast reductions, while ensuring vascular integrity of the pedicle and Nipple-Areolar complex (NAC) to prevent any complication. It is crucial to remember that loss of sensation is also substantial complication, mainly due to unique characteristic features of the NAC. This study aimed to compare early and long-term sensory results by performing topographic analysis of NAC sensation after superomedial pedicle breast reduction. METHODS: A prospective study was conducted by including nonrandomized female patients who underwent breast reduction surgery with wise pattern excision superomedial pedicle technique between January 2019 and June 2022. Semmes-Weinstein Monofilament (SWM) test performed at preoperatively, 3-6 months and 15-18 months postoperatively. NAC complex was divided into four equal quadrants and nipple: superomedial (SM), inferomedial (IM), inferolateral (IL), superolateral (SL) and Nipple (N). Touch-Test® Sensory Evaluator Chart was used to evaluate sensory results. RESULTS: None of the patients had any loss of sensation during preoperative SWM test. In postoperative 3-6 months, statistically significant differences were observed between N and SL (p = 0.002), SL and IM (p < 0.05), SM and IM (p < 0.05). In postoperative 15-18 months, there was no difference between the quadrants and nipple (p = 0.07). In early and long-term comparisons of the same quadrants, IL less pronounced than other quadrant comparisons (p = 0.034). A statistical difference was observed in overall NAC score (p < 0.05). CONCLUSIONS: It would be beneficial to inform patients overall NAC sensation in the postoperative may not be as good as preoperative, there might be variations in NAC sensation across different quadrants in early period. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Comparison Study of Nipple-Areolar Complex Measurement: Light Detection and Ranging (LiDAR) Camera Versus Photometry.

BACKGROUND: In breast surgery, achieving esthetic outcomes with symmetry is crucial. The nipple-areolar complex (NAC) plays a significant role in breast characteristic measurement. Various technologies have advanced measurement techniques, and light detection and ranging (LiDAR) technology using three-dimensional scanning has been introduced in engineering. Increasing effort has been exerted to integrate such technologies into the medical field. This study focused on measuring NAC using a LiDAR camera, comparing it with traditional methods, and aimed to establish the clinical utility of LiDAR for obtaining favorable esthetic results. METHODS: A total of 44 patients, who underwent breast reconstruction surgery, and 65 NACs were enrolled. Measurements were taken (areolar width [AW], nipple width [NW] and nipple projection [NP]) using traditional methods (ruler and photometry) and LiDAR camera. To assess correlations and explore clinical implications, patient demographics and measurement values were collected. RESULTS: NAC measurements using a periscope and LiDAR methods were compared and correlated. LiDAR measurement accuracy was found to be high, with values above 95% for AW, NW and NP. Significant positive correlations were observed between measurements obtained through both methods for all parameters. When comparing body mass index, breast volume with AW and NW with NP, significant correlations were observed. These findings demonstrate the reliability and utility of LiDAR-based measurements in NAC profile assessment and provide valuable insights into the relationship between patient demographics and NAC parameters. CONCLUSIONS: LiDAR-based measurements are effective and can replace classical methods in NAC anthropometry, contributing to consistent and favorable esthetic outcomes in breast surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

[Management of nipple-areolar complex anomalies]. / Comment j'explore une atteinte de la plaque aréolo-mamelonnaire.

Nipple-areolar complex anomalies may be secondary to many etiologies from simple anatomic variations to malignant processes as Paget disease or invasive breast cancer, passing through benign locally aggressive processes as erosive adenomatosis of the nipple. Differential diagnosis is not always simple. If clinical exam and standard radiological checkup can't confirm the benignity of the lesion, a biopsy specimen will be obtained to allow an anatomopathological examination. A precise diagnosis can then be made leading to optimal management. This paper describes how to explore nipple-areolar complex anomalies through an uncommon clinical case associating independently an invasive retro-areolar cancer and a dermatological disease of the areola mimicking a Paget disease.

Les anomalies de la plaque aréolo-mamelonnaire peuvent être secondaires à de nombreuses étiologies, allant de simples variantes anatomiques à des pathologies malignes telles que la maladie de Paget ou un cancer invasif, tout en passant par des pathologies bénignes localement agressives comme l'adénomatose érosive du mamelon. Le diagnostic différentiel n'est pas toujours aisé. Si l'examen clinique et le bilan radiologique standard ne permettent pas d'affirmer la bénignité de la lésion, un prélèvement biopsique sera réalisé afin de permettre une analyse anatomopathologique. Un diagnostic précis pourra alors être posé pour guider la prise en charge optimale. Cet article a pour but de détailler la mise au point d'une atteinte de la plaque aréolo-mamelonnaire par l'intermédiaire d'un cas clinique peu fréquent associant de manière indépendante un cancer invasif rétro-aréolaire et une atteinte dermatologique de l'aréole mimant une maladie de Paget.

Expected Reduction of The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone.

BACKGROUND: The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia. OBJECTIVE: The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL). MATERIALS AND METHODS: A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed. RESULTS: The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=<0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cm2 (SD 1.48) or 23.37% (SD 9.78) after 5.82 years and in the SCM+UAL cohort 2.60cm2 (SD 1.60) or 35.85% (SD 6,86) after 7.43 years. As independent significant factors for reduction of the NAC, the resection weight and SCM+UAL combination were identified. There were no significant differences regarding the patients' satisfaction measured with the BODY-Q (p=0.222) and the ordinal scale (p=0.445) between the two cohorts. CONCLUSIONS: The SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Percutaneous Intradermal Purse-String closure for Correction of Male Tuberous Nipple-Areola Complex Deformity.

BACKGROUND: Male tuberous breast is an exceedingly rare condition that not fit properly into the majority of existing classifications of gynecomastia. This deformity has been categorized by Cordova and Moschella as gynecomastia grade III; however, they do not make any reference to the isolated tuberous deformity of the nipple-areola complex (NAC). Considering that the areolar area is the main ''esthetic unit'' in the male chest, surgical correction of the isolated tuberous NAC deformity can be challenging. There is a belief that this deformity is unsuccessfully corrected when approached through a limited periareolar incision at the lower pole. A complete periareolar incision, with a concentric excision of excess areolar skin, is usually required leaving an unnatural-looking round periareolar scar on the male thorax. METHODS: We describe a variation of a surgical technique for the correction of a male tuberous NAC deformity in a teenager who rejected a conspicuous round periareolar scar after surgery. This modification combines a conventional lower hemiareolar approach with a percutaneous intradermal purse-string suture in the superior areolar margin to reduce the areolar diameter, avoiding an evident circumareolar scar. RESULT: At the six-month follow-up, areolar widening or tuberous deformity relapse was not observed. The patient felt satisfied with the outcome. CONCLUSION: The use of percutaneous intradermal purse-string periareolar suture for correction of this rare deformity is a simple and reproducible surgical technique that could help to obtain a better cosmetic result by restoring the contour of the male chest while minimizing the visibility of the residual scar. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Oncological safety of therapeutic 'nipple-sparing mastectomy' followed by reconstruction: a systematic review.

BACKGROUND: Breast cancer (BC) treatment traditionally consisted of radical and often mutilating surgery. Advances in the field of BC have led to new remedies, enabling the paradigm shift from radical to conservative surgery. New treatments such as nipple-sparing mastectomy (NSM) are becoming more popular, aiming to improve both oncological and aesthetic outcomes. However, evidence confirming the oncological safety of NSM is currently lacking, hindering its application. This systematic review sought to analyze NSM's oncological safety as an alternative to conventional mastectomy (CM). PATIENTS AND METHODS: A systematic review was performed, respecting the PRISMA guidelines. Pubmed, Embase, and Web of Science databases were consulted and searched for keywords: 'nipple-sparing mastectomy' and 'mammaplasty', or combinations of synonyms. Only original studies published between 2000 and 2020 reporting tumor recurrence and/or survival rates with a minimum of 5-year follow-up were included. RESULTS: From the 1675 unique records found, 14 studies were included, amounting to 5980 female BC patients who underwent NSM plus reconstruction. Included studies described either only ductal carcinoma in situ (DCIS, n = 1), only invasive BC (n = 3) or DCIS and invasive BC (n = 10). The most recurrent oncological metrics were 5-year local recurrence (0-10%), locoregional recurrence (0-7.4%), distant recurrence (1.6-15.6%), and overall survival rate (93.1-100%). CONCLUSION: Based on long-term low BC recurrences and high survival rates, NSM is perceived to be non-inferior to CM from an oncological perspective. This identifies NSM plus reconstruction to be a safe curative treatment. Further studies should aim to elicit clear and applicable selection criteria in order to maximize NSM's potential.

A rare case of Bowen's disease of the nipple: Literature review and management pathway.

INTRODUCTION: Bowen's disease or squamous cell carcinoma in situ is a precursor malignant neoplasm restricted to the epidermis. Clinically and histologically, Bowen's disease of the nipple can resemble Paget's disease. It is crucial to differentiate between the two with immunohistological staining in order to provide the appropriate treatment. This review of Bowen's disease of the nipple will examine the diagnostic and treatment modalities previously used. We also present our own case of Bowen's disease of the nipple and propose a clinical pathway for this rare disease process. METHODS: A review of published literature using MEDLINE, PubMed, and Google Scholar revealed seven articles were identified with a total of eight cases of Bowen's disease of the nipple. RESULTS: Treatment modalities varied within the literature. This ranged from photodynamic therapy to simple mastectomy and sentinel lymph node biopsy. Standard surgical margins are inadequate for Bowen's disease of the nipple, as it has been shown to spread along the lactiferous ducts. Our case is of a 57-year-old female with Bowen's disease of her right nipple, confirmed through immunohistological staining. Wide local excision with immediate full-thickness skin graft reconstruction was performed and is now disease-free with a healed graft. CONCLUSION: There is no accepted management pathway for Bowen's disease of the nipple. We propose a treatment algorithm that involves immunohistological staining to diagnose Bowen's disease of the nipple. This would then be followed by a wide local excision, complete nipple excision including underlying lactiferous ducts and glandular tissue and subsequent reconstruction.

3D Mammometric Changes in the Treatment of Idiopathic Gynecomastia.

BACKGROUND: Three-dimensional surface imaging (3DSI) has shown promise for plastic surgeons to objectively assess changes in body contour and breast volume. OBJECTIVES: To assess the surgical outcome after bilateral subcutaneous mastectomy (BSM) and water jet-assisted liposuction (WAL) as treatment for idiopathic gynecomastia, using 3DSI to document changes regarding nipple-areolar complex (NAC) and breast volume. METHODS: Thirty male patients (Simon II A to B) receiving BSM and WAL were enrolled. Eight subjects received additional mastopexy and NAC reduction. Use of a Vectra 3D Imaging System® before and 6 months after surgery provided data regarding changes of NAC placement and NAC and breast dimensions. The sum volume of intraoperatively approximated lipoaspirate before and after centrifugation and mastectomy specimens quantified using water displacement were compared with 3D-assessed differences in volume. RESULTS: When compared to the NAC dimensions defined during surgery, patients receiving NAC reductions showed nonsignificant postoperative changes in NAC dimensions. Patients without additional mastopexy showed a significant (p < 0.001) vertical (15.7 ± 14.3%) and horizontal (17.1 ± 15.0%) reduction in NAC diameter. 3D volume changes (92.8 ± 26.4 mL) showed significant differences (p < 0.001) 6 months after surgery compared to the intraoperatively measured lipoaspirate before (182 ± 54.5 mL) and after (120 ± 34.6 mL) centrifugation. CONCLUSION: Although it is clear that patient satisfaction must remain the prime focus of surgical body contouring, 3DSI has proven valuable to objectively demonstrate both the anticipated outcome and further findings regarding treatment of idiopathic gynecomastia. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan.

BACKGROUND: Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. PATIENTS AND METHODS: The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. RESULTS AND CONCLUSIONS: After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circular type mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Reduction: 33 Years Using a Single Central Block.

BACKGROUND: Since 1985, the author has been using the single central block technique for breast reduction and mastopexy, prioritizing the good relation between the final breast shape and the length of the scars, different from other authors who emphasize only the shape of the breast (Peixoto in Plast Reconstr Surg 65(2):217-225, 1980; Aesthet Plast Surg 8:231-236, 1984) and others who have drawn attention to the length of the scars (Arié in Rev Latinoam Cir Plast 3:23-31, 1957; Bozola in Plast Reconstr Surg 85:728-738, 1990; Sepúlveda in Rev Bras Cir 71(1):11-18, 1981). In this study, the author describes the use of a single central block of the mammary tissue and the nipple-areolar complex (NAC), dissected from the skin flaps and based on the superior vascular pedicle for reduction mammoplasty and mastopexy (Erfon et al. in Annals of the international symposium recent advances in plastic surgery, São Paulo, 1989; Hinderer (ed) Plastic surgery, Elsevier, Madrid, 1992; Proceedings of the 65th annual scientific meeting of the American society of plastic and reconstructive surgeons, Dallas, 1996). METHODS: A retrospective study was performed, evaluating patients who underwent breast reduction and mastopexy using the single central block technique from July 1985 to December 2018 by a senior author. RESULTS: A total of 2097 procedures were performed using this technique, 1556 being reduction mammoplasties and 541 mastopexies. The mean patient age was 44, and the mean weight of tissue resected was 455 g. Fat necrosis on the distal area of the flap was observed in 47 cases (2.24%). Hematoma was observed in 6 patients (0.28%). Surgical revisions were undertaken in 75 patients (3.57%). Hypertrophic scars occurred in 12 of the cases (0.57%). Dehiscence in the inverted "T" scars occurred in 78 of the surgeries (3.71%). CONCLUSIONS: This technique allows the surgeon to easily form a good cone shape of the breast, repositioning the NAC and preserving its vascularization and sensation without tension on the skin flaps sutures, resulting in smaller and better scars. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction.

BACKGROUND: More attention is focused on sensory outcomes following breast reduction operations. We conducted this prospective, non-randomized study to compare two commonly used breast reduction techniques, superomedial pedicle and inferior pedicle, regarding sensation of the nipple-areolar complex. METHODS: We prospectively assigned 60 patients with macromastia into the superomedial pedicle group (SMP group, n = 30) or the inferior pedicle (IP group, n = 30) group. Six patients who withdrew from the study and another six patients who did not attend return visits were excluded. Algometry was used to measure the sensation of breast skin, cardinal points of the areola and the nipple. Two-point discrimination was also measured on the areola. Measurements were performed before surgery, at 3 weeks, and 6 months postoperatively. RESULTS: There were 20 patients in the SMP group and 28 patients in the IP group. The mean ages of the patients were 43.2 ± 12.7 and 45.9 ± 10.8 years, respectively (p = 0.438). The mean BMI of the patients were 32.4 ± 6.7 and 30.4 ± 5.3 kg/m2, respectively (p = 0.257). The mean weights of resected tissues were 802.5 (280-2180) versus 773.7 (349.5-1425.0) g, respectively (p = 0.900). Although breast sensation did not change in the SMP group, sensation in the upper medial and lower lateral portions of breast skin was reduced in the IP group. Two-point discrimination test results did not change in either group. The amount of changes in algometry and two-point discrimination tests were similar in both groups. CONCLUSION: Both superomedial and inferior pedicle breast reduction techniques are safe and reliable in terms of sensory changes. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[The reconstruction of the nipple-areolar]. / La reconstruction de l'aréole et du mamelon.

The reconstruction of the nipple-areolar complex is the final stage of breast reconstruction that restores the visual identity of the breast. The most common options for reshaping the areola are tattooing, total skin grafting of the inner thigh and the total skin graft taken from the contralateral areola. Nipple reconstruction solutions include duplication of contralateral nipple, local flap, total skin graft and tattoo in three-dimension. Duplication of the nipple is the technique of choice because it immediately offers optimal color, texture and projection. The areolar tattoo is the most common procedure for its simplicity and reproducibility.

Radiotherapy and nipple-areolar complex necrosis after nipple-sparing mastectomy: a systematic review and meta-analysis.

OBJECTIVE: To perform a meta-analysis to determine the effect of radiotherapy (RT) on nipple-areolar complex (NAC) and skin flap necrosis, and local recurrence in women who undergo nipple-sparing mastectomy (NSM) and immediate breast reconstruction. METHODS: Medline, PubMed, Cochrane, and Google Scholar databases were searched until October 16, 2015. Randomized-controlled-trials, prospective, retrospective, and cohort studies were included. The primary outcome was the NAC necrosis rate, and the secondary outcomes were the skin flap necrosis and local recurrence rates. RESULTS: Of 186 studies identified, 2 prospective and 5 retrospective studies including a total of 3692 patients were included in the meta-analysis. Five, 3, and 2 studies reported data of NAC necrosis (3461 breasts), skin flap necrosis (2490 breasts), and local recurrence (988 breasts), respectively. Pooled results showed no difference in the odds of NAC necrosis [odds ratio (OR) = 1.250, 95% confidence interval (CI) 0.481-3.247, P = 0.647], or local recurrence (OR = 0.564, 95% CI 0.056-5.710, P = 0.627) between patients who received and did not receive RT. Patients treated with RT had a higher likelihood of skin flap necrosis (OR = 2.534, 95% CI 1.720-3.735, P < 0.001). Significant heterogeneity, however, was noted in the analysis of NAC and local recurrence. CONCLUSIONS: Because of the limitations of the small number of studies and heterogeneity in the analysis, this study does not allow drawing any definitive conclusions and highlights the need of well-controlled trials to determine the effect of RT in patients undergoing NSM.

Combination of Würinger's Horizontal Septum and Inferior Pedicle Techniques to Increase Nipple-Areolar Complex Viability During Breast Reduction Surgery.

BACKGROUND: Breast reduction techniques depend on the vascularity of the pedicle. Preserving vascularity of the nipple-areolar complex (NAC) is mandatory for reduction mammoplasties, as the NAC is the most important aesthetic and functional unit of the breast. The inferior pedicle technique is the most common method for breast reduction; however, pedicle length may increase after using this technique and cause problems related to NAC viability in gigantomastic and hypertrophic breasts. In this study, we present our technical approach to preserve NAC viability by combining Würinger's horizontal septum and inferior pedicle techniques. METHODS: This study included 60 women (mean age 39.71 ± 10.52 years) who underwent a breast reduction combining Würinger's horizontal septum and inferior pedicle procedures from April 2012 to January 2016. All patients were marked preoperatively in a standing upright position using a prefabricated Wise-pattern template. The base of the pedicle was marked at the level of the inframammary ridge at a width of 8 cm. RESULTS: The patients were followed up for a mean of 5.6 ± 3.3 months. The resection weights of the right and left sides were 1406 ± 566 and 1340 ± 563 g, respectively. Venous insufficiency was encountered in five cases (8.3%) and caused partial NAC necrosis in one case (1.6%). No cases of total NAC necrosis were encountered. Fifteen breasts (12.5%) were described as gigantomastic (resection weight >2000 g). CONCLUSIONS: This combined method may promote safer and more satisfying outcomes from inferior pedicle breast reduction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction.

BACKGROUND: Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. METHODS: With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less. RESULTS: The anatomic study determined the cis-male nipple to be positioned on average 2.5 cm medial to the lateral border of the pectoralis muscle and 2.4 cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae. CONCLUSIONS: Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND: Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES: The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS: A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS: Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS: Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites.

Purpose: The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions. Methods: In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed. Results: We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012). Conclusion: Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.

Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan.

BACKGROUND: Position of the nipple-areolar complex (NAC) is an important factor in the esthetic impression of the breast, and NAC malposition is often an issue in breast reconstruction after nipple-sparing mastectomy (NSM). The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan). METHODS: Patients who underwent unilateral breast reconstruction after NSM at eight hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6-24 months post-operatively. The degree of malpositioning was then statistically compared using various factors. RESULTS: The NAC deviated more cranially and medially with implants than that with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition, and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to the degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants. CONCLUSIONS: This study provides insights into the tendencies and characteristics of NAC malposition.

Clinically node-negative invasive lobular carcinoma of the breast showing multiple lymph node metastases.

A 73-year-old woman was pointed out of her right breast tumor on screening computed tomography (CT). Mammography showed distortion of the mammary gland and skin retraction. Ultrasound (US) showed an irregular tumor with hyperechoic haloes adjacent to the anterior tumor borders. Neither lymphadenopathy nor image findings suggesting lymph node metastasis were detected on US and CT. Core needle biopsy pathologically showed the tumor to be invasive lobular carcinoma. Under the preoperative diagnosis of node-negative breast cancer, the patient underwent mastectomy and sentinel node biopsy. Due to no sentinel node detection, a small but hard lymph node was identified and submitted for frozen section as a sampling node. After confirming the lymph node metastasis on frozen section, axillary lymph node dissection revealed 12 lymph node metastases. Postoperative pathological study showed cancer cell infiltration to the dermis near the nipple-areolar complex. In addition, immmunostaining showed the tumor to have low proliferative biology, i.e., Ki-67 labelling index of 10%. Breast surgeons should note that indolent invasive lobular carcinoma with cancer cell infiltration to the skin near the nipple-areolar complex can have multiple lymph node metastases even though showing neither lymphadenopathy nor image findings suggesting lymph node metastasis.

Evaluating Pedicled Pectoralis Major Myocutaneous Flap Reconstructions for Oral Malignancy and the Influence of Laterally Based Rotational Advancement Flap on Donor Site Integrity and Nipple Position in Male Patients.

Oral cancer poses a significant health burden, particularly in the male population of India. This study focuses on evaluating the outcomes of 48 pedicled Pectoralis major myocutaneous (PMMC) flap reconstructions in male patients with oral malignancy. Given the challenges associated with microvascular flap reconstructions, especially in advanced cancer cases, older patients, and resource-constrained settings, the PMMC flap still serves as a valuable alternative. The study introduces a novel approach by incorporating a laterally based rotational advancement flap (LBRA) to address donor site integrity and decrease the nipple-areolar complex (NAC) displacement. Traditionally, PMMC flap designs tend to cause inward shifting of the NAC during chest donor site closure, impacting the aesthetic outcome. Surgical techniques involved wide local resection, neck dissection, and PMMC flap reconstruction. The Flap design included a horizontal orientation with adjustments based on defect location. Additionally, a laterally based rotational flap from the chest aided in donor site closure. Results demonstrate the versatility and reliability of PMMC flap reconstructions, with no total flap necrosis or major complications observed in the 48 cases. The LBRA technique effectively mitigated NAC displacement. The study contributes to the existing literature by providing insights into the advantages of PMMC flap reconstructions and introducing a technique to optimize donor site closure and decrease the medial shifting of the nipple. The adaptability, reliable vascular supply, and simplified learning curve make the PMMC flap a preferred choice in resource-constrained settings with high patient demand. In conclusion, this research underscores the continued relevance and effectiveness of the PMMC flap in head and neck reconstruction, offering satisfactory cosmetic and functional results. The introduction of the LBRA technique adds a nuanced dimension to improve outcomes, particularly in male patients with oral malignancy.