Semilunar Flap for Minimizing the Scar Length in Nipple Reconstruction

Summary:

Nipple reconstruction is an essential procedure to change an amorphous breast mound to a distinct breast. Various skin flaps have been proposed for nipple reconstruction. In the C-V flap technique, which is one of the most commonly used flaps for nipple reconstruction, the scar that is developed after closure of the donor site of the V-flap frequently extends beyond a new areola area. To reduce the length of the donor site scar, various modifications of the C-V flap have been proposed. We adopted the semilunar flap instead of the V flap of C-V flap by changing the angle of V flap for nipple reconstruction. The semilunar flap design allowed generation of a donor flap with sufficient width and length of the skin flap for a nipple barrel without increasing the length of the donor site scar. In most cases, the semilunar flaps showed stable outcomes and resulted in angled donor-site scars that were usually located within the boundary of a new areola. We think the semilunar flap represents a good alternative method in nipple reconstruction by changing the angle of the donor-site scar and leaving the scar length within the new areolar area.

Nipple reconstruction is an essential procedure to change an amorphous breast mound into a distinct breast and various skin flaps, such as star flap, arrow flap and C-V flap, have been proposed for nipple reconstruction.^1–3 However, there is a drawback to long-term planning that the donor-site scar of the skin flap is commonly so long that it extends beyond the boundary of a future areola. Therefore, many surgeons have made efforts to decrease the scar length within the area of a future nipple areola complex (NAC). In this article, we propose a semilunar flap for nipple reconstruction that resulted in an angled scar at the donor site of skin flap and allowed the donor-site scar to remain within the boundary of a new NAC in most cases.

PATIENTS AND METHODS

Between March 2017 and April 2018, a total of 20 nipple reconstructions were performed using a semilunar flap on reconstructed breast mounds after breast implant by the single surgeon. The follow-up period ranged from 6 to 12 months.

Surgical Techniques

The nipple position was marked in the upright position for preoperative flap design. The width of the flap varies from 10 to 13 mm, according to the contralateral nipple size. We modified the horizontal lateral V flap of the C-V flap to a semilunar shape that was angled toward the superior direction. The angle of the semilunar flap axis was approximately 45 degrees. The length of the semilunar flap was usually approximately 2 times the width of the flap base. We designed the semilunar flap and C flap in the center of the proposed nipple position (Fig. 1A). The skin flap was elevated with a #15 blade from the distal end, and the proximal site of the flap base was meticulously elevated with blunt dissection to secure circulation to a skin flap. After completion of flap elevation, the donor site of the semilunar flap was closed from the distal to proximal side with interrupted sutures using #5-0 nylon suture. The bilateral ends of the semilunar flap were brought together and fixed to the skin edge of the donor site of the C-flap with a #5-0 nylon suture, forming a barrel. The left distal parts (dotted area) of the semilunar flap after making a barrel were discarded and fixed to each other. The inner edge of the semilunar flap was connected to the C-flap (Fig. 1B). The area was covered with 2-layered 5-mm foam dressings for protection from external compression for 3 weeks. The suture material was removed at postoperative 2 weeks.

Fig. 1.

Schematic illustration of semilunar flap in nipple reconstruction: design of a semilunar flap (A). Flap elevation (B). Closure of donor-site (C). Semilunar flap donor-site scar hidden within the tattooed areola (D).

RESULTS

There was no flap necrosis, infection, and wound dehiscence in these 20 cases. In 1 case, the distal margin of the flap was partially congested due to unexpected external compression by a brassiere on the immediate postoperative day. We revised the distal part of the flap at 2 weeks postoperative and noted that the size of nipple was slightly decreased as a result of the revision. The scar at the donor site of the semilunar was confined within the area of the new NAC (Fig. 1 C, D). The mean outer limb length of the semilunar flap was 25.5 mm, the mean inner limb length was 13.6 mm, and mean postoperative scar length of the donor site was 15.3 mm (Table 1 and Fig. 1). The final scar length of semilunar flap is 1–2 mm longer than the length of inner limb of semilunar flap. Postoperative views of the nipple reconstruction with semilunar flap are shown in Figure 2. Areolar reconstructions by tattooing were usually performed 3 months after nipple reconstructions.

Table 1.

Evaluation of Scar Length Change of a Semilunar Flap

Fig. 2.

Case 1. Views of nipple reconstruction with a semilunar flap: immediately postoperative view (A). Postoperative view at 3 months (B). Three months after tattooing (C); semilunar flap donor-site scar was hidden within the tattooed areola.

DISCUSSION

A variety of techniques have been developed to generate skin flaps for nipple reconstruction to maximize aesthetic outcomes and overall patient satisfaction. In most methods, the skin flaps were elevated from the area of the future NAC, and a donor-site scar that remains beyond the future areolar area, reduces the aesthetic outcome of a reconstructed nipple. The C-V flap, one of most popular methods in nipple reconstruction, has the drawback that the donor-site scars frequently extend beyond the boundary of the NAC. A larger V flap produces a longer length of the scar on the future areolar area. To reduce the length of the donor-site scar, various modifications of the C-V flap have been developed. The design of 2 V flaps was changed to “V” and “M” patterns at each end that fit into each other like a jigsaw piece on closure, with the advantage of reducing the dog ear deformities.⁴ The C-Y trilobed flap proposed by Butz et al.⁵ has focused on the donor-site scar length by modification of the end of the V- flap to a Y pattern.

We adopted the semilunar flap instead of the V flap for nipple reconstruction. The semilunar flap design allowed generation of a donor flap with sufficient width and length of the skin flap for a nipple barrel without extending the length of the donor-site scar beyond the future areolar area. We think that the semilunar flap has several advantages. First, the donor-site scar was usually confined to the boundary of the NAC, except in patients with a very small areola. Second, the angled skin flap was more easily approximated with each end than a straight lateral skin flap for generation of a cylindrical shape; therefore, the tension to the skin flap base was much less, and usually the distal parts of the semilunar flap were left and could be discarded. Third, in comparison with the straight lateral flap, the axis of the semilunar flap is relatively parallel to the axis of the entire skin flap to secure the blood supply of the lateral wing of the skin flap.

The semilunar flaps showed stable outcomes and resulted in aesthetically pleasing donor-site scars that were usually located within the boundary of the new areola. We think the semilunar flap represents a good alternative method in nipple reconstruction by changing the angle of the donor-site scar and leaving the scar length within the new areolar area.