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Free Nipple Grafting: An Alternative for Patients Ineligible for Nipple-Sparing Mastectomy?
Erin L. Doren, MD1, Jaime Lewis, MD2, Jonathan Lopez, BS1, Christine Laronga, MD, FACS2, Paul D. Smith, MD3.
1University of South Florida, Tampa, FL, USA, 2Moffitt Cancer Center, Tampa, FL, USA, 3University of South Florida, Moffitt Cancer Center, Tampa, FL, USA.

Purpose:
Nipple-sparing mastectomy (NSM) is an option for patients fitting oncologic criteria, and may improve cosmetic outcomes of breast reconstruction. When anatomical limitations exist, some surgeons recommend pre-mastectomy staged reconstruction to permit the nipple sparing approach (1). We propose the use of free nipple grafting, akin to reduction mammaplasty, with anticipated similar complication rates.
Methods:
A retrospective review of 18 prospectively gathered patients having a NSM/immediate reconstruction using free nipple grafting. Patients were excluded from standard NSM based on prior periareolar incisions (n=2), breast size >700gms (n=2), ptosis (n=1), radiation (n=5) and desire for autologous reconstruction (n=8). Skin-sparing mastectomies were performed via a circumareolar incision. The nipple areola complex was harvested from the mastectomy specimen, frozen sections from the base were sent and then the nipple was defatted. Grafts were re-implanted to de-epithelialized recipient sites and covered with a xeroform bolster. Bolsters were removed on postoperative days 7-10.
Results:
Of 18 patients, 7 had bilateral prophylactic mastectomy and 5 had unilateral mastectomies and 6 had bilateral mastectomies for unilateral cancer, totaling 31 nipple areola grafts harvested. Mean age was 48 years (range 21- 66), BMI 25.7 (21.5-33.1), breast weight 514g (110.4-1378.0), and follow-up 11.6 months (0.3-51). Reconstruction was performed with TE + alloderm (2/31), implant sparing with latissimus (2/31), TRAM (13/31), and latissimus /TE (14/31). All nipple base pathology was benign. Upon removal of bolsters, most patients had some degree of epidermolysis. Average graft take was 95% (60-100%). One patient (5.5%) had complete bilateral graft loss secondary to TE infections. Five nipples (16%) lost all projection. Seven nipples experienced hypopigmentation (23%) with 1 patient requiring tattooing. Comparable rates of epidermolysis, graft loss, loss of projection, and hypopigmentation are reported in the literature for reduction mammaplasties with free nipple grafts (2,3). Type of reconstruction did not impact complication rates.
Conclusions:
Increasingly popular NSM is an option for women meeting oncologic and anatomic criteria. For those ineligible for technical reasons, free nipple grafting is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties and, more importantly, saves the women a subsequent operation for nipple reconstruction (figures 1,2).
References:
1.
Spear, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. PRS. 2011;128(5):1005-1014.
2.
Mcgregor, Hafeez. Is there still a place for nipple areolar grafting in breast reduction surgery? JPRAS. 2006;59:213-218.
3.
Colen. Breast reduction with use of the free nipple graft technique. AES. 2001;21:261-271.
Figure 1:
Preoperative patient, post-irradiation of the left breast
Figure 2:
Postoperative latissimus dorsi flap and free nipple graft reconstruction of bilateral breasts.


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