Repairing the High-Riding Nipple with Reciprocal Transposition Flaps; and Classification and Management of the Postoperative, High-Riding Nipple

Sir: We read with interest the recent article by Spear et al.1 describing a useful technique for correction of the postoperative, high-riding nipple, and the subsequent review and classification.2 We too have found nipple-sparing mastectomy reconstruction with either expanders or single-stage implants to confer an excellent aesthetic outcome in suitable patients. With increasing volume and laxity of the skin envelope, however, the potential for shear at the mastectomy flap/implant pocket interface increases, manifest by a tendency for the nipple-areola complex to migrate superolaterally during the postoperative recovery and/or expansion phase. This aesthetically undesirable outcome may also be exacerbated by, but is not exclusive to, postreconstruction radiotherapy. Several other solutions have been described in the literature, including techniques where the nipple is lowered through a buttonhole,3 transposed as a flap, or Z-plasty.4 Excision and repositioning as a graft may result in the least scarring, but at the risk of nipple loss. Techniques that involve elevating the entire breast relative to the nipple have been described both by elevating the inframammary fold3 and with the use of implants or tissue expanders,3,5 but are less useful for correcting multiple vectors of displacement. Thus, given that these techniques may be complex and often provide suboptimal results,4 prevention should be preferable to cure. We currently use a simple suture technique to anchor the spared nipple-areola complex to the underlying implant pocket, which maintains its position on the breast mound throughout the expansion/postoperative period. The nipple-sparing mastectomy is performed and submuscular pocket created as described previously. Care is taken to ensure optimal placement of the device such that the nipple-areola complex is located and marked at the pinnacle of the breast mound, or for expanders, once the desired intraoperative fill volume is achieved. The nipple-areola complex dermis is then tacked to the muscle pocket using three 4-0 absorbable monofilament anchoring sutures (Fig. 1). The radial mastectomy scar may also be anchored in this way (Fig. 2). Intraoperative sitting of the patient is invaluable, not only in the key assessment of the final nipple-areola complex placement but also in ensuring that no adverse skin folding or traction on the nipple-areola complex is caused by the anchoring sutures. A drain placed between the muscle and skin flap reduces potential shear. The remainder of the procedure and postoperative management is unaltered.Fig. 1: On-table marking of the nipple-areola complex.Fig. 2: Three-point fixation of the nipple-areola complex to the underlying implant pocket.We have successfully used this technique over a series of 25 consecutive alloplastic reconstructions following nipple-sparing mastectomy, evenly split between two-stage expander and single-stage reconstructions. Postoperative irradiation was also administered in 16 percent. No revisions to the nipple-areola complex were required over the median 6-month follow-up period (range, 2 to 12 months). Given that the technique results in negligible additional operative time, complications, and costs, we suggest that it be included among solutions to this difficult problem. DISCLOSURE Dr. Lennox is a speaker for LifeCell Corp. Esta S. Bovill, Ph.D., F.R.C.S.(Plast.) Sheina A. Macadam, M.D. Peter A. Lennox, F.R.C.S. Division of Plastic Surgery University of British Columbia, and Burn, Plastic & Trauma Unit Vancouver General Hospital Vancouver, British Columbia, Canada

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