Annals of Burns and Fire Disasters - vol. XII - n° 3 - September 1999

SUPERIORLY BASED NIPPLE-AREOLA COMPLEX FLAP:
A MILESTONE FOR RECONSTRUCTION OF THE POST-BURN DEFORMED BREAST

Elsayed M. Abdel-Razek

Tanta Faculty of Medicine, Tanta, Egypt

SUMMARY. Post-burn deformities of the female breast pose a problem for plastic and reconstructive surgeons as well as psychological problem, for the patient. The female breast is roughly circular, except at the upper outer quadrant where the axillary tail of Spence extends to the axilla. To achieve good cosmetic results we should endeavour to regain the shape of the breast and the nipple-arcola complex. In this study we reconstructed 35 breasts in 23 females suffering from post-burn deformed breasts, including malpositioned or destroyed nipple-arcola complex, in patients aged 16 to 23 yr. In all patients we made a superiorly based nipple-areola complex Hap with two kiteral flaps advanced below it to provide protrusion, in addition to shifting whole breast tissues upwards into the correct position. The post-operative results and follow-Lip have proved satisfactory to both surgeon and patients. We recommend employing this technique in the reconstruction of the burned female breast.

Reconstruction of the burned breast has two aspects: first, reshaping of the breast as a whole and, second, reconstruction of the nipple-areola complex. Reconstruction of these structures following deep burns is still a challenge for plastic surgeons.
Descriptions of procedures for the total reconstruction of post-burn deformed breasts are surprisingly scarce in the literature. Even when they can be found, they are discussed only in terms of' surgery of the unburned breast.
Most methods for reconstruction of the post-burn deformed breast involve reconstruction of the nipple-areola complex, including the quadripod dermal flap, composite grafts as such as the earlobe graft or toe-pulp graft, the dough-nut or double-bubble techniques, and split-thickness skin grafts or tattooing for areola reconstruction.
The repair procedure should not be performed until breast development is reasonably well advanced for fear of causing further destruction.
The nipple-areola complex flap has been described for reduction mammoplasty or the correction of the ptosed breast. This nap is variously defined as the bipedicle flap, the inferiorly based flap, or the superiorly based flap. The choice of technique is a matter of the surgeon's surgical preference. The condition of the post-burn deformed breast is suitable for use of the superiorly based flap.

Between 1996 and 1999, 23 female patients aged 6 to 23 yr underwent reconstruction of 35 post-burn deformed breasts with superiorly based nipple-areola complex flaps. The displaced or deformed nipple was marked and the new nipple site was determined and marked 9-11 cm from the mid-stemal line and 19-21 cm from the suprastemal notch. A periareolar marking was located 2 cm above and around the future nipple site, and two lines were drawn joining the border of the old areola to that of the proposed new areola (Fig. 1).

Fig. 1 - Identification of site of the old nipple-areola complex and localization of new site, with two lines connecting the edges of both. Shading indicates area to de-epithelialized.

Under general anaesthesia, sterilization, and draping, the lateral margin markings were incised and deepithelialization of the skin was performed between the two incisions and the circle of the new nipple-areola complex. The two lateral incisions were deepened to the level of the pectoral fascia and the whole nipple-areola complex flap was dissected freely from the pectoral fascia, maintaining its superior pedicle. The areola was then sutured into its new position (Fig. 2).

Fig. 2 - Nipple-areola complex shifted superiorly by doubling the de-epithelialized dennis. The inframammary fold is lifted superiorly and the entire gland is dissected upwards off the pectoral fascia.

The two lateral pillars of the breast were then advanced medially after release incisions and sutured together. After lifting the whole breast upwards, the raw area left underneath was covered with split-thickness skin graft (Fig. 3).

Fig. 3 - Closure of medial and lateral glandular pillars by the creation of a new inframammary fold. Split-thickness skin graft is applied over the raw area left.

A tie-over dressing was used for the grafted area and the breast was dressed by supporting it upwards and maintaining its protrusion. The dressing was removed one week later and the patient continued to wear a strong elastic brassiere for three months in order to maintain breast protrusion and minimize the effect of graft contracture. The follow-up period ranged between 4 and 16 months.

We operated on 35 breasts in 23 patients, always using the same technique (the superiorly based nipple-areola complex flap). Twenty patients (31 breasts) were burned before puberty, and three patients (four breasts) were burned after puberty. All the breasts were flat and adherent to underlying tissues, with obliteration of the inframammary fold due to scarring. Thirty nipple-areola complexes were displaced far from the normal anatomical position. The other five were destroyed, and here we used a hyperpigmented, healed burn area for the areola and transferred it by the same technique to the new normal anatomical position. The nipples were reconstructed subsequently.
The post-operative follow-up showed that breast protrusion in the patients was excellent, and all were happy with the results. Nipple-areola complex viability was excellent in 33 breasts, with partial necroses in two where we transferred hyperpigmented scarred tissues. Conservative measures were sufficient for healing. The grafted area beneath the breasts healed smoothly and was accepted by the patients (Figs. 4-6).

Fig. 4a - Nineteen-year-old female patient with unilateral post-burn deforme.d hreq-t Fig. 4b - Same patient one year after surgery, with good protrusion, creation of submarnmary fold, excellent nipple-areola complex, and acceptable graft area over chest wall. Fig. 5a - Seventeen-year-old female patient with post-burn deformed breast and displaced nipple-areola complex. Fig. 5b - Same patient five months after reconstruction. Nipple areola complex reconstructed using the hyperpigmented submarnmary scarred area. Fig. 6a - Twenty-two-year old female patient with bilateral post-burn breast deformities. Fig. 6b - Same patient 16 months after surgery. Acceptable shape and protrusion.

Discussion

The surgical reconstruction of post-burn breast deformity is still a challenge for plastic surgeons. The procedures for total reconstruction are surprisingly scarce in the literature.
Complete reconstruction of the burned breast requires reconstruction of the nipple-areola complex, which plays a key role in reconstruction.
Numerous papers have been written on the subject, but the majority regard only nipple and areola reconstruction. In our study we used a technique that primarily described reduction marnmoplasty in normal breasts, with some modifications to overcome the deformities that we faced during reconstruction of burned breasts. Vertical mammoplasty was first described by Marchac and modified by Lejour in order to obtain only a vertical scar. Following their principle we applied our technique of the superiorly based nipple-areola complex flap for deformed breast reconstruction.
We are of the opinion that the superiorly based nipple areola complex flap for reconstruction of post-burn female breast deformities gives better cosmetic results than other methods for the same problem 2 as it takes into account the whole deformity, providing breast protrusion and repositioning the nipple-areola complex in the correct site.