<% vol = 16 number = 3 prevlink = 144 nextlink = 151 titolo = "POST-BURN NIPPLE RECONSTRUCTION WITH MODIFIED FISHTAIL FLAP" volromano = "XVI" data_pubblicazione = "September 2003" header titolo %>

Abdel-Hamid Abdel-Khalek

Plastic, Reconstructive and Burns Unit, Tanta Faculty of Medicine, Tanta University, Egypt

SUMMARY. Post-burn deformities of the female breast pose a problem for plastic and reconstructive surgeons, as well as a psychological problem for the patient. Many methods of reconstruction of the nipple have been described in the last few years, but none is completely satisfactory. The main objectives are the reconstruction, suitable size, and forward projection of the nipple comparable to the other breast. In this study, using the modified fishtail flap, we reconstructed 37 nipples in 28 females suffering from post-burn deformed nipples, including destruction and malpositioning of the nipple areola complex. The patients were aged 17 to 25 yr. In all the patients we used the modified fishtail flap for nipple reconstruction, and a nipple projection between 3-4 mm was achieved. The post-operative results and follow-up have proved satisfactory to both surgeon and patients. We recommend the modified fishtail flap for the reconstruction of post-burn nipple deformities, as it provides excellent projection, size, and shape.


The methods of reconstruction of the post-burn deformed nipple-areola complex and after mastectomy include quadrapod dermal flap,1 halux pulp,2,3 earlobe composite graft,4 sharing from the other nipple,5 the double-bubble technique,6 the double-opposing tab flap,7,8 and the C-V flap.9 Bell flap nipple reconstruction provides a single-stage technique that produces a properly pigmented nipple-areola complex projecting above the breast mound without the need of skin grafts.10 Nipple reconstruction using double-opposing pennant flaps produces a realistic-looking nipple.11

The repair procedure should not be performed until breast development is reasonably well advanced for fear of causing further destruction.12 The aim of this study is to evaluate the modified fishtail flap in the reconstruction of post-burn nipple, as regards shape and projection.

Patients and methods

Between April 1999 and September 2001, 28 female patients aged 17 to 25 yr underwent reconstruction of 37 post-burn deformed nipples with modified fishtail flap. The modified fishtail flap consists of a pedicle of epidermis, dermis, and subcutaneous fat centred at the site of the future nipple. The cutaneous plexus and the subdermal plexus provide the major blood supply to the flap.

Flap design

The location of the nipple is marked pre-operatively in a location agreed upon by the surgeon and patient, guided by the location of the opposite nipple. A circle matching the diameter of the desired nipple and areola is drawn. In cases of bilaterally deformed nipples the new nipple site is determined and marked 9-11 cm from the mid-sternal line and 19-21 cm from the suprasternal notch, according to body build. The orientation of the flap is assessed and scars are positioned to decrease risk to flap vascularity. The base of the flap is in the 12 o’clock position, and the angles between the flaps may vary according to local conditions, in an effort to assure flap safety. The diameter of the desired nipple varies from 1 to 1.5 cm and the length of each flap is about 2.5 cm.

<% immagine "Fig. ","gr0000019.jpg"," 1a - Diagram of modified fishtail flap on breast. The angle between flaps may vary according to local conditions.
Fig. 1b - Flaps are elevated with care taken at flap base to avoid vascular compromise. Flap A is rotated into position and secured.
Fig. 1c - Flap B is de-epithelialized and passed beneath flap A and secured; donor defects are closed.
Fig. 1d - Complete nipple construction.",230 %>

Operative technique

Under general anaesthesia, sterilization, and draping, full-thickness flaps are raised with a generous subcutaneous fat pad. Dissection stops at the nipple margin. The dissection is deepened into the subcutaneous fat, and the nipple base must not be further undermined (Fig. 1a). The tip of flap A is inset at the base of flap B (Fig. 1b). Flap B is marked and de-epithelialized to allow passage beneath flap A, and flap B is then secured to the base of flap A as indicated (Fig. 1c). The donor sites are closed with fine suture (Fig. 1d). A rigid nipple guard is fashioned from a 5-ml syringe barrel cut 2 cm in length; the flange is padded with gauze prior to application. This stent is left for seven days. Follow-up ranged between 4 and 18 months.


In this study 37 nipples in 28 female patients were reconstructed using the modified fishtail flap technique. Flame burn was the cause of nipple destruction in 19 patients (67.9%), while scald burn was the cause in nine patients (32.1%). In 24 patients (85.7%) the burn occurred after puberty and in four patients (14.3%) the burn and nipple destruction were inflicted in pre-puberty. In all cases the nipple areola complex was destroyed and in most cases it was displaced from its position. In deep burns there was hyper- or hypopigmentation in the area of reconstruction (Figs. 2,3).

<% immagine "Fig. 2a","gr0000020.jpg","20-yr-old female with post-burn deformed nipple of right breast.",230 %> <% immagine "Fig. 2b","gr0000021.jpg","Operative design of modified fishtail flap.
 ",230 %>
<% immagine "Fig. 2c","gr0000022.jpg","Post-operative condition after one week with good nipple projection.",230 %> <% immagine "Fig. 2d","gr0000023.jpg","Post-operative condition after ten months with well-maintained nipple projection.",230 %>
<% immagine "Fig. 3a","gr0000024.jpg","18-yr-old female with post-burn deformed nipple of left breast.",150 %> <% immagine "Fig. 3b","gr0000025.jpg","Intra-operative view after closure of donor sites.",150 %> <% immagine "Fig. 3c","gr0000026.jpg","Lateral view showing good nipple projection after one week.
 ",150 %>
<% immagine "Fig. 3d","gr0000027.jpg","Post-operative condition after one year with good nipple projection.",230 %> <% immagine "Fig. 3e","gr0000028.jpg","Post-operative condition after 18 months (lateral view) with well-maintained nipple projection.",230 %>

In flap design, we avoid areas of deep burns, if possible. However, in seven nipples, the area surrounding the site selected for nipple reconstruction was the site of deep burns.

Partial flap necrosis was encountered in three cases (8.1%), two of which were in cases of deep burns. However, all these flaps healed by secondary intention with a reduction of nipple projection. Total flap loss was not reported in this study. In the other 34 cases (91.9%), nipple projection and size were reasonable during the follow-up period, but if shrinkage occurred this was overcome by slight flap oversizing. A nipple projection of 3-4 mm was achieved.

A generous wedge of subcutaneous tissue should accompany the flap in order to provide adequate blood supply, and careful handling is necessary to protect the delicate vasculature from injury. Tension-free advancement of the donor margins is required to prevent deformation of the breast mound.


The surgical reconstruction of the post-burn deformed nipple is still a challenge for plastic surgeons. The procedures for post-burn nipple-areola reconstruction are surprisingly scarce in the literature, most papers having concentrated on the reconstruction of the nipple-areola complex as an important procedure after breast reconstruction.13 Saker, in his series (40 cases) of post-burn breast deformities, found that 20 patients had been burned at the age of 1 to 10 yr and another 20 at a greater age as a result of scalds in children in hot bath water, and he is of the opinion that simple education can reduce the incidence of scalds in children.14 In an analysis of 585 burn patients Darko found that lack of education and low economic status were associated with a high incidence of thermal injury.15

In our study, flame burn was the cause of nipple destruction in 19 patients (67.9%), while scald burn was the cause in nine patients (32.1%). Burn insult occurred after puberty in 24 patients (85.7%), while burn and nipple destruction were inflicted before puberty in four patients (14.3%). In our study the modified fishtail flap was used to reconstruct 37 nipples in 28 patients. The results were satisfactory in 34 nipples (91.9%) with acceptable projection and size. The vascularity of the flaps was versatile, in spite of deep burns in some cases. These flaps were random, with a length-to-width ratio of 2.5:1.5. A generous wedge of subcutaneous tissue should accompany the flap in order to ensure adequate blood supply. Areas of deep burns should be avoided as far as possible in order to provide good flap vascularity. Reconstructive results in 115 burned nipple-areola complexes in 84 female patients were reviewed by Pensler et al.,12 who used local quadrapod flaps (33% good, 45% fair, 22% poor) and composition graft from the earlobe (20% good, 60% fair, 20% poor). These were comparable, and both were superior to the results obtained with the quot double-bubble technique. They recommend employing local quadrapod flaps for the nipple, provided there is adequate surrounding dermis, and full-thickness skin grafts for the areola in the reconstruction of the burned breast. Kroll and Hamilton7 used the double-opposing tab flap in 50 patients and their results show a nicely shaped nipple that can be designed directly over a scar, maintains a projection averaging 3.8 mm at 10 months, and is technically easy to reconstruct. Hugo et al.11 performed 102 reconstructions of the nipple-areolar complex in post-mastectomy breast reconstruction using double-opposing pennant flaps for nipple reconstruction and intradermal tattooing for areolar pigmentation, and they found that this procedure was simple and fast and produced a realistic-looking nipple with no flap necrosis. Kroll et al.17 compared nipple projection with the modified double-opposing tab and star flaps and concluded that although both methods were effective, the modified double-opposing tab flap had a slightly greater projection after two years.

Few et al.16 found that long-term nipple projection and shape could be achieved by using the modified star dermal fat flap technique following breast reconstruction. Losken et al.,18 in their long-term evaluation of nipple reconstruction using the C-V flap technique, showed that the average nipple projection was 3.77 mm and was not statistically different compared with the opposite nipple. In our patients the modified fishtail flap for post-burn nipple reconstruction gave excellent shape and projection.


In conclusion, the modified fishtail flap provides a reliable method for producing durable nipples of adequate projection and length. The procedure is simple and reliable, and causes minimal donor defects.

RESUME. Les difformités du sein féminin brûlé présentent un problème pour le chirurgien plastique et reconstructif et dans le même temps un problème psychologique pour la patiente. Pendant ces dernières années beaucoup de méthodes ont été décrites pour la reconstruction du mamelon, mais aucune n’est complètement satisfaisante. Les buts principaux sont la reconstruction, la dimension appropriée et la projection du mamelon en avant comme dans l’autre sein. L’Auteur de cette étude a reconstruit 37 mamelons dans 28 patientes brûlées atteintes de mamelons difformés, y inclus la destruction et le malpositionnement du complexe aréole/mamelon, utilisant le lambeau modifié à queue de poisson. L’âge des patientes variait entre 17 et 25 ans. Dans toutes les patientes le lambeau modifié à queue de poisson a été utilisé pour la reconstruction du mamelon, et une projection du mamelon de 3-4 mm a été réalisée. Les résultats post-opératoires et le suivi se sont démontrés satisfaisants soit pour le chirurgien soit pour les patientes. L’Auteur recommande l’emploi du lambeau modifié à queue de poisson pour la reconstruction des difformités des seins brûlés, vu l’excellence, la dimension et la forme que cette technique peut offrir.


  1. Little J.W., Munsifi T., McCulloch D.T.: One-stage reconstruction of a projecting nipple by quadrapod flap. Plast. Reconstr. Surg., 71: 126, 1983.
  2. Amarante J.T., Santa-Comba A., Ries J., Malheiro E.: Malheiro E.: Halux pulp composite graft in nipple reconstruction. Aesth. Plast. Surg., 18: 299-300, 1994.
  3. Klatsky S., Manson P.N.: Toe-pulp free graft in nipple reconstruction. Plast. Reconstr. Surg., 68: 245, 1981.
  4. Rose E.H.: Nipple reconstruction with four-lobe composite auricular graft. Ann. Plast. Surg., 15: 78-81, 1985.
  5. Kargul G., Deutinger M.: Reconstruction of breast areola complex. Comparison of different techniques. Handchir. Mickrochir. Plast. Chir., 33: 133-7, 2001.
  6. Bunchman H.H.: Nipple and areola reconstruction in burned breast: The double-bubble technique. Plast. Reconstr. Surg., 54: 531, 1974.
  7. Kroll S.S., Hamilton S.: Nipple reconstruction with the double-opposing tab flap. Plast. Reconstr. Surg., 84: 520, 1989.
  8. El-Mofty A.M.: Reconstruction of areola nipple in burned breasts. Egypt. J. Plast. Reconstr. Surg., 21: 131, 1997.
  9. Hudson D.A., Dent D.M., Lozarus D.: One-stage immediate breast and nipple-areolar reconstruction with autologous tissue: A preliminary report. Ann. Plast. Surg., 45: 471-6, 2000.
  10. Eng J.S.: Bell flap nipple reconstruction - a new wrinkle. Ann. Plast. Surg., 36: 485-8, 1996.
  11. Hugo N.E., Sultan M.R., Hardy S.P.: Nipple-areola reconstruction with interadermal tattoo and double-opposing pennant flaps. Ann. Plast. Surg., 30: 510-3, 1993.
  12. Pensler J.M., Haab R.L., Parry S.W.: Reconstruction of the burned nipple areola complex. Plast. Reconstr. Surg., 78: 480, 1986.
  13. Hamori C.A., Larossa D.: The top hat flap: For one-stage reconstruction of a prominent nipple. Aesth. Plast. Surg., 22: 142-4, 1998.
  14. Saker W.M. : Local fasciocutaneous flaps in managing post-burn breast deformities. Egypt. J. Plast. Reconstr. Surg., 26: 233-93, 2002.
  15. Darko D.F., Wachtel T.L., Ward H.W.: Analysis of 585 burn patients. Burns, 12: 384-90, 1986.
  16. Few J.W., Marcus J.R., Casasl A., Atkin M.E., Redding J.: Long-term predictable nipple projection following reconstruction. Plast. Reconstr. Surg. 104: 1321-4, 1959.
  17. Kroll S.S., Reece G.P., Miller M.J., Evans G.R., Robb G.L., Baldwin B.J., Wang B.G., Schusterman M.A.: Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast. Reconstr. Surg., 99: 1602-5, 1997.
  18. Losken A., Mackay G.J., Bastwick J.: Nipple reconstruction using C-V flap technique: A long-term evaluation. Plast. Reconstr. Surg., 108: 361-69, 2001.
<% riquadro "This paper was received on 7 February 2003.

Address correspondence to: Dr Abdel-Hamid Abdel-Khalek, Plastic, Reconstructive and Burns Unit, Tanta Faculty of Medicine, Tanta University, Egypt." %>

<% footer %>