The double opposing periareola flap: a novel concept for nipple-areola reconstruction.

BACKGROUND: This report describes the authors' currently favored method of nipple reconstruction that has been developed and used by the senior author over the past 26 months.
METHODS: A pull-out flap is derived as the lead edge of one of two opposing skin flaps contained in a circular design approximating the areola complex of the opposite breast. The larger flap gives rise to the nipple construct, a derivative of the skate flap design. The flap donor areas are closed by suture approximation centrally and peripherally within the areolar margins. The donor area resulting from elevating the central flaps that give rise to the nipple is closed by direct suturing; the opposing subcutaneous dermal pedicle flaps are advanced or "slid" toward each other centrally, and the peripheral area is closed by a purse-string suture placed in the periareolar incision. The only undermined area is the nipple flap itself. There is no undermining of the larger flaps or peripheral breast skin. The dissection is straightforward and the technique is rapid.
RESULTS: The procedure was used 47 times in 36 patients (unilateral reconstruction, 25 patients; bilateral reconstruction, 11 patients), with no flap losses or wound separations. In one case of redo bilateral nipple reconstruction, ischemia noted at the most anterior aspect (distal portion) of both flaps healed with the application of topical ointment.
CONCLUSIONS: This novel design for nipple-areola complex reconstruction can be used in either primary or secondary nipple reconstruction. Of particular advantage, all of the scars are contained within the peripheral periareolar incision and thus can be completely camouflaged by an intradermal tattoo. Nipple projection has been consistently maintained and appears similar to that of a skate flap.