Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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Surgical Treatment of Nipple Malposition in Nipple Sparing Mastectomy Device-Based Reconstruction
Kathleen Kelly, B.A., Kevin Small, M.D., Alexander Swistel, M.D., Briar Dent, M.D., Erin Taylor, B.A., Mia Talmor, M.D..
New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.

PURPOSE:
We report our senior author’s experience with nipple-areolar complex (NAC) malposition following nipple sparing mastectomy (NSM), surgical options for treatment, and an analysis of patient risk factors.
METHODS:
A retrospective chart review was conducted on a prospectively-collected IRB-approved database of NSM cases with immediate implant-based reconstruction performed by a single plastic surgeon between July 2006 and October 2012. Malposition was graded as mild displacement (1cm), moderate (2cm), and severe (>3cm).
RESULTS:
319 NSMs with were reviewed. Malposition occurred in 13.79% (n=44). Significant factors associated with malposition included older age (p <0.0001), comorbid diabetes mellitus (p=0.024), increased body mass index (BMI) (p=0.0093), preoperative sternal notch to nipple distance (p=0.015), preoperative breast base width (p=0.0001), peri-areolar mastectomy incision with lateral extension (p<0.0001), prior radiation therapy (p=0.0004), prior ipsilateral lumpectomy (p=0.0125), and postoperative nipple-areolar complex (NAC) ischemia (p=0.0174). Smoking status, breast volume resected, implant size, inframammary mastectomy incision, acellular dermal matrix, and single stage reconstruction were not significant.
19/44 (43.2%) malposition cases were satisfied and deferred surgical correction (9 mild, 7 moderate, 3 severe). 8/44 (18.2%) cases were not offered surgical correction because of an inadequate skin envelope secondary to radiation tissue fibrosis, contracture, or thinning. 8/44 (18.2%) cases were corrected with crescent mastopexy (7 mild, 1 severe), 3/44 (6.8%) with implant exchange and pocket revision (1 moderate, 2 severe), 4/44 (9.1%) with free nipple grafts (4 severe), and 2/44 (4.5%) with pedicled nipple transposition (2 severe). Of note, 2/44 (4.5%) had nipple excision and reconstruction secondary to recurrence. There were no incidences of nipple necrosis or nipple malposition after surgical correction.
CONCLUSION:
NSM followed by immediate implant-based reconstruction has an identifiable risk of nipple malposition. We found several risk factors to be significantly associated with nipple malposition. Various surgical options are available to correct nipple malposition based on clinical presentation and are safe procedures in a well-selected patient population to improve overall cosmesis.


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