Modern Plastic Surgery, 2012, 2, 87-90
http://dx.doi.org/10.4236/mps.2012.24021 Published Online October 2012 (http://www.SciRP.org/journal/mps) 87
Usefulness of Free Nipple-Areola Complex Graft for
Nipple Malposition after Nipple Sparing Mastectomy
Kyoichi Matsuzaki1,2
1Department of Plastic and Reconstructive Surgery, Kawasaki Municipal Tama Hospital, Kawasaki, Japan; 2Department of Plastic
and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
Received July 9th, 2012; revised August 6th, 2012; accepted September 7th, 2012
ABSTRACT
Purpose: This article identifies the advantage and disadvantage of a free nipple areola complex graft (FNACG) for nip-
ple malposition which resulted from tissue-expander insertion and subsequently replaced with an implant after nipple
sparing mastectomy (NSM). Methods: The subjects were three such patients treated using FNACG and who were fol-
lowed up for at least one year postoperatively. The surgical outcome was assessed for symmetry of nipple-areola posi-
tion, graft take, depigmentation, and shrinkage. Results: In all patients, the graft was accurately transferred to a po sition
to achiev e symmetry with the unaffected breast, and there was complete graft take in the areola by simple surgical de-
sign and techniques. No depigmentation of the areola was observed. The size of the areola was almost unchanged after
grafting in two patien ts, but areolar shrinkage occu rred in one other patient. There was complete graft take in th e nipple
in one patient and no depigmentation of the nipple was observed. Necrosis occurred at the tip of the nipple in two other
patients. These patients had depigmentation, and the height of nipples decreased in proportion to the level of necrosis.
Conclusion: FNACG can be a useful method if its advantages and disadvantages are well considered.
Keywords: High-Riding Nipple; Nipple Areola Complex Graft; Nipple Sparing Mastectomy; Nipple Malpositio n;
Nipple Transposition
1. Introduction
Many women who undergo breast cancer surgery not
only face anxiety and fear toward cancer but also are
affected by the sense of loss of their breasts. Thus, nipple
sparing mastectomy (NSM) tends to be selected in pa-
tients who want to preserve their nipples and areolas and
for whom this treatment is indicated [1]. In NSM, the re-
sected breast tissue needs to be replaced with autologous
tissue in a single-stage surgery. Otherwise, nipple-areola
complex malposition occurs due to contraction of the
skin and changes to the breast volume.
Patients are placed in an unexpected situation of facing
breast cancer, and some of them are unprepared to decide
at the stage of breast cancer surgery whether they want to
use autologous tissue to recon struct their breasts. Thus, a
tissue expander is often inserted at the site of the breast
tissue resection in NSM. Postoperatively, the patients can
take their time to decide on breast reconstruction when
they are in a state of mind to make such a decision.
There have been many reports on surgical methods to
correct nipple-areola complex malposition. This article
identifies the adv antage and disadvantage of a free nipple
areola complex graft (FNACG) [2].
2. Patients and Methods
2.1. Patients
The subjects were selected among patients in whom a
tissue expander (Integra® Tissue Expander Model 3612-
06, PMT® Corporation, USA) was inserted after NSM
and it was subsequently replaced with an implant (Mc-
Ghan Style 410, INAMED Corporation, Ireland). The
subjects were three such patients whose nipple sensation
was lost, nipple-areola complex malposition was cor-
rected using FNACG, and who were followed up for at
least one year postoperatively (Table 1).
2.2. Operative Procedures
The tissue expander inserted after NSM was inflated so
that the affected breast was approximately 20% more
than the volume of the unaffected breast (Figures 1(a)
and (b)). One year after NSM, the tissue expander was re-
placed with an implant (Figure 1(c)). After replacement
with an implant and six months postoperatively, FNACG
was performed with local anesthesia. The nipple-areola
complex was resected in a spindle shape. The resection
was performed in the same drection as the laxity of sk in i

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy
88
(a) (b) (c)
(d) (e)
(f) (g) (h)
Figure 1. (a) Case 1: A 39-year-old female. Nipple sparing mastectomy (NSM) with axillary dissection was performed for the
left breast cancer. A tissue expander was inserted; (b) One year after NSM. A tissue expander was inflated so that the af-
fected breast was approximately 20% more than the volume of the unaffected breast; (c) Replacement with an implant at six
months postoperatively; (d) The nipple-areola complex was resected in a spindle shape. The size of the new areola was estab-
lished to be the same as the unaffected areola; (e) The immediate postoperative result; (f) One month after free nipple areola
complex graft (FNACG); (g) One year after FNACG. Frontal view; (h) One year after FNACG. Oblique view.
Table 1. Cases treated with a free nipple areola complex
graft.
Case Age Type of Implant Follow-Up
1 39 Cohesive Gel 27-FL 1 2 0 - 250 19 months
2 55 Soft Touch Gel ST-LM 130 - 320 18 months
3 49 Soft Touch Gel ST-FL 100 - 140 17 months
which was less susceptible to deformation of the breast
mound, and then suturing was performed. At this stage,
the patients came off of the operating table and were in a
standing position. The design was established so that
nipple transposition would result in the same distance
between the sternal notch and the new nipple on the af-
fected breast as between the notch and the unaffected
nipple. The size of the new areola was established to be
the same as the unaffected areola (Figure 1(d)). Epider-

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy 89
mal resection was performed in the area where the areola
was to be created. A full-thickness graft was used to re-
construct the nipple-areola complex and fixed with a
tie-over dressing (Figure 1(e)). Seven days postopera-
tively, the tie-over dressing was removed. Subsequently,
petroleum jelly was applied followed by a dressing until
complete epithelialization occurred in the nipple-areola
area. In the six-month postoperative period, the nipple
was protected by a sponge with the center cut out to cre-
ate a doughnut shape. This sponge was used to prevent
pressure on the nipple by underwear or while sleeping.
2.3. Assessment of Surgical Outcome
At least one year postoperatively, the results were as-
sessed for symmetry of nipple-areola p osition, graft tak e,
depigmentation, and shrinkage.
3. Results
In all patients, the graft was accurately transferred to a
position to achieve symmetry with the unaffected breast,
and there was complete graft take in the areola. No de-
pigmentation of the areola was observed. The size of the
areola was almost unchanged after grafting in two pa-
tients, but areolar shrinkage occurred in one other patient
(Figures 1( f) -(h)).
There was complete graft take in the nipple in one pa-
tient. No depigmentation of the nipple was observed
(Figure 2). Necrosis occurred at the tip of the nipple in
two other patients. These patients had depigmentation,
and the height of their nipples decreased in proportion to
the level of necrosis (Figures 1(f)-(h)). In one patient
without necrosis, there was slight flattening of the nipple
(Figure 2 and Table 2).
4. Discussion
There have been many reports on surgical methods to
correct nipple-areola complex malposition (Table 3).
There is a method in which a tissue expander is inserted
and the skin on the cranial aspect is inflated to lower the
high-riding nipple-areola complex [3]. The advantage of
this method is that no new breast scar is created if the
(a) (b) (c)
Figure 2. (a) Case 2: A 55-year-old female. Before free nip-
ple areola complex graft (FNACG); (b) The immediate
postoperative result; (c) One and a half years after FNACG.
Table 2. Results of a free nipple areola complex graft for 3
cases.
No. of Areolae No. of Nipples
Symmetry of nipple-areola
position 3 3
Complete graft take 3 1
Depigmentation 0 2
Shrinkage 1 Not applicable
Table 3. Transposition of the nipple areola complex.
Tissue expander
Periareolar skin excision
Myocutaneous flap
Skin flap (Z-plasty flap technique)
Island flap (Subcutaneous pedicle)
Free nipple areola complex graft
tissue expander is inserted from the preexisting scar from
NSM. However, its procedure can become complicated,
the treatment period can be prolonged, and the stretched
skin can revert back to its original state. The method of
periareolar skin resection [4] has the advantage of a
camouflaged breast scar because the areolar margin ob-
scures the scar. If there is insufficient skin laxity of the
breast, it is difficult to su ccessfully achieve nipple-areola
complex transposition. A defect resulting from the trans-
position can be treated using a myocutaneous flap [5,6].
This method enables successful nipple-areola complex
transposition. However, there is morbid ity of the myocu-
taneous flap donor site and prominent patchworklike
scars of flaps. A method using a Z-plasty flap technique
[7] can result in prominent geometric scars with an un-
natural appearance. Another method involves an island
flap in which the nipple-areola complex is transferred as
a subcutaneous pedicle flap [8]. In this method, the
transfer can be achieved without the interruption of the
blood flow. Therefore, compared with the FNACG me-
thod, this method is less susceptible to problems such as
areolar shrinkage, necrosis of the tip of the nipple, and
depigmentation. However, the skin of the breast is thin,
and caution is required due to potential flap necrosis if
blood flow of the subcutaneous pedicle is unstable. In
addition, sufficient breast skin laxity is important to pre-
vent impeded blood flow due to pressure on the subcuta-
neous pedicle in the subcutaneous tunnel in the breast. In
FNACG, suturing also cannot be performed at the donor
site of the nipple-areola complex if there is insufficient
skin laxity of the breast. Thus, a tissue expander is in-
serted after NSM to adequately stretch the skin of the

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy
90
breast. The disadvantages of FNACG are that areolar sh-
rinkage can occur, the height of the nipple can decrease
due to necrosis if the nipple is high, and depigmentation
can occur.
Ahmed et al. [9] reported on temporary banking of the
nipple-areola complex in cases of skin sparing mastec-
tomy. The complex was temporarily banked in areas such
as the groin region. The banked nipple-areola complex
was replanted onto the reconstructed breast mound in a
second surgery. Their results of the first transplantation
showed that 88% of the cases had nipple-areola complex
graft survival rates of at least 80%, and that 51% of the
cases maintained at least 50% nipple projection. In their
study, the color change was graded at 3 levels of good,
moderate, and poor. Pig mentation was defined as good if
the color of the nipple areola complex had not changed.
Loss of pigment was considered a moderate result in
cases where the nipple-areola complex was still clearly
darker than the surrounding skin of the breast mound.
The result was poor if there was no distinction between
the color of the nipple areola complex and surrounding
skin. Their results of the first transplantation were good
in 48% of the cases, moderate in 51% of the cases, and
poor in 1% of the cases. In this study, there was areolar
shrinkage in one patient. Since areolar shrinkage was not
included as an item examined by Ahmed et al., there
could be racial differences in the results of the FNACG
just as there are racial differences in scar contracture and
keloid formation. Further studies will be necessary to
examine the usefulness of this method in Asians, who are
more susceptible to conspicuous scar formation than
Caucasians [10,11].
The advantage of FNACG is that a graft can be trans-
ferred to a site far from the donor site. Treatment using
flaps can result in th e position o f a nipp le-areola co mplex
that might be slightly different from the preoperatively
planned position because of the state of the subcutaneous
scar and the thickness and texture of the skin of the
breast. In FNACG, the position of the nipple-areo la com-
plex is determined after the donor site of the complex is
sutured. Th erefo r e, th e graf t can be accurately transferred
to a position to achieve symmetry with the unaffected
breast. The method of FNACG involves simple surgical
design and techniques, and is not greatly affected by the
technical skills of surgeons. Thus, the method should be
considered as one surgical treatment option.
In conclusion, the disadvantages of FNACG are that
areolar shrinkage can occur, the height of the nipple can
decrease due to necrosis of the tip if the nipple is high,
and depigmentation can occur. The advantage of FN-
ACG is that a graft can be transferred to a site far from
the donor site. It involves simple surgical design and
techniques and is not greatly affected by the technical
skills of surgeons. Therefore, the method can be useful if
its advantages and disadvantages are well considered.
REFERENCES
[1] J. Y. Petit, U. Veronesi, A. Luini, R. Orecchia, P. C. Rey,
S. Martella, F. Didier, F. De Lorenzi, M. Rietjens, C. Ga-
rusi, A. Sonzogni, V. Galimberti, E. Leida, R. Lazzari and
A. Giraldo, “When Mastectomy Becomes Inevitable: The
Nipple-Sparing Approach,” Breast, Vol. 14, No. 6, 2005,
pp. 527-531. doi:10.1016/j.breast.2005.08.028
[2] S. R. Colen, “Breast Reduction with Use of the Free Nip-
ple Graft Technique,” Aesthetic Surgery Journal, Vol. 21,
No. 3, 2001, pp. 261-271. doi:10.1067/maj.2001.116439
[3] A. S. Colwell, J. W. May Jr. and S. A. Slavin, “Lowering
the Postoperative High-Riding Nipple,” Plastic and Re-
constructive Surgery, Vol. 120, No. 3, 2007, pp. 596-599.
doi:10.1097/01.prs.0000270283.64971.dd
[4] R. P. Gruber and H. W. Jones Jr., “The ‘Donut’ Mas-
topexy: Indications and Complications,” Plastic and Re-
constructive Surgery, Vol. 65, No. 1, 1980, pp. 34-38.
doi:10.1097/00006534-198001000-00007
[5] P. Berrino, E. Campora and P. Santi, “Postquadrantec-
tomy Breast Deformities: Classification and Techniques
of Surgical Correction,” Plastic and Reconstructive Sur-
gery, Vol. 79, No. 4, 1987, pp. 567-572.
doi:10.1097/00006534-198704000-00010
[6] S. A. Slavin, S. M. Love and N. L. Sadowsky, “Recon-
struction of the Radiated Partial Mastectomy Defect with
Autogenous Tissues,” Plastic and Reconstructive Surgery,
Vol. 90, No. 5, 1992, pp. 854-865.
doi:10.1097/00006534-199211000-00022
[7] B. A. Frenkiel, M. D. Pacifico, M. Ritz and G. Southwick,
“A Solution to the High-Riding Nipple-Areola Complex,”
Aesthetic Plastic Surgery, Vol. 34, No. 4, 2010, pp. 525-
527. doi:10.1007/s00266-009-9421-1
[8] H. Mohmand and A. Naasan, “Double U-Plasty for Cor-
rection of Geometric Malposition of the Nipple-Areola
Complex,” Plastic and Reconstructive Surgery, Vol. 109,
No. 6, 2002, pp. 2019-2022.
doi:10.1097/00006534-200205000-00036
[9] A. K. Ahmed, D. E. Hahn, J. J. Hage, E. M. Bleiker and L.
A. Woerdeman, “Temporary Banking of the Nipple-Are-
ola Complex in 97 Skin-Sparing Mastectomies,” Plastic
and Reconstructive Surgery, Vol. 127, No. 2, 2011, pp.
531-539. doi:10.1097/PRS.0b013e3181fed578
[10] H. P. Dustan, “Does Keloid Pathogenesis Hold the Key to
Understanding Black/White Differences in Hypertension
Severity?” Hypertension, Vol. 26, No. 6, 1995, pp. 858-
862.
[11] D. D. Datubo-Brown, “Keloids: A Review of the Litera-
ture,” British Journal of Plastic Surgery, Vol. 43, No. 1,
1990, pp. 70-77. doi:10.1016/0007-1226(90)90047-4