C-V Flap for Nipple Reconstruction

Katie E. Weichman

DEFINITION

Nipple-areolar reconstruction is the final stage in the process of postmastectomy reconstruction.
This procedure has been shown to positively influence overall satisfaction with breasts and outcomes in several series and transforms the mound to a breast.¹^,² The C-V flap is the most commonly performed technique in both implant and autologous reconstruction.
This local flap was first introduced in 1994 by Bostwick for use in nipple reconstruction after mastectomy and breast reconstruction.³ Long-term results with this technique were further shown by Losken and Bostwick in 2001.⁴
The C-V flap evolved from the skate flap but uniquely allows primary closure of the donor site.
The main advantage of this technique is that the full-thickness skin graft is not required.
- The main limitation is maintenance of projection of the C-V flap, as the thickness of the subcutaneous tissue and dermis is the main determinant of nipple projection. The loss of intraoperative volume has been shown to be up to 50%.⁵
Further modifications of this flap to maintain and increase projection have been described and include using rolled triangular dermal fat flaps, a “Swiss roll” flap, V-V flap, CC-V flap, and C-V-M flap.⁶^,⁷^,⁸^,⁹^,¹⁰

ANATOMY

The C-V flap is a local flap with a pedicle of epidermis, dermis, and subcutaneous fat centered at the site of the desired future nipple. The basic concept of the C-V flap is that the nipple consists of three flaps: 2 V flaps and 1 C flap.
- Blood supply
  - Subdermal plexus
  - Subcutaneous plexus

PATIENT HISTORY AND PHYSICAL FINDINGS

Patients undergoing C-V flap nipple reconstruction have reached the end of the reconstructive process.
Patients having a history of breast cancer requiring mastectomy, prophylactic mastectomy, and congenital abnormalities and transgender patients who have had mastectomy with complications associated with silicone injection are indicated for the procedure.
History of radiation therapy or need for further radiation therapy should be considered when deciding timing of nipple reconstruction.
Patients should not be actively smoking at least 3 months prior to surgery.
Patients should have a final breast mound without need for further revision.
Nipple reconstruction should be performed when the breast has taken its final form and has adequately settled to prevent malposition.
- This timing is least 3 to 6 months after either the direct to implant reconstruction, tissue expander exchange for implant, or the autologous reconstruction. All revisions of the breast mounds should be performed prior to nipple reconstruction.
- Revision of autologous reconstruction can often be performed synchronously with nipple reconstruction; however, ensuring correct nipple position can be more challenging with an increased incidence of nipple malposition requiring further revision.

SURGICAL MANAGEMENT

The authors perform C-V flaps for nipple-areolar reconstruction when the nipple-areolar complex is absent.
A 50% reduction of the nipple projection should be anticipated, and therefore, C-V flap should be designed accordingly based on patient preference and contralateral nipple size in unilateral reconstructions.⁴^,⁵

Preoperative Planning