Skate Flap for Nipple Reconstruction



Skate Flap for Nipple Reconstruction


Katie E. Weichman





ANATOMY



  • The skate flap is a local flap with a pedicle of epidermis, dermis, and subcutaneous fat centered at the site of the desired future nipple. The skate flap is named based on skin flaps that are shaped like wings of a skate fish (FIG 1).



    • Blood supply



      • Subdermal plexus


      • Subcutaneous plexus


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Patients undergoing skate flap nipple reconstruction have reached the end of the reconstructive process.


  • Indications: A history of breast cancer requiring mastectomy, prophylactic mastectomy, congenital abnormalities, and transgender patients who have had mastectomy with complications associated with silicone injection


  • 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 for 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 months 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, assuring correct nipple position can be more challenging with an increased incidence of nipple malposition requiring further revision.


SURGICAL MANAGEMENT



  • The authors perform skate flaps for nipple-areolar reconstruction when the nipple-areolar complex is absent.


  • Patients who desire larger nipples and agree to harvest of full-thickness skin graft from a secondary donor site
    (abdomen, inner thigh, or lateral chest wall roll) should be considered for the Cordeiro modification. Patients with autologous reconstruction should be considered for the Hammond modification.






    FIG 1 • A. Skate fish. B. Skate flap centered on breast mound. D represents the diameter of nipple and pedicle of nipple; H represents the desired height of the nipple. The length of the flap wings measures at least 3D, and the height of wings measures 2H.






    FIG 2 • A. Traditional landmarks for nipple position. Sternal notch to nipple distance of 19 to 21 cm. Distance from midline to nipple measuring 9 to 11 cm. Distance from nipple to inframammary fold measuring 7 to 8 cm. B. Ideal nipple position in asymmetric breasts. Maintain ratios of nipple in relation to the medial breast border, lateral breast border, inframammary fold, and superior breast extent.


  • A 50% reduction of the nipple projection should be anticipated, and therefore, skate flap should be designed accordingly based on patient preference and contralateral nipple size in unilateral reconstructions.5,6


Preoperative Planning



  • Patients are marked in the standing position with shoulders relaxed in the preoperative holding area.


  • Nipple position should be centered on the breast at the point of maximal convexity and projection. Additionally, it should be symmetric to the contralateral nipple in unilateral reconstructions. In bilateral reconstructions, nipple position is often easier to match, and the location is less critical as long as it is symmetric and located on the center of the breast.


  • Specific landmarks are often helpful in determining the correct position of the nipple-areolar complex on the breast. These include the level of the contralateral nipple-areolar complex, the position at the Pitanguy point (reflection of the inframammary fold), and triangle from the sternal notch to nipple/midsternal line (FIG 2A).


  • When breasts are asymmetric, the surgeon should try to maintain the ratios of the nipple to the breast footprint. This includes midline, lateral breast, superior breast, and inframammary fold (FIG 2B).


Positioning



  • The patient is positioned in supine position. Surgery should be performed in the operating room because a full-thickness skin graft is needed to cover the nipple site.

Dec 6, 2019 | Posted by in Reconstructive microsurgery | Comments Off on Skate Flap for Nipple Reconstruction

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