New Technique for Nipple Areola Reconstruction: Arrow Flap and Rib Cartilage Graft for Long-Lasting Nipple Projection

In Brief The nipple–areola complex is an integral part of breast reconstruction. It serves as an important landmark for the new breast and many techniques have been described for its reconstruction. Historically, nipple projection has been most difficult to achieve and maintain. The authors found that techniques that use isolated soft tissue flaps eventually fail secondary to scar contraction with loss of projection. Since 1994, the authors have used a local skin fat flap shaped as an arrow for the reconstruction of the nipple on 454 breasts. The arrow shape is advantageous because it allows the scar to be broken on closure, minimizing postoperative wound contracture. Within the flap, the authors routinely use a rib cartilage graft, which provides additional support and projection for the skin–soft-tissue envelope. The graft is harvested during the initial breast flap transfer for the purpose of exposing the internal mammary vessels and has been obtained without any additional morbidity. By combining a skin fat flap and rib cartilage graft, the authors have achieved excellent long-term projection and a more esthetically pleasing nipple reconstruction. Four hundred fifty-four nipple reconstructions were performed using a local arrow-shape skin-fat flap containing a rib cartilage graft that had been harvested during the earlier breast reconstruction procedure. A 4% cartilage graft loss was experienced, and long-term nipple projection was achieved.