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Der Wiederaufbau des Mamillen-Areola-Komplexes (MAK) stellt den letzten Schritt der Brustrekonstruktion dar. Viele bewährte Techniken können angepasst an die individuellen Voraussetzungen und Wünsche der Patientin sowie die Erfahrung des Operateurs eingesetzt werden. Bei Protheseneinlage empfiehlt sich die Rekonstruktion der Mamille mit einem Verfahren, das einen geringen Projektionsverlust aufweist, wie dem Skate-Nipple oder dem Nipple-Sharing, insbesondere bei prominenter Gegenseite. Für die mittels autologem Material wiederaufgebaute Brust eignen sich auch Methoden, die nach Protheseneinlage im Langzeitverlauf einen stärkeren Projektionsverlust zeigen, wie der Star-Nipple, die Malteserkreuz-Mamille oder die modifizierte Hartrampf-Mamille. Der Vorhof kann über Transplantation von Spalthaut aus der Leiste oder von der Gegenseite wiederhergestellt werden. Bei Patientinnen, die im Bereich der Narben von Mastektomie oder Rekonstruktion „dog-ears“ aufweisen, kann die Spalthaut hierfür auch durch Resektion der Bürzel gewonnen werden. Eine natürliche Farbe kann durch Tätowierung erreicht werden, wobei sich durch Tätowierung auch der gesamte MAK ohne vorhergehende Rekonstruktion imitieren lässt, allerdings fehlt in diesem Fall die Projektion der Mamille. Die Aufklärung muss neben den üblichen Einschränkungen plastischer Eingriffe insbesondere die mangelnde Sensibilität und den Projektionsverlust der wiederhergestellten Brustwarze umfassen.

BackgroundNipple-areola complex reconstruction (NAR) most commonly represents the finishing touch to breast reconstruction (BR). Nipple presence is particularly relevant to the patient’s psyche, beyond any shadow of doubt. Many reconstructive options have been described in time. Surgery is easy, but final result is often disappointing on the long run.MethodsThe goal of this manuscript is to analyze and classify knowledge concerning NAR techniques and the factors that influence success, and then to elaborate a practical evidence-based algorithm. Out of the 3136 available articles as of August 8th, 2020, we selected 172 manuscripts that met inclusion criteria, which we subdivided into 5 main topics of discussion, being the various NAR techniques; patient factors (including patient selection, timing and ideal position); dressings; potential complications and finally, outcomes/patient satisfaction.ResultsWe found 92 articles describing NAR techniques, 41 addressing patient factors (out of which 17 discussed patient selection, 14 described ideal NAC location, 10 described appropriate timing), 10 comparing dressings, 7 studying NAR complications, and 22 addressing outcomes and patient satisfaction. We elaborated a comprehensive decision-making algorithm to help narrow down the choice among NAR techniques, and choose the correct strategy according to the various scenarios, and particularly the BR technique and skin envelope.ConclusionsNo single NAR technique provides definitive results, which is why we believe there is no “end-all be-all solution”. NAR must be approached as a case-by-case situation. Furthermore, despite NAR being such a widely discussed topic in scientific literature, we still found a lack of clinical trials to allow for more thorough recommendations to be elaborated.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

ABSTRACT Background: Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients’ satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis. Aims: In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result. Methods: We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery). Results: In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate. Conclusions: This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Breast surgery has long been viewed as an art more than a science. However, defining and objectively measuring the ideal breast morphology and aesthetic proportions are fundamental for surgical planning and to setting the goals of surgery as well as to evaluate surgical outcomes. Despite the fact that much has been written about aesthetic and reconstructive breast surgery, there is still no real consensus about what the attributes are of an ideal breast. Moreover, there are in fact no objective standard measurement systems and guidelines to describe ideal or even normal breast shape. Though there is great variability in the perception of beauty among patients and surgeons alike due to many factors among which are age, sex, and sociocultural background, there is common agreement that beauty is a universal phenomenon that has a universal standard present across all civilizations and centuries, and that perceived beauty is enhanced and optimal aesthetics are achieved when proper measurements are made and anthropometric proportions as well as attractive harmonious ratios are respected. The current review is an attempt to summarize the most relevant information available trying to introduce some harmony in our perception of aesthetic ideals of breast surgery.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Medical tattoos after breast cancer surgery are a therapeutic approach to regain psychophysical integrity. The tattooing of the Nipple-Areola Complex (NAC) in the ARCADE clinic involves three sessions, 30–40 days apart, and specialized nurses perform it upon medical indication. This study aims to assess the feasibility of a NAC tattooing clinic for women who have undergone surgical treatment for breast cancer in the Comprehensive Cancer Center of Azienda USL–IRCCS di Reggio Emilia, in Italy. This project is guided by the Medical Research Council framework for the development and evaluation of complex interventions, focusing specifically on the feasibility phase. The objectives of this phase include assessing organisational sustainability through retrospective analysis of activity data (Endpoint 1); evaluating the NAC tattoos’ quality, by selecting a panel of experts that scored photographs’set, in a 1–5 Likert scale (Endpoint 2); exploring the professionals’ perceptions on their involvement in the clinic, through a qualitative study with semi-structured interviews (Endpoint 3). Endpoint 1: The activity had a standard character in timing and materials. 100% of the sample ( N  = 33) gained a satisfactory cosmetic result, without adverse events, or other complications like excessive color fading or pain (none or mild for 79%). Endpoint 2: 22 sets were retrospectively retrieved and included in the analysis. The tattooed NACs demonstrated excellent quality, achieving a medium score of 4.7 for color similarity and symmetry, and 4.8 for 3D effect. Endpoint 3: Five professionals (two nurses, one surgeon, two managers) were interviewed. The main macro-themes acknowledged considerations about the value of the clinic, the barriers and the facilitators encountered, and the related future needs. A nurse-led NAC tattooing clinic is a feasible, complex intervention for breast cancer care. The combination of the retrieved data analysis and those generated by the qualitative approach underlines how resource availability and personnel motivation are influential in determining goal achievement, as well as accountability promotion and competence development. The implementation of this service empowered a support network by engaging the community and professionals in collaborative efforts to provide this final step of care, which can be determinant for psychophysical recovery.

Background Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. Methods NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. Results A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. Conclusions Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Purpose The dermopigmentation of the Nipple-Areola Complex (NAC) is a safe non-surgical reconstruction technique that can restore psychophysical integrity, representing the final step after oncological surgery. This scoping review aims to identify and synthesize the literature focused on medical tattooing for NAC reconstruction in women who underwent breast reconstruction after cancer surgery. Competence and training, outcomes and organizational aspects were assessed as specific outcomes. Methods The Joanna Briggs Institute (JBI) methodology for scoping reviews was followed. MEDLINE, Embase, Cochrane Library, Clinical Key, Scopus and Cinahl databases were consulted. After title ( N  = 54) and abstract ( N  = 39) screening and full-text review ( N  = 18), articles that met eligibility criteria were analyzed , critically apprised and narratively synthesized. Results 13 articles were analysed, with full texts ( N  = 11) and only abstract ( N  = 2). The overall quality of the literature (N observational studies = 11; N pilot experimental studies = 2) is weak. Nurses were the professionals mostly involved ( N  = 6), then medical staff ( N  = 4) and tattoo artists ( N  = 2). The professional training is poorly described in 6 papers. The most frequently assessed outcome was the satisfaction rate ( N  = 8). One study explored aspects of quality of life with a validated questionnaire. The management of these services resulted variable. Nurse-led services were implemented in 2 studies. Conclusion Despite methodological weaknesses, NAC tattooing research is relevant because it helps women redefine their identity after demolitive cancer treatments. Further research on processes and outcomes is needed.

Introduction Breast hypertrophy, a common pathological condition, often requires surgical intervention to alleviate musculoskeletal pain and improve patients’ quality of life. Various techniques have been developed for breast reduction, each with its own advantages and complications. The primary aim of this study is to evaluate the efficacy, safety, and patient-reported outcomes of the authors technique: the Superomedial-Posterior Pedicle-Based Reduction Mammaplasty. Material and Methods A prospective study was conducted on 912 patients who underwent breast reduction surgery between November 2012 and July 2020. The surgical technique involved preserving all glandular tissue from the areola to the pectoralis major muscle using the superomedial-posterior pedicle. The patients’ demographic data, operative details, complications, breast-related quality of life (measured using the Breast-Q questionnaire), and nipple–areola complex sensitivity were analyzed. Results The average operative time was 62.12 ± 10.3 minutes. Complications included minor wound dehiscence (4.05%) and hematoma (1.2%), with no cases of nipple–areola complex necrosis. Nipple–areola sensitivity was fully restored in all patients at the 2-year follow-up. Patient satisfaction with the procedure was high with a statistically significant difference observed between pre- and postoperative scores ( p < 0.001) of the Breast-Q questionnaire. Conclusion Authors technique offers reliable vascularization and innervation of the nipple–areola complex and achieves satisfactory aesthetic outcomes. It is associated with shorter operative times compared to other techniques reported in the literature. The Superomedial-Posterior Pedicle-Based Reduction Mammaplasty represents a safe and effective method for breast reduction surgery, providing significant benefits to patients with breast hypertrophy. Level of Evidence I This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance. It has always been difficult to objectively quantify the risk of nipple-areola complex involvement (NACi). The goal was to develop a prediction model for clinical application. Methods Patients who had a total mastectomy (TM) between January 2016 and January 2020 at a single institute formed the development cohort ( n  = 578) and those who had NSM + immediate breast reconstruction (IBR) between January 2020 and January 2021 formed the validation cohort ( n  = 112). The prediction model was developed using univariate and multivariate logistic regression studies. Based on NACi risk variables identified in the development cohort, a nomogram was created and evaluated in the validation cohort. Meanwhile, stratified analysis was performed based on the model’s risk levels and was combined with intraoperative frozen pathology (IFP) to optimize the model. Results Tumor central location, clinical tumor size (CTS) > 4.0 cm, tumor-nipple distance (TND) ≤ 1.0 cm, clinical nodal status positive (cN +), and KI-67 ≥ 20% were revealed to be good predictive indicators for NACi. A nomogram based on these major clinicopathologic variables was employed to quantify preoperative NACi risk. The accuracy was verified internally and externally. The diagnostic accuracy of IFP was 92.9%, sensitivity was 64.3%, and specificity was 96.9% in the validation group. Stratified analysis was then performed based on model risk. The diagnostic accuracy rates of IFP and NACiPM in low-risk, intermediate-risk, and high-risk respectively were 96.0%, 93.3%, 83.9%, 61.3%, 66.7%, and 83.3%. Conclusion We created a visual nomogram to predict NACi risk in breast cancer patients. The NACiPM can be used to distinguish the low, intermediate, and high risk of NAC before surgery. Combined with IFP, we can develop a decision-making system for the implementation of NSM.

Background The goal of breast reconstruction after breast cancer is to obtain symmetrical breasts, including the nipple-areola complex. However, in some cases the nipple-areola complex may not be symmetrical even though a symmetrical breast shape has been created. In such cases the nipple-areola complex has been transpositioned, leaving a scar to close the wound or skin graft in the original position. Methods To treat this problem, skin surrounding the areola is removed and two pedicles are created to bear the nipple-areola complex. The nipple-areola complex is then moved to the proposed position and the surrounding circular edge of the skin is closed using a purse-string suture. Results The author performed this technique in three nipple-areolae of two patients. All the nipple-areolae were transposed to the proposed position to create symmetrical breasts without any complications. Conclusion This technique can be used when the malpositioned nipple-areola complex is not too far from the proposed position. The nipple-areola complex can be moved without leaving any scar at the original position of the complex.