Correction of Postoperative Nipple/Areola Malposition without Nipple Grafting

R ietjens et al 1 report 16 cases of nipple grafting. Fourteen of these cases were for treatment of nipple malposition in patients undergoing nipple-sparing mastectomies or breast-conserving surgery and radiation. Two primary breast reduction patients were included, although they presumably did not have malpositioned nipples. Still, 14 cases of nipple grafting to correct nipple malposition is a high volume for 1 surgeon over 3 years. Some cautionary notes are in order lest this operation be considered a " go to " procedure for cases of nipple overelevation. A high-riding nipple is very common, present in at least 1 breast in 41.9% of published mammaplas-ties 2 (and apparent in the contralateral breast in the authors' Figs. 3 and 4). In mastopexies and breast reductions, nipple overelevation is usually caused by (1) the inverted-T technique, a design that overel-evates the nipple, 2,3 and (2) preoperative marking of the planned nipple position. 3 Preoperative marking commits the surgeon to a nipple level before the new breast mound is formed. Nipple overelevation may be avoided by (1) using the vertical technique and (2) determining nipple level after breast mound creation and locating the new nipple site at or just below the apex. 3 Similarly, technical considerations help reduce the risk of superior nipple migration after a nipple-sparing mastectomy. 4 Unfortunately, the authors provide no clinical information for the patient depicted in their Figure 1. The authors' Figure 3 is evidently an intraopera-tive photograph of a different woman treated with a right nipple/areola graft. Before-and-after photographs of the same patient would have been helpful. Without at least 1 example of results, the authors' claim that their technique is superior to other methods 1 is unsupported. Nipple and areola tissue loss, as documented here, 1 is an expected complication in the context of breast reconstruction in irradiated tissue. The authors promote fat injection but do not provide examples of its efficacy. Might simultaneous fat injection impair the already compromised vascu-larity of the recipient site? In 1998, Spear and Hoffman 5 published the use of reciprocal skin grafts, essentially the same operation as the one used by these authors, except that the donor site is skin grafted rather than closed primarily. More recently, Spear et al 6 have promoted reciprocal skin flaps instead, with no cases of flap loss. These investigators evidently prefer the more reliable vascularity of a local flap. Both skin grafts and flaps …