Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.
he transverse myocutaneous gracilis flap was described for breast reconstruction in 1992 following cadaveric perfusion studies suggesting that transverse orientation of skin paddles lowered the risk of distal skin necrosis compared to vertical orientation. 1 Despite the local popularity of the transverse upper gracilis flap, previously published high donor-site complication rates and a perception of poor patient satisfaction limit its use. [2][3][4][5][6][7][8] Over the past three decades, techniques have developed with modifications likely to decrease donor-site morbidity and improve patient satisfaction. 2,3,9 Transverse upper gracilis flap breast reconstruction accounts for 8 percent of autologous mastectomy defect reconstruction at the reporting institution, making it the most used donor site after the abdomen. The deep inferior epigastric
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