To the best of our knowledge, this is the first study assessing long-term changes in the NAC diameter after reconstruction using a full-thickness skin graft from the contralateral areola following mastectomy with breast reconstruction. We focus on the areola size, not the loss of nipple projection. We showed that the size of the donor NAC gradually increased for 36 months, while the size of the graft site showed only slight changes within 24 months, followed by a relatively small increase. Despite constituting the smaller size of the donor NAC, it eventually became larger than the graft NAC, especially in patients who had large implant or without additional operations.
Areola reconstruction has been achieved by grafting as well as by tattooing. Although tattooing is a useful procedure and getting popular for areola reconstruction, special medical equipment is necessary and the technique requires training and experience to optimize results. Kargul et al. stated that the best color match on NAC reconstruction was achieved by grafting from the contralateral areola rather than by grafting from the groin and tattooing (Kargül and Deutinger 2001). Moreover, patients with large areola are, rather than reconstruct the areola large by tattooing, overlooking the areola reduction surgery at the same time as the areola reconstruction. Therefore, grafting still remains an important technique worldwide.
Postoperative complications such as hypertrophy, contraction, and graft failure have been described for full-thickness grafts (Stephenson et al. 2000; Leibovitch et al. 2005). In general, however, full-thickness grafts tend to contract slightly with time, and, in this respect, our results are consistent with those of the previous studies. Interestingly, our study revealed an opposite trend for the size of the donor site. The size of the donor NAC showed and immediate increase reaching as much as 30 % one month after the operation. Importantly, the periareolar edge was sutured for both the donor and graft sites when the areola was reconstructed using a full-thickness skin graft. Therefore, the differences in NAC size dynamics are unlikely to result from variations in the surgical technique. However, it is possible that the increase in the size of the donor NAC was due to expansion of the scar in the process of wound healing. The long-term use of the micropore skin tape after suture removal to prevent later stretching of the wound likely precluded such expansion at the graft site. The tendency of the donor NAC size to increase for at least 36 months postoperatively might be related to the softness of scar caused by maturing.
Mastopexy or reduction surgery were significantly associated with reduced size of the donor site. In this regard, these surgeries resulted in additional scars around the donor areola. Moreover, hypertrophic scars were removed at the time of the NAC reconstruction. This may have contributed to the contraction of the NAC. On the other hand, large implants had a tendency to increase the size of the donor NAC, which is a reasonable explanation of the expansion of the NAC as well as the breast skin. These factors might not have affected the size of the graft site because of the small magnitude of the changes, However, According to implant size, the number of patients who received large implant was too small to confirm the association with change in NAC size in this study. Further study is warranted for this point.
The usage of the purse-string suture technique for the periareolar skin closure has been reported to reduce the expansion of the areola and the loss of nipple projection (Weinfeld et al. 2008; Caterson et al. 2015). Bodin et al. suggested that removing a part of the contralateral nipple and areola might be the most effective technique in terms of stable long-term results (Bodin et al. 2008). Although we did not assess the efficacy of these published techniques in the present study, they may be useful to prevent the expansion of the donor NAC.
Our study has some limitations. First, this study had a retrospective design. Second, the use of the adjuvant hormone therapy or changes in the body weight, that may influence the size of the breast, were not assessed in this study because of the limited amount of data. This warrants further study with a longer follow-up and larger sample size.
Our findings showed that the donor sites expanded about 36.8 % while the graft sites didn’t have a significant change. The results confirmed that the NAC size after reconstruction using a composite nipple graft was changed over time compared to the completion size. To account for this change, we should design the size of the areola at the graft site for NAC reconstruction as 20 % larger than that of donor site, to prevent the asymmetry after few years. Furthermore, it is better to re-design the size of graft site intraoperatively when suturing the donor site was done.
The judgment of the degree to enlarge the graft site should examine the individual factors of the patient. The natural processes of contraction inherent with wound healing and aging cause the change in the size of areola in all NAC reconstructions. To successfully anticipate the long-term sizes of the donor and graft NACs, graft diameter and patient factors must all be considered. The donor site is usually enlarged, but the donor site in patient with a history of additional operations does not become larger than expected. In this case, we design the graft site larger than the opposite site, but it is smaller than when designing usually.