Sir: Despite civilization and progress, burns and traumas occur frequently in the world, resulting in important sequelae and severe scars. If the scar areas involve the nipple-areola complex, reconstructive surgery is particularly difficult and the outcomes are often unsatisfactory. Nipple-areola reconstruction is often performed after trauma and burn injury. In burned patients, the excessive nipple flattening and difficult reconstruction are attributable to the small amount of subcutaneous fat and thin dermis caused by the tight scar.1 According to our evidence in scar remodeling by lipostructure,2 we attempted to evaluate an alternative approach to improve nipple projection in selected patients presenting burn and trauma outcomes. We called this technique “nipple resuscitation.” From November of 2005 to July of 2006, 24 informed voluntary patients with mature scars resulting from chest burns or traumas involving at least monolaterally a breast with its nipple-areola complex (nipple projection <1 mm in all patients) were selected. Twenty-two of 24 patients presented some degree of areolar pigmentation loss. Patients' data and history are summarized in Table 1.Table 1: Anamnestic Patient DataAfter clinical assessment and routine preoperative examinations, patients underwent liposuction of the subumbilical area under local anesthesia (10 ml of mepivacaine 1% with adrenaline 1:10,000 in 100 ml of saline). An average 10.1 ml (range, 7 to 14 ml) of adipose tissue was harvested and processed following Coleman's technique (i.e., centrifuged at 3000 rpm for 3 minutes). The adipocyte fraction was isolated and a mean volume of 1.35 ml (range, 0.7 to 2.2 ml) was injected using an 18-gauge angiographic needle with a snap-on wing (Cordis, a Johnson & Johnson Company, N.V., Roden, The Netherlands) at the dermal-subdermal junction in an area corresponding to the nipple. Dressing included a nipple-areola splint, left in place for 7 weeks, following our protocol.3 Only one patient needed a further surgical procedure 6 months later. Clinical assessment was performed 2 weeks, 6 months, and 2 years after lipostructure. The mean follow-up was 23.1 months (range, 18 to 29 months). At each clinical examination, photographs were obtained (Figs. 1 and 2) and all patients were asked whether their satisfaction degree was excellent, good, or unsatisfactory. Two weeks after lipostructure, mean nipple projection was 4.6 mm (range, 3 to 7 mm) and all patients rated their satisfaction as excellent. At 2-year follow-up examination, all patients showed a little nipple flattening caused by fat resorption (mean projection, 2.9 mm; range, 1 to 6 mm). The degree of satisfaction was good for 21 patients and excellent for three patients. Moreover, skin texture, softness, and elasticity of the nipple-areola complex were improved.Fig. 1.: Preoperative view of patient 4 of our series. The nipple is not projected.Fig. 2.: Photograph obtained 2 years postoperatively. Nipple projection is 3 mm.Considering our excellent results performing lipostructure in severely burned areas and other mature scars,2,4 we believe that nipple resuscitation is an available technique for nipple projection reconstruction. This has also shown encouraging clinical results in terms of texture, color, softness, and quality of skin patterns of the nipple- areola complex. To our knowledge, this is the first reported application of this technique in nipple projection loss following burn and trauma injuries, providing excellent results, with many advantages, including rapidity, ease, and safety. Fabio Caviggioli, M.D. Federico Villani, M.D. Davide Forcellini, M.D. Valeriano Vinci, M.D. Francesco Klinger, M.D. Cattedra di Chirurgia Plastica Università degli Studi di Milano U.O. Chirurgia Plastica 2 IRCCS Istituto Clinico Humanitas Rozzano, Milano, Italy DISCLOSURE The authors have no commercial associations or financial interests to disclose.
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