Dr. Koumanis creates nipples when the nipples and areolas must be excised during a mastectomy due to breast cancer. The nipple flap reconstruction is the final surgical step in the breast reconstruction process. It is performed either under local anesthesia, light/deep conscious sedation or general anesthesia depending on the patient’s medical circumstances or preference. The nipple flap is created using the patient’s native skin in the are and the tissues are essentially rearranged and folded over to create the nipples.
The first step in the markings which are performed in the preoperative holding area. Then the flaps are surgically created by lifting tissue in the form of a ¾ star pattern with three limbs. The limbs of the star flap are then interdigitated to form a cylinder type shape which is the sewn together and then sewn back down onto the skin of the breast mound. Once healing has occurred and the scars have had at least 3 months of maturation, our patients are referred to a medical tattoo artist to finalize the appearance. Figures of measurements, rendering of the procedure and actual cases of Dr. Koumanis follow this case description.
Key Markings from Sternal Notch to each Nipple (SN-N), Nipple to Nipple (N-N), Nipple to Inframammary Fold (N-IMF) and Mid-Sternal Line (MSL).
Creation of Star Flap for nipple reconstruction as described by Shestak et al. and Gurunluoglu et al. Schematic recreated with some variation.
Modified star flap design with a superior-based pedicle. The pedicle is the blood supply to the flap. In this patient, the flap will remain attached at the top or superiorly as represented here by the two vertical lines drawn.
Patient of Dr. Koumanis. Close-up of immediate postoperative result of nipple reconstruction with a modified star flap
Patient of Dr. Koumanis. Implant based breast reconstruction: Nipple flaps healed and ready for tattoo
Transition preoperative, to nipple flap stage, and final result with nipple/areola tattoos completed.