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1.  Our Experiences in Nipple Reconstruction Using the Hammond flap 
Archives of Plastic Surgery  2014;41(5):550-555.
Nipple reconstruction following breast mound reconstruction is the final step in breast reconstruction. Although nipple reconstruction is a simple surgery, the psychological aspects of nipple reconstruction are thought to be important. Nipple projection is a key factor in determining patient satisfaction with the surgery. In the present study, the Hammond flap technique was introduced for nipple reconstruction.
Twenty-six patients who had undergone breast reconstruction from February 2008 to March 2012 were enrolled in this prospective study. All patients were evaluated based on preoperative photos, and their nipple diameters and heights were measured. Postoperative evaluation was conducted 3, 6, 9, and 12 months following nipple reconstruction. A questionnaire on patient satisfaction with the nipple reconstruction was administered 12 months after nipple reconstruction. Moreover, the same plastic surgeon scored nipple projection and overall cosmetic result of the new nipple.
The mean projection was 4.4 mm (range, 3-6 mm), and it well matched the contralateral nipple. Twelve months following nipple reconstruction, the mean reduction rate in the nipple projection was 43.6%. Patients were satisfied or very satisfied with the nipple projection and the overall cosmetic result in 80.7% cases.
In the present study, compared with other techniques, the use of the Hammond flap technique in nipple reconstruction showed competitive results with regard to nipple projection and patient satisfaction.
PMCID: PMC4179360  PMID: 25276648
Nipples; Surgery; Plastic; Mammaplasty
2.  A modified technique for nipple-areola complex reconstruction 
From a historical perspective, many techniques of nipple reconstruction have been performed, including a graft from the contralateral nipple, composite grafts such as toe pulp or earlobe tissue and even an intra-dermal tattoo alone. This is the final stage of breast reconstruction, and is carried out only when the surgeon is confident that acceptable symmetry and shape of the reconstructed breast has been achieved. The technical challenges of nipple reconstruction include correcting position, maintaining adequate projection and creating an inconspicuous scar. An alternative to a surgically reconstructed nipple is the use of silicone prosthetic nipples.
Materials and Methods:
From August 2006 until September 2007, 80 cases of nipple/areola reconstruction were performed in our department (UDINE UNIV.) following mammary reconstruction or conservative breast surgery. Forty cases were carried out with the classical technique and another 40 cases with the introduction of our modification in the form of deepithelization of a semicircular area of the adjacent skin at the base of the flap. Postoperative follow-up as regards the nipple size, site, projection, symmetry and donnar scar were assessed. Patient satisfaction was also addressed and evaluated.
There were good to excellent results as regards nipple size, symmetry and projection. The technique is suitable for different autologous and implant reconstruction. The technique is an outpatient procedure, is easy and is not consuming time. Areolar graft from the contra-lateral areola is colouur matching and shows nearly no deference from the opposite one.
Simple technique and not time consuming. Maintains the consistency and projection of the new nipple. Patient satisfaction. Minimal complication.
PMCID: PMC3111130  PMID: 21713165
Areola; breast; niple; reconstruction
3.  Nipple Reconstruction with Rolled Dermal Graft Support 
Archives of Plastic Surgery  2014;41(2):158-162.
Loss of nipple projection is a common problem following nipple reconstruction. The aim of this study was to demonstrate that the use of a tightly rolled dermal graft is effective in the long-term maintenance of nipple projection.
Nipple reconstruction was performed using the C-V flap technique. A dermal graft was harvested from the dog-ear portion of previous scars. The graft was rolled tightly into a compact cylinder and used to augment the nipple reconstruction. Postoperatively, stacked Allevyn dressing was used for protecting the nipple from compression for a minimum of two months. Nipple projection was measured at the time of surgery and at 12 months postoperatively.
Forty nipple reconstructions were performed using this technique. There were 19 transverse rectus abdominis musculocutaneous (TRAM) flaps, 10 latissimus dorsi (LD) flaps, and 11 tissue-expanded breast mounds. At one year, the mean projection was 0.80 cm (range, 0.62-1.22 cm). The twelve-month average maintenance of nipple projection was 70.2% for the TRAM flap group, 76.3% for the LD flap group, and 61.8% for the tissue-expanded group. In two patients with previous irradiation of the reconstructed breasts, relatively poor maintenance of nipple projection was noted (45.7%). No complications were noted, and all of the donor sites healed well primarily.
Our results demonstrated that the use of a C-V flap with a tightly rolled dermal graft for nipple reconstruction improves the long-term maintenance of nipple projection. Its advantages include reproducibility, technical simplicity, cost-effectiveness, and minimal donor site morbidity.
PMCID: PMC3961614  PMID: 24665425
Mammaplasty; Nipples; Dermis; Transplants
4.  Nipple Reconstruction: Risk Factors and Complications after 189 Procedures 
European journal of plastic surgery  2013;36(10):633-638.
A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction.
Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy.
A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001).
While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead.
Level of Evidence
PMCID: PMC3780439  PMID: 24072956
5.  Early Results of an Endoscopic Nipple-Sparing Mastectomy for Breast Cancer 
Endoscopic mastectomy has been reportedly associated with smaller scars and greater patient satisfaction; however, few reports on this topic have been made. The purpose of this retrospective study was to examine the early results of endoscopic nipple-sparing mastectomy (ENSM) and to investigate the safety of this procedure.
Between January 2002 and December 2005, a total of 87 patients with breast cancer but without skin and nipple involvement, including two cases of bilateral breast cancer, underwent E-NSM. In case of bloody nipple discharge and suspicious extension near the nipple as assessed by magnetic resonance imaging, the major ducts within the nipple were cored (nipple coring). In other cases, nipple coring was not performed.
Of the 89 breasts in 87 patients, 42 had tumors of >2 cm and 80 were diagnosed as having invasive carcinoma. Lymph node involvement was observed in 36 procedures. The overall rate of nipple necrosis was 18% (16 of 89). The rate of nipple necrosis among the procedures with nipple coring was statistically higher than that among those without nipple coring (7 of 17, 41%, vs. 9 of 72, 13%) (P = .01). Nipple involvement was observed in 2.2% (2 of 89). After a median follow-up period of 52 months, distant metastasis was observed in nine cases; no local recurrences occurred in this series.
E-NSM is an oncologically safe procedure and an acceptable method in selected patients requiring a mastectomy. The higher rate of nipple necrosis may have been the result of a technical problem, indicating the need for continued improvement in nipple coring procedures.
PMCID: PMC3372951  PMID: 22695768
6.  The Efficacy of Artecoll Injections for the Augmentation of Nipple Projection in Breast Reconstruction 
Eplasty  2010;10:e7.
Introduction: Various techniques have been used in an attempt to achieve long-term nipple projection following nipple-areolar reconstruction. A common setback, however, is the diminution of projection overtime; this phenomenon is particularly evident following implant-based breast reconstruction. Artecoll may be suitable for injection into the nipple complex to maintain permanent, 3-dimensional projection. Artecoll is an injectable substance that is biocompatible and immunologically inert and resists degradation in vivo. The purpose of this study was thus to prospectively evaluate the efficacy of Artecoll (polymethylmethacrylate microspheres suspended in 3.5% denatured bovine collagen with 0.3% lidocaine) in obtaining and maintaining nipple projection following postmastectomy, nipple-areolar reconstruction. Methods: A prospective, clinical trial was performed. Consecutive patients deemed to have inadequate nipple projection at least 6 months following “C-V flap” or “modified-skate flap” reconstruction were identified. Only women who had postmastectomy reconstruction with tissue expanders and implants were considered eligible for participation. Artecoll was injected under the nipple at 2 time points: baseline and 3 months. Calipers were used to measure nipple projection preinjection and postinjection at baseline, 3, 6, and 9 months. Results: Thirty-three nipples were injected in 23 patients. There were no adverse events. Prior to injection, mean nipple projection was 1.33 ± 1.0 mm. The mean increase in projection over the 9-month study period was both clinically and statistically significant (1.60 ± 1.24 mm; P <.001). A history of prior irradiation was a significant negative predictor of final nipple projection (P = .012). Conclusion: Artecoll injection is both feasible and effective in increasing and maintaining nipple projection in the setting of implant-based breast reconstruction.
PMCID: PMC2848402  PMID: 20360871
7.  Nipple Reconstruction After Implant-Based Breast Reconstruction – A “Matched-Pair” Outcome Analysis Focusing on the Effects of Radiotherapy 
The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed.
A “matched-pair” study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study.
A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23 – 69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03).
While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.
PMCID: PMC3731405  PMID: 23664573
8.  One-Stage Nipple and Breast Reconstruction Following Areola-Sparing Mastectomy 
Archives of Plastic Surgery  2013;40(5):553-558.
Skin-sparing mastectomy with immediate breast reconstruction is increasingly becoming a proven surgical option for early-stage breast cancer patients. Areola-sparing mastectomy (ASM) has also recently become a popular procedure. The purpose of this article is to investigate the reconstructive and aesthetic issues experienced with one-stage nipple and breast reconstruction using ASM.
Among the patients who underwent mastectomy between March 2008 and March 2010, 5 women with a low probability of nipple-areolar complex malignant involvement underwent ASM and immediate breast reconstruction with simultaneous nipple reconstruction using the modified C-V flap. The cosmetic outcomes of this series were reviewed by plastic surgeons and patient self-assessment and satisfaction were assessed via telephone interview.
During the average 11-month follow-up period, there were no cases of cancer recurrence, the aesthetic outcomes were graded as excellent to very good, and all of the patients were satisfied. Two patients developed a gutter-like depression around the reconstructed nipple, and one patient developed skin erosion in a small area of the areola, which healed with conservative dressing. The other complications, such as necrosis of the skin flap or areola, seroma, hematoma, or fat necrosis did not occur.
Since one-stage nipple and breast reconstruction following ASM is an oncologically safe, cost-effective, and aesthetically satisfactory procedure, it is a good surgical option for early breast cancer patients.
PMCID: PMC3785589  PMID: 24086809
Breast; Mammaplasty; Nipples; Mastectomy
9.  Accessory nipple reconstruction following a central quadrantectomy: a case report 
Cases Journal  2009;2:32.
nipple dichotomy (or intra-areolar polythelia) is a rare congenital malformation in which one or more supernumerary nipples are located within the same areola.
A case of a woman undergoing a central quadrantectomy with a contralateral supernumerary nipple used for reconstruction is reported. No other report in the Literature, according to our search, has focused on reconstructive use of an accessory nipple after breast conserving surgery.
Case presentation
the patient is a 73 year-old Caucasian woman, who two years earlier underwent a lower-outer left Quadrantectomy plus axillary sampling and radiation therapy for a 2,2 cm lobular carcinoma with no lymph node involvement.
A routine follow-up assessment showed an important fibrotic change on the operated breast, just across the infra-mammary fold; at a breast Magnetic Resonance Imaging, a 1,5 cm area in retroareolar position, suspicious for local recurrence, was evident.
An open biopsy was therefore performed, under local anaesthesia, including the nipple-areolar complex to realize a central Quadrantectomy with a Grisotti procedure; a congenital dichotomic nipple in the contralateral breast was then used to repair the defect through a "nipple-sharing" technique. The final histological examination reported a fibrotic mastopathy without atypias.
in this case, the "nipple-sharing" technique has allowed in the same time the correction of a rare congenital defect and provided the surgeon with a supernumerary nipple to be used in the immediate reconstruction after breast conserving surgery.
PMCID: PMC2639561  PMID: 19133154
10.  A self-made disposable iris retractor in small pupil phacoemulsification 
To explore a simple and low-cost self-made disposable flexible iris retractor and study its clinical efficacy and safety in small pupil phacoemulsification.
Polyproplyene suture and scalp acupuncture were used to make iris retractor. A prospective study were carried on 50 patients (50 eyes) with a maximally dilated pupil size of 2.5-4.0 mm which underwent phacoemulsification using this self-made iris retractor. Another 50 cases of phacoemulsification with normal pupil size sever as control group. The mean operation time, ultrasound time and ultrasonic power, volume of irrigation fluid were documented intraoperatively. The visual acuity, pupil size and complication were observed on 1d, 1wk, 1mo and 1y after operation. Corneal endothelial cell was measured at 1mo postoperatively.
Pupils could be expanded to approximately 4.5-5.5 mm with our self-made iris retractor in operation. No serious postoperative complication was found. Most (88%) of the pupils returned round or oval shape, light reflex restored to varying degrees at the first day after surgery. Best corrected visual acuity stabilized in 37 eyes (74%) at one day, in 43 eyes (86%) at one week, in 44 eyes (88%) at one month and 46 eyes (92%) at one year. Compared with the control, more time was needed to complete the operation in the small pupil group. There was no significant difference of the mean ultrasound time, ultrasonic power, volume of irrigation fluid required and corneal endothelial cell loss in 1mo follow up between the two groups.
Our self-made disposable flexible iris retractor could be easy obtained preoperatively or intraoperatively. It performed both safety and efficacy in our clinical trials. This simple self-made device has shown economic and practical values, especially in primary care hospital of the less developed districts.
PMCID: PMC4003084  PMID: 24790872
small pupil; iris retractor; phacoemulsification
11.  Patient satisfaction following nipple reconstruction incorporating autologous costal cartilage 
Nipple-areolar reconstruction completes post-mastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time.
To determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction.
Sixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction.
Of 26 respondents (mean ± SEM follow-up period 3.7±3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstructions. While both groups would opt for nipple reconstruction again, patients with cartilage grafts incorporated into their reconstructions had overall satisfaction ratings 1.92 grades higher on average (not significant, P=0.12) than those without. This difference increased to 3.2 grades when the satisfaction of the patient’s partner was taken into account (P<0.05). Improved satisfaction corresponded to higher scores for volume, consistency, texture, and particularly for projection and contour of the nipple (P<0.05). Although nipple morphology changed over time, there was a trend toward improved stability in the cartilage group.
Patient satisfaction with nipple reconstruction can be improved by incorporating costal cartilage beneath the skin flaps. Superior contour and projection are sustained over time.
PMCID: PMC2691559  PMID: 19554171
Autologous cartilage; Nipple reconstruction
12.  Impact of Surgical Techniques, Biomaterials, and Patient Variables on Rate of Nipple Necrosis after Nipple-Sparing Mastectomy 
Plastic and reconstructive surgery  2013;132(3):330e-338e.
Nipple-sparing mastectomy (NSM) is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the rate of nipple necrosis after NSM is relatively high (10% to 30%). No study has specifically evaluated whether clinical and technical factors contribute to nipple necrosis after NSM. The objectives of this study were to determine the impact of clinicopathologic and surgical variables on rates of partial and total nipple necrosis after NSM and to compare overall complication rates between NSM and skin-sparing mastectomy (SSM).
The study included 233 cases, 113 had NSM and immediate breast reconstruction and 120 matched (for disease stage, comorbidities, and age) cases of SSM and immediate reconstruction performed at our institution from September 2003 through May 2011. Complications were analyzed using the Fisher’s exact test, and in the NSM group, clinicopathologic and surgical variables were analyzed using Rao-Scott chi-squared tests for relationship with partial or total nipple necrosis.
The overall complication rate was 28% for NSM and 27% for SSM (p>0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate of complications was significantly higher in the NSM group than in the SSM group (26% versus 9%; p=0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the overall complication rate did not differ between the two groups. For NSM, the overall incidence of any (partial or total) nipple necrosis was 20%. There were only 2 cases (2%) with total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (34% for C cup; 6% for A and B cup; p=0.003). Smoking (p=0.08) and vascular comorbidities (p=0.09) did not reach statistical significance as predictors of nipple necrosis. The other factors analyzed were not predictors of nipple necrosis.
We found no significant difference in the overall incidence of complications in patients who have NSM compared to those who have SSM. Interestingly, the exclusion of axillary lymphatic surgery in patients undergoing risk-reducing NSM for high breast cancer risk did not decrease the incidence of complications, probably because of the inherent technical complexity of performing NSM in and of itself. Although partial nipple necrosis did occur quite frequently (19%), total nipple necrosis after NSM occurred infrequently (2%). Importantly, patients with breast size of C cup or larger had an increased risk for nipple necrosis after NSM and immediate breast reconstruction.
Clinical Level of Evidence
Therapeutic, III.
PMCID: PMC3935717  PMID: 23985644
13.  Reducing Donor Site Morbidity When Reconstructing the Nipple Using a Composite Nipple Graft 
Archives of Plastic Surgery  2012;39(4):384-389.
Numerous procedures are available for nipple reconstruction without a single gold standard. This study presents a method for reducing donor-site morbidity in nipple reconstruction using a composite nipple graft after transverse rectus abdominis musculocutaneous flap breast reconstruction.
Thirty-five patients who underwent nipple reconstruction using a composite nipple graft technique between July of 2001 and December of 2009 were enrolled in this study. To reduce the donor site morbidity, the superior or superior-medial half dome harvesting technique was applied preserving the lateral cutaneous branch of the fourth intercostal nerves. The patients were asked to complete a previously validated survey to rate the color and projection of both nipples, along with the sensation and contractility of the donor nipple; and whether, in retrospect, they would undergo the procedure again. To compare projection, we performed a retrospective chart review of all the identifiable patients who underwent nipple reconstruction using the modified top hat flap technique by the same surgeon and during the same period.
Thirty-five patients were identified who underwent nipple reconstruction using a composite nipple graft. Of those, 29 patients (82.9%) responded to the survey. Overall, we received favorable responses to the donor site morbidity. Projection at postoperative 6 months and 1 year was compared with the immediate postoperative results, as well as with the results of nipples reconstructed using the modified top hat flap.
The technique used to harvest donor tissue is important. Preserving innervation of the nipple while harvesting can reduce donor site morbidity.
PMCID: PMC3408285  PMID: 22872843
Morbidity; Nipples; Reconstructive surgical procedures
14.  Aesthetic Design of Skin-Sparing Mastectomy Incisions for Immediate Autologous Tissue Breast Reconstruction in Asian Women 
Archives of Plastic Surgery  2014;41(4):366-373.
The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer.
We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision.
281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction.
Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.
PMCID: PMC4113696  PMID: 25075359
Mastectomy; Mammaplasty; Breast; Asia; Esthetics
15.  Staphylococcus aureus and sore nipples. 
Canadian Family Physician  1996;42:654-659.
OBJECTIVE: To correlate clinical symptoms and signs of sore nipples with the presence of Staphylococcus aureus and to determine the probability of mothers having S aureus-infected nipples when these local symptoms and signs are found. DESIGN: Two cohorts of consecutive patients were enrolled regardless of presenting complaint. A questionnaire was administered to determine the presence and severity of sore nipples. Objective findings on breast examination were documented. A nipple swab was taken for culture and sensitivity. SETTING: Breastfeeding clinic serving patients referred by family physicians, pediatricians, and community health nurses. PATIENTS: A sample of 227 breastfeeding mothers was collected in two cohorts. MAIN OUTCOME MEASURES: Answers to questions about sore nipples, objective findings from physical examination, and results from nipple swabs. RESULTS: Most subjects (51%) had sore nipples, and 45% of subjects had objective findings on examination; 23% of subjects had a positive nipple swab culture; 15% grew S aureus on culture. The risk of having S aureus colonization was 4.8 times greater if nipple pain was moderate or severe rather than mild. A break in nipple integument associated with cracks, fissures, ulcers, or pus gave a 35% chance of having S aureus colonization, five times greater than when the integument was intact. CONCLUSIONS: The study showed that mothers with infants younger than 1 month who complained of moderate to severe nipple pain and who had cracks, fissures, ulcers, or exudates had a 64% chance of having positive skin cultures and a 54% chance of having S aureus colonization.
PMCID: PMC2146426  PMID: 8653033
16.  Effect of peppermint water on prevention of nipple cracks in lactating primiparous women: a randomized controlled trial 
Nipple pain and damage in breastfeeding mothers are common causes of premature breastfeeding cessation. Peppermint water is popularly used for the prevention of nipple cracks in the North West of Iran. The aim of this study was to determine the effectiveness of peppermint water in the prevention of nipple cracks during breastfeeding in comparison with the application of expressed breast milk (EBM).
One hundred and ninety-six primiparous breastfeeding women who gave birth between February and May 2005 in a teaching hospital in Tabriz, Iran, were randomized to receive either peppermint water or EBM. Each woman was followed for up to three visits or telephone calls within 14 days and then by telephone call at week six postpartum.
Women who were randomized to receive peppermint water were less likely to experience nipple and areola cracks (9%) compared to women using EBM (27%; p < 0.01). Women who used the peppermint water on a daily basis were less likely to have a cracked nipple than women who did not use peppermint water (relative risk 3.6, 95%CI: 2.9, 4.3). Nipple pain in the peppermint water group was lower than the expressed breast milk group (OR 5.6, 95% CI: 2.2, 14.6; p < 0.005).
This study suggests that peppermint water is effective in the prevention of nipple pain and damage. Further studies are needed to assess the usefulness of peppermint water in conjunction with correct breastfeeding techniques.
Trial registration number: NCT00456404
PMCID: PMC1865372  PMID: 17442122
17.  Magnetic Resonance Imaging and Clinicopathological Factors for the Detection of Occult Nipple Involvement in Breast Cancer Patients 
Journal of Breast Cancer  2014;17(4):386-392.
Nipple sparing mastectomy provides good cosmetic results and low local recurrence rates for breast cancer patients. However, there is a potential risk of leaving an occult tumor within the nipple, which could lead to cancer relapse and poor prognosis for the patient. The objective of this study was to investigate the occult nipple involvement rate in mastectomy specimens, and to identify preoperative magnetic resonance imaging (MRI) findings and the clinicopathological characteristics of the primary tumor that may correlate with nipple invasion.
Four hundred sixty-six consecutive mastectomy samples with grossly unremarkable nipples were evaluated. Demographic and clinicopathological data were collected. Nipple involvement was evaluated using serial histological sections. The tumor size and tumor-nipple distance were measured using preoperative MRI images.
Thirty-six of the 466 therapeutic mastectomy specimens (7.7%) were found to have occult nipple involvement. In univariate analysis, tumor size, tumor-nipple distance, lymph node status, p53 mutation, and lymphovascular invasion (LVI) were found to influence the likelihood of nipple involvement. Multivariate logistic regression analysis, adjusted by lymph node status, p53 mutation, and LVI, showed that tumor size and tumor-nipple distance were predictive factors indicating nipple involvement. With regard to tumor location, only tumors in the central area of the breast showed a significant association with nipple involvement.
In this study, a statistically significant association was found between occult nipple involvement and tumor size, tumor-nipple distance, axillary lymph node status, LVI, and p53 mutation. A cutoff point of 2.2 cm for tumor size and 2 cm for tumor-nipple distance could be used as parameters to predict occult nipple involvement.
PMCID: PMC4278059  PMID: 25548588
Breast; Carcinoma; Magnetic resonance imaging; Mastectomy
18.  Computerized nipple identification for multiple image analysis in computer-aided diagnosis 
Medical physics  2004;31(10):2871-2882.
Correlation of information from multiple-view mammograms (e.g., MLO and CC views, bilateral views, or current and prior mammograms) can improve the performance of breast cancer diagnosis by radiologists or by computer. The nipple is a reliable and stable landmark on mammograms for the registration of multiple mammograms. However, accurate identification of nipple location on mammograms is challenging because of the variations in image quality and in the nipple projections, resulting in some nipples being nearly invisible on the mammograms. In this study, we developed a computerized method to automatically identify the nipple location on digitized mammograms. First, the breast boundary was obtained using a gradient-based boundary tracking algorithm, and then the gray level profiles along the inside and outside of the boundary were identified. A geometric convergence analysis was used to limit the nipple search to a region of the breast boundary. A two-stage nipple detection method was developed to identify the nipple location using the gray level information around the nipple, the geometric characteristics of nipple shapes, and the texture features of glandular tissue or ducts which converge toward the nipple. At the first stage, a rule-based method was designed to identify the nipple location by detecting significant changes of intensity along the gray level profiles inside and outside the breast boundary and the changes in the boundary direction. At the second stage, a texture orientation-field analysis was developed to estimate the nipple location based on the convergence of the texture pattern of glandular tissue or ducts towards the nipple. The nipple location was finally determined from the detected nipple candidates by a rule-based confidence analysis. In this study, 377 and 367 randomly selected digitized mammograms were used for training and testing the nipple detection algorithm, respectively. Two experienced radiologists identified the nipple locations which were used as the gold standard. In the training data set, 301 nipples were positively identified and were referred to as visible nipples. Seventy six nipples could not be positively identified and were referred to as invisible nipples. The radiologists provided their estimation of the nipple locations in the latter group for comparison with the computer estimates. The computerized method could detect 89.37% (269/301) of the visible nipples and 69.74% (53/76) of the invisible nipples within 1 cm of the gold standard. In the test data set, 298 and 69 of the nipples were classified as visible and invisible, respectively. 92.28% (275/298) of the visible nipples and 53.62% (37/69) of the invisible nipples were identified within 1 cm of the gold standard. The results demonstrate that the nipple locations on digitized mammograms can be accurately detected if they are visible and can be reasonably estimated if they are invisible. Automated nipple detection will be an important step towards multiple image analysis for CAD.
PMCID: PMC2898150  PMID: 15543797
computer-aided detection; mammography; nipple detection; texture orientation field analysis
19.  Squamous cell carcinoma of the nipple following radiation therapy for ductal carcinoma in situ: a case report 
Radiation-induced nonmelanoma skin cancer was first reported seven years after the discovery of X-rays, but has received relatively little consideration in the literature. Specifically, nonmelanoma skin cancer after conservative surgery and radiation for early stage breast cancer has not been well studied. We report the case of a woman who developed squamous cell carcinoma of the nipple nine years after conservative surgery and radiation for ductal carcinoma in situ of the ipsilateral breast. We also review the relevant literature available to date.
Case presentation
A 66-year-old African-American woman presented to the hospital with a non-healing ulcer of the right nipple. Her past medical history was significant for right breast ductal carcinoma in situ for which she had undergone lumpectomy and whole breast radiation therapy nine years previously. Mammography and magnetic resonance imaging studies were negative for recurrent breast cancer. However, the latter demonstrated abnormal enhancement in the nipple-areolar region. An incisional biopsy of the lesion demonstrated invasive squamous cell carcinoma. Subsequently, the patient underwent wide excision of the nipple-areolar complex. Sentinel lymph-node biopsy was offered but our patient declined. She was considered to have local disease and hence no further treatment was recommended.
This case represents the first reported occurrence of squamous cell carcinoma of the nipple to follow conservative surgery and radiation for ductal carcinoma in situ of the ipsilateral breast. It is likely that radiation overexposure resulted in a radiation burn and subsequent radiodermatitis, placing it at risk for squamous cell carcinoma. A diagnosis of squamous cell carcinoma should be considered in a patient with a nipple lesion following radiation therapy for breast cancer.
PMCID: PMC2907399  PMID: 20565942
20.  The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction 
The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis.
A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis.
Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis.
The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.
PMCID: PMC3269196  PMID: 23204883
Acellular dermis; Breast reconstruction; Nipple-areola complex; Nipple-sparing mastectomy; Nipple necrosis; Tissue expansion
21.  Vertical mammaplasty: Postoperative changes, complications and patient evaluation 
The aim of the present study was to investigate postoperative changes after vertical mammaplasty. Between 2002 and 2005, 72 consecutive patients aged 15 to 69 years with an average weight of 72 kg underwent bilateral vertical mammaplasty. Forty-two patients attended the regular follow-up one week, four weeks, three months, six months and one year after the operation. Nipple diameter, notch-to-nipple distance, scar length and the number of skin folds along the vertical scar were evaluated. Complications were recorded during the entire follow-up period. A questionnaire was used to document patient satisfaction 12 months after the operation. The main changes took place during the first three months after surgery. Nipple diameter showed an average increase of 28% after surgery, and the notch-to-nipple distance increased by an average of 17% over the intraoperative value. The average increase of the scar length after one year was 22%. The rate of complications was low, and patient satisfaction was high.
PMCID: PMC2686044  PMID: 19554130
Complications; Notch-to-nipple distance; Patient satisfaction; Vertical mammaplasty
22.  A descriptive study of Swedish women with symptoms of breast inflammation during lactation and their perceptions of the quality of care given at a breastfeeding clinic 
Women's perceptions of quality of care during episodes of breast inflammation have been scantily explored. It was the objective of the present study to describe a cohort of breastfeeding women with inflammatory symptoms of the breast during lactation regarding demographical variables, illness history and symptoms at first contact with a breastfeeding clinic and to explore their physical health status, psychological well-being and perceptions of quality of care received, at a six-week postal follow-up.
This is a descriptive study set at a midwife-led breastfeeding clinic in Sweden, which included a cohort of women with 210 episodes of breast inflammation. The women had taken part in a RCT of acupuncture and care interventions and were recruited between 2002 and 2004. Of the total cohort, 176 (84 %) responded to a postal questionnaire, six weeks after recovery.
Of the 154 women for whom body temperature was recorded at the first visit, 80 (52%) had fever ranging from 38.1°C to 40.7°C. There was no significant difference between those with favourable outcomes (5 or less contact days) and those with less favourable outcomes (6 or more contact days) for having fever or no fever at first contact. Thirty-six percent of women had damaged nipples. Significantly more women with a less favourable outcome (6 or more contact days) had damaged nipples. Most women recovered well from the episode of breast inflammation and 96% considered their physical health and 97% their psychological well-being, to be good, six weeks after the episode. Those whose illness lasted 6 days or more showed less confidence in the midwives and in the care given to them. Twenty-one (12%) women contacted health care services because of recurring symptoms and eight of the 176 responders (4.5%) were prescribed antibiotics for these recurring symptoms. A further 46 women (26% of the responders) reported recurring symptoms that they managed without recourse to health care services.
Initial fever may not be indicative of outcomes for women with inflammatory breast symptoms and treatment by antibiotic therapy may be necessary less often than has been supposed. Women who are also suffering from damaged nipples may need special attention. Those with protracted symptoms were less satisfied with care and showed less confidence in caregivers. International research collaboration might help us find the optimal level of antibiotic therapy for this group of women. This is an important consideration for the global community.
PMCID: PMC1784075  PMID: 17244353
23.  Presence of papillomavirus sequences in condylomatous lesions of the mamillae and in invasive carcinoma of the breast 
Breast Cancer Research  2004;7(1):R1-R11.
Viruses including Epstein–Barr virus (EBV), a human equivalent of murine mammary tumour virus (MMTV) and human papillomavirus (HPV) have been implicated in the aetiology of human breast cancer. We report the presence of HPV DNA sequences in areolar tissue and tumour tissue samples from female patients with breast carcinoma. The presence of virus in the areolar–nipple complex suggests to us a potential pathogenic mechanism.
Polymerase chain reaction (PCR) was undertaken to amplify HPV types in areolar and tumour tissue from breast cancer cases. In situ hybridisation supported the PCR findings and localised the virus in nipple, areolar and tumour tissue.
Papillomavirus DNA was present in 25 of 29 samples of breast carcinoma and in 20 of 29 samples from the corresponding mamilla. The most prevalent type in both carcinomas and nipples was HPV 11, followed by HPV 6. Other types detected were HPV 16, 23, 27 and 57 (nipples and carcinomas), HPV 20, 21, 32, 37, 38, 66 and GA3-1 (nipples only) and HPV 3, 15, 24, 87 and DL473 (carcinomas only). Multiple types were demonstrated in seven carcinomas and ten nipple samples.
The data demonstrate the occurrence of HPV in nipple and areolar tissues in patients with breast carcinoma. The authors postulate a retrograde ductular pattern of viral spread that may have pathogenic significance.
PMCID: PMC1064094  PMID: 15642157
areolar tissue; breast carcinoma; papillomavirus
24.  Bilateral reduction mammoplasty following breast cancer: A case-control study 
Little information has been published regarding reduction mammoplasty performed on women previously treated for breast cancer. Although there can be changes in the shape and size of the treated breast as a result of lumpectomy or radiation treatment, it is usually minimal, resulting in asymmetry. It is unclear whether reduction mammoplasty in the radiated breast can be safely performed without interfering with mammography and cancer surveillance. This matched case-control study reviewed the outcomes of patients who underwent bilateral reduction mammoplasty following lumpectomy and radiation for breast cancer. The authors stress that patients must be informed of the potential risks of postoperative complications and require careful follow-up.
Many women undergo a bilateral reduction mammoplasty after lumpectomy and radiation for breast cancer due to breast hypertrophy. The outcomes of these patients, focusing on complications and the need for additional surgery, are reviewed.
A matched case-control study with patients serving as their own control (treated breast cancer breasts were ‘cases’, healthy breasts were ‘controls’) was performed. Patients were identified through hospital records between 1980 and 2007. Patients treated by lumpectomy and radiation with subsequent bilateral reduction surgery were included. Data regarding demographics, medical history, and peri- and postoperative complications were collected. Measured outcomes included hematoma or seroma, delayed wound healing, infection, nipple-areolar complex problems, scarring, asymmetry and the need for further surgery. Continuous variables are reported as mean ± SD, and categorical variables are reported as proportions.
Of the nine patients included in the study, delayed wound healing occurred in 22% of cases. Wound infections occurred in 66.7% of cases, with 22.2% experiencing a second wound infection. One patient experienced partial nipple-areolar complex loss on the radiated breast. There was abnormal scarring in 33.3% of radiated breasts. Postoperative asymmetry occurred in 77.8% of patients. Additional surgery was performed on three patients (33.3%).
Results of the present study suggest that women with a history of breast cancer treated by lumpectomy and radiation experience higher occurrence of postoperative complications on the radiated breast following bilateral breast reduction. Patients must be informed of these potential risks and require careful postoperative follow-up. An appropriately powered, prospective, multicentred study is required to draw definitive conclusions.
PMCID: PMC3307685  PMID: 23598771
Bilateral reduction mammoplasty; Breast hypertrophy; Radiation
25.  Breast Positioning during Mammography: Mistakes to be Avoided 
Breast positioning is the key factor affecting a mammogram. If care is taken during positioning, it maximizes the amount of breast tissue being imaged, eliminates most of the artifacts, and increases sensitivity of the mammogram. This retrospective study was carried out in our department to assess correctness, and also the incorrectness of breast positioning, which need to be avoided to obtain an ideal mammogram.
A total of 1369 female patients were included in this study. Mammography was performed on full field detector digital mammography equipment. Craniocaudal (CC) view and mediolateral oblique (MLO) view were carried out for each breast. Four views were done for 1322 patients. The remaining 47 patients had undergone a mastectomy and underwent two views for the other breast. Mistakes in improperly positioned mammogram were assessed with respect to proper visualization of nipple, position of pectoralis major, pectoral–nipple distance (PND), inframammary fold, and adequate coverage of all breast quadrants.
As per prescribed guidelines, mistakes in positioning were recognized in 2.879% of total mammograms. Improper positioning of the nipple was the commonest problem, seen in 3.827% of mammograms, CC view. On MLO view, bilaterally, pectoralis shadow was not seen in 0.520% mammograms, its margin was not straight/convex in 0.706%, lower edge of pectoralis was above pectoralis–nipple line in 2.081%, and inframammary fold was not seen in 1.189%. There was inadequate coverage of lower quadrants in 2.787%, and mismatch in PND was seen in 3.864%. In few of the patients, the shortcomings as a result of improper positioning were noted on one view, the rest being normal.
Positioning is the most important factor affecting the resultant mammography image. During mammography, many cases are improperly positioned and as a result the examination is inconclusive, which reduces the sensitivity of mammography.
PMCID: PMC4125373  PMID: 25125982
mammography; positioning; mistakes

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