Skip to main content
SpringerLink
Log in

Breast Reconstruction Under Local Anesthesia: Second-Stage Implant Exchange, Nipple Flap Reconstruction, and Nipple Flap Tattoo

  • Chapter
  • First Online:
Nipple-Areolar Complex Reconstruction

  • 950 Accesses

Abstract

Implant-based reconstruction is strictly performed in three stages in the authors’ practice. The first stage is the tissue expander and acellular dermal matrix sling procedure performed immediately after the mastectomies. The second-stage reconstruction involves the removal of the tissue expander with a small incision, replacement with a permanent silicone gel implant, and possible revisions of the breast flaps breast pocket if needed. Finally, the third stage involves nipple flap reconstruction. Patients typically wait a few months post surgeries before undergoing medical tattooing of the areola and nipple to give it a three-dimensional look. The authors discuss the techniques used for each stage, the possible complications, and the complications of anesthesia. Star flap method, out of all stages of breast implant reconstruction, is the most amenable to local anesthetic techniques due to its minimalist approach.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Phillips BT, Bishawi M, Dagum AB, Khan SU, Bui DT. A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence? Plast Reconstr Surg. 2013;131(1):1–13.

    Article  PubMed  CAS  Google Scholar 

  2. Bogue DP, Mungara AK, Thompson M, Cederna PS. Modified technique for nipple-areolar reconstruction: a case series. Plast Reconstr Surg. 2003;112(5):1274–8.

    Article  PubMed  Google Scholar 

  3. Huber KM, Zemina KL, Tugertimur B, Killebrew SR, Wilson AR, DallaRosa JV, Prabhakaran S, Dayicioglu D. Outcomes of breast reconstruction after mastectomy using tissue expander and implant reconstruction. Ann Plast Surg. 2016;76(Suppl 4):S316–9.

    Article  PubMed  CAS  Google Scholar 

  4. Nicholson RM, Leinster S, Sassoon EM. A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction. Breast. 2007;16(4):396–410.

    Article  PubMed  CAS  Google Scholar 

  5. Draper LB, Bui DT, Chiu ES, Mehrara BJ, Pusic AL, Cordeiro PG, Disa JJ. Nipple-areola reconstruction following chest-wall irradiation for breast cancer: is it safe? Ann Plast Surg. 2005;55(1):12–5.

    Article  CAS  PubMed  Google Scholar 

  6. Disa JJ, McCarthy CM, Mehrara BJ, Pusic AL, Hu QY, Cordeiro PG. Postmastectomy reconstruction: an approach to patient selection. Plast Reconstr Surg. 2009;124(1):43–52.

    Article  PubMed  CAS  Google Scholar 

  7. Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1983;1(8322):459–62.

    Article  PubMed  CAS  Google Scholar 

  8. Stevens LA, McGrath MH, Druss RG, Kister SJ, Gump FE, Forde KA. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg. 1984;73(4):619–28.

    Article  PubMed  CAS  Google Scholar 

  9. Wellisch DK, Schain WS, Noone RB, Little JW III. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg. 1985;76(5):713–8.

    Article  PubMed  CAS  Google Scholar 

  10. Rosenqvist S, Sandelin K, Wickman M. Patients’ psychological and cosmetic experience after immediate breast reconstruction. Eur J Surg Oncol. 1996;22(3):262–6.

    Article  PubMed  CAS  Google Scholar 

  11. Elder EE, Brandberg Y, Björklund T, Rylander R, Lagergren J, Jurell G, Wickman M, Sandelin K. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast. 2005;14(3):201–8.

    Article  PubMed  Google Scholar 

  12. Colque A, Eisemann ML. Breast augmentation and augmentation-mastopexy with local anesthesia and intravenous sedation. Aesthet Surg J. 2012;32(3):303–7.

    Article  PubMed  Google Scholar 

  13. Yang JD, Ryu JY, Ryu DW, Kwon OH, Bae SG, Lee JW, Choi KY, Chung HY, Cho BC. Our experiences in nipple reconstruction using the Hammond flap. Arch Plast Surg. 2014;41(5):550–5.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D’Aniello C, Nisi G. Nipple-areola complex reconstruction techniques: a literature review. Eur J Surg Oncol. 2016;42(4):441–65.

    Article  PubMed  CAS  Google Scholar 

  15. Adams WM. Labial transplant for correction of loss of the nipple. Plast Reconstr Surg. 1949;4(3):295–8.

    Article  CAS  Google Scholar 

  16. Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg. 2006;59(1):40–53.

    Article  PubMed  Google Scholar 

  17. Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009;62(5):591–5.

    Article  PubMed  CAS  Google Scholar 

  18. Berson MI. Construction of pseudoareola. Surgery. 1946;20(6):808.

    PubMed  CAS  Google Scholar 

  19. Barton FE Jr. Latissimus dermal-epidermal nipple reconstruction. Plast Reconstr Surg. 1982;70(2):234–7.

    Article  PubMed  Google Scholar 

  20. Silversmith PE. Nipple reconstruction by quadrapod flaps. Plast Reconstr Surg. 1983;72(3):422.

    Article  PubMed  CAS  Google Scholar 

  21. Chang WH. Nipple reconstruction with a T flap. Plast Reconstr Surg. 1984;73(1):140–3.

    Article  CAS  PubMed  Google Scholar 

  22. Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg. 2014;133(5):1073–5.

    Article  PubMed  CAS  Google Scholar 

  23. McKay DR. Costs of regional and general anesthesia: what the plastic surgeon needs to know. Clin Plast Surg. 2013;40(4):529–35.

    Article  PubMed  Google Scholar 

  24. Koumanis DJ, Colque A, Eisemann ML, Smith J. Breast surgery under local anesthesia: second-stage implant exchange, nipple flap reconstruction, and breast augmentation. Clin Plast Surg. 2013;40(4):583–91.

    Article  PubMed  Google Scholar 

  25. Mohamed SA, Parodi PC. A modified technique for nipple-areola complex reconstruction. Indian J Plast Surg. 2011;44(1):76–80.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Macadam SA, Ho AL, Cook EF Jr, Lennox PA, Pusic AL. Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients. Plast Reconstr Surg. 2010;125(3):761–71.

    Article  PubMed  CAS  Google Scholar 

  27. Paek LS, Giot JP, Tétreault-Paquin JO, St-Jacques S, Nelea M, Danino MA. The impact of postoperative expansion initiation timing on breast expander capsular characteristics: a prospective combined clinical and scanning electron microscopy study. Plast Reconstr Surg. 2015;135(4):967–74.

    Article  PubMed  CAS  Google Scholar 

  28. Cordeiro PG, Albornoz CR, McCormick B, Hudis CA, Hu Q, Heerdt A, Matros E. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135(6):1509–17.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  29. Krueger EA, Wilkins EG, Strawderman M, Cederna P, Goldfarb S, Vicini FA, Pierce LJ. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys. 2001;49(3):713–21.

    Article  PubMed  CAS  Google Scholar 

  30. Motwani SB, Strom EA, Schechter NR, Butler CE, Lee GK, Langstein HN, Kronowitz SJ, Meric-Bernstam F, Ibrahim NK, Buchholz TA. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys. 2006;66(1):76–82.

    Article  PubMed  Google Scholar 

  31. Nava MB, Pennati AE, Lozza L, Spano A, Zambetti M, Catanuto G. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg. 2011;128(2):353–9.

    Article  PubMed  CAS  Google Scholar 

  32. Nahabedian MY. Minimizing incisional dehiscence following 2-stage prosthetic breast reconstruction in the setting of radiation therapy. Gland Surg. 2013;2(3):133–6.

    PubMed  PubMed Central  Google Scholar 

  33. Phillips BT, Fourman MS, Bishawi M, Zegers M, O’Hea BJ, Ganz JC, Huston TL, Dagum AB, Khan SU, Bui DT. Are prophylactic postoperative antibiotics necessary for immediate breast reconstruction? Results of a prospective randomized clinical trial. J Am Coll Surg. 2016;222(6):1116–24.

    Article  PubMed  Google Scholar 

  34. Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson EG. Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130(3):495–502.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  35. Phillips BT, Halvorson EG. Antibiotic prophylaxis following implant-based breast reconstruction: what is the evidence? Plast Reconstr Surg. 2016;138(4):751–7.

    Article  CAS  PubMed  Google Scholar 

  36. Adams WP Jr, Conner WC, Barton FE Jr, Rohrich RJ. Optimizing breast pocket irrigation: an in vitro study and clinical implications. Plast Reconstr Surg. 2000;105(1):334–8.

    Article  PubMed  Google Scholar 

  37. Delay E, Mojallal A, Vasseur C, Delaporte T. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006;118(6):1303–12.

    Article  CAS  PubMed  Google Scholar 

  38. Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg. 1997;50(5):331–4.

    Article  CAS  PubMed  Google Scholar 

  39. Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108(2):361–9.

    Article  PubMed  CAS  Google Scholar 

  40. Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, Schusterman MA. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997;99(6):1602–5.

    Article  PubMed  CAS  Google Scholar 

  41. Lesavoy M, Liu TS. The diamond double-opposing V-Y flap: a reliable, simple, and versatile technique for nipple reconstruction. Plast Reconstr Surg. 2010;125(6):1643–8.

    Article  PubMed  CAS  Google Scholar 

  42. Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110(3):780–6.

    Article  PubMed  Google Scholar 

  43. Anton MA, Eskenazi LB, Hartrampf CR Jr. Nipple reconstruction with local flaps: star and wrap flaps. Semin Plast Surg. 1991;5(1):67–78.

    Article  Google Scholar 

  44. Mathes SJ, Ueno CM. Reconstruction of the nipple areola complex. In: Mathes SJ, Hentz VR, editors. Plastic surgery. Philadelphia, PA: Saunders Elsevier; 2006. p. 791–818.

    Google Scholar 

  45. Gurunluoglu R, Shafighi M, Williams SA, Kimm GE. Incorporation of a preexisting scar in the star-flap technique for nipple reconstruction. Ann Plast Surg. 2012;68(1):17–21.

    Article  PubMed  CAS  Google Scholar 

  46. Mets B, Janicki PK, James MF, Erskine R, Sasman B. Lidocaine and bupivacaine cardiorespiratory toxicity is additive: a study in rats. Anesth Analg. 1992;75(4):611–4.

    Article  PubMed  CAS  Google Scholar 

  47. Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51(4):285–7.

    Article  PubMed  CAS  Google Scholar 

  48. Marx GF. Cardiotoxicity of local anesthetics–the plot thickens. Anesthesiology. 1984;60(1):3–5.

    Article  PubMed  CAS  Google Scholar 

  49. Li J, Iorga A, Sharma S, Youn JY, Partow-Navid R, Umar S, Cai H, Rahman S, Eghbali M. Intralipid, a clinically safe compound, protects the heart against ischemia-reperfusion injury more efficiently than cyclosporine-a. Anesthesiology. 2012;117(4):836–46.

    Article  PubMed  CAS  Google Scholar 

  50. Picard J, Meek T. Lipid emulsion to treat overdose of local anaesthetic: the gift of the glob. Anaesthesia. 2006;61(2):107–9.

    Article  PubMed  Google Scholar 

  51. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88(4):1071–5.

    Article  CAS  PubMed  Google Scholar 

  52. Richter DF, Reichenberger MA, Faymonville C. Comparison of the nipple projection after reconstruction with three different methods. Handchir Mikrochir Plast Chir. 2004;36(6):374–8.

    Article  PubMed  CAS  Google Scholar 

  53. Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110(2):457–63.

    Article  PubMed  Google Scholar 

  54. Boccola MA, Savage J, Rozen WM, Ashton MW, Milner C, Rahdon R, Whitaker IS. Surgical correction and reconstruction of the nipple-areola complex: current review of techniques. J Reconstr Microsurg. 2010;26(9):589–600.

    Article  PubMed  Google Scholar 

  55. Moyer HR, Ghazi B, Saunders N, Losken A. Contamination in smooth gel breast implant placement: testing a funnel versus digital insertion technique in a cadaver model. Aesthet Surg J. 2012;32(2):194–9.

    Article  PubMed  Google Scholar 

  56. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Surg. 2006;117(1):30–6.

    PubMed  CAS  Google Scholar 

  57. Van Laeken N, Genoway K. Nipple reconstruction using a two-step purse-string suture technique. Can J Plast Surg. 2011;19(2):56–9.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Mulroy MF. Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures. Reg Anesth Pain Med. 2002;27(6):556–61.

    Article  PubMed  CAS  Google Scholar 

  59. Barash PG, Cullen BF, Stoelting RK, editors. Clinical anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 459–62.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Capital Area Plastic Surgery of New York, 377 Church Street, Saratoga Springs, NY, 12866, USA

    Dimitri J. Koumanis M.D.

  2. 262 Callaway Rd, London, ON, Canada, N6G 0M3

    Jessie Bujouves BSc

Authors
  1. Dimitri J. Koumanis M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jessie Bujouves BSc
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dimitri J. Koumanis M.D. .

Editor information

Editors and Affiliations

  1. Private Practice, Tustin, California, USA

    Melvin A. Shiffman

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Koumanis, D.J., Bujouves, J. (2018). Breast Reconstruction Under Local Anesthesia: Second-Stage Implant Exchange, Nipple Flap Reconstruction, and Nipple Flap Tattoo. In: Shiffman, M. (eds) Nipple-Areolar Complex Reconstruction. Springer, Cham. https://doi.org/10.1007/978-3-319-60925-6_70

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-60925-6_70

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60924-9

  • Online ISBN: 978-3-319-60925-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation