British Journal of Plastic Surgery (2002) 55, 504-506 9 2002 The BritishAssociationof Plastic Surgeons doi: 10.1054/bjps.2002.3895

PLASTIC

SURGERY

The Marshall technique: an economic one-stage technique for nipple-areola reconstruction J. M. Skillman, O. Ahmed, B. Dheansa and A. R. Rowsell

Department of Plastic Surgery, St Thomas'Hospital, London, UK SUMMARY. The goals of nipple-areola reconstruction are symmetry in position, shape, size, colour, tone, texture, sensation and responsiveness. These goals are best attempted when the breast-mound reconstruction has been completed. We describe a technique in which the skin of the neo-areola is raised as a split-thickness skin graft, and then re-grafted to the same site with a free nipple graft. This technique is always available, requires no special equipment, causes no donor-site morbidity and produces excellent results. The disadvantage is that it may be more difficult following radiotherapy or if the mastectomy scar traverses the desired site of nipple-areola reconstruction. As with any skin graft, the neo-areola may lose pigmentation, imperfectly 'take' or contract with time. This technique has not been previously described in the literature. 9 2002 The British Association of Plastic Surgeons

Keywords: nipple-areola reconstruction, free nipple graft.

The goals of nipple-areola reconstruction are symmetry in position, shape, size, colour, tone, texture, sensation and responsiveness. 1 These goals are best attempted when the breast-mound reconstruction has been completed. We describe a technique in which the skin of the neo-areola is raised as a split-thickness skin graft, and then re-grafted to the same site with a free nipple graft. The senior author (ARR) has used this technique in 30 breasts. The colour of the grafts has been well maintained, and there have been no graft losses. This technique has not previously been described in the literature.

The manual elevation of the graft produced slightly uneven areas, which gave a natural texture to the areola, and several small punctures were made to imitate Montgomery's tubercles. The graft was then secured using a tie-over bolster dressing, without compressing the nipple. 3 The dressing was removed for inspection 1 week postoperatively. At follow-up 3 months postoperatively the nipple had maintained 3 m m protrusion. The colour of the nipple and areola matched well with the normal

Method We describe a case that illustrates our method of nipple-areola reconstruction. A 48-year-old woman had a left mastectomy in 1993 for Grade I breast carcinoma. Her breast was reconstructed using a pedicled latissimus dorsi flap and a silicone gel prosthesis 18 months later. The implant was too small and too high, so in 1998 it was exchanged for a Becker type expandable prosthesis. An open capsulotomy was required for Baker Grade III capsular contracture. Once the reconstructed breast mound was optimised (Fig. 1), the position of the neonipple-areola complex was marked. The normal right breast was ptotic, preventing symmetrical placement of the nipple. The patient had declined right mastopexy. Under general anaesthesia, the periphery of the neoareola was scored and the whole disc was de-epithelialised as a single sheet, using a 15 scalpel blade. The dermal layer was left intact on the breast mound, and haemostasis was performed as necessary. A smaller central disc was removed from the skin graft. This provided a site for the horizontally shaved nipple composite graft (5 mm high) harvested from the opposite nipple; this technique of nipple reconstruction has been described elsewhere. 2

Figure 1--Lateral view of left breast following reconstruction of the breast mound.

504