Key words
areola reconstruction - upper blepharoplasty - patient satisfaction
Schlüsselwörter
Areolenrekonstruktion - obere Blepharoplastik - Patientenzufriedenheit
Introduction
The choice of treatment and the therapeutic options available to patients with breast
cancer are constantly increasing [1], [2]. Breast reconstruction after mastectomy is usually done in several
stages. Reconstruction using foreign/own body tissue is followed, after an average
period of 8–12 weeks, by breast reconstruction. Reconstruction of the areola complex
can be done using skin grafts obtained from various areas of the body, such as the
upper eyelids, the groin, the inside of the upper thigh, the labia minora or the
contralateral areola. As with all types of skin transplants, morbidity in the donor
skin graft area (scarring, pigmentation changes) remains a factor which must also
be
taken into consideration when making a decision about the most suitable surgical
method [3]. Another method for reconstruction of the
nipple areola complex (NAC) consists of reconstructing only the nipple, followed
after a few weeks by tattooing of areola complex. With the exception of the
procedure used to tighten the upper eyelid (upper blepharoplasty), all other methods
mentioned above have been compared in different comparative studies [4], [5]. The ideal NAC
reconstruction includes optimal position of the nipple, with the nipple consistent
in size, consistency and pigmentation with the contralateral side.
According to the American Society for Aesthetic Plastic Surgery, blepharoplasty was
the third most common cosmetic plastic surgery performed in 2003. The main goal of
surgery, if carried out as a single procedure, is visible facial rejuvenation [6]. If upper blepharoplasty is used as an adjunct to areola
reconstruction, NAC reconstruction can be combined with cosmetic facial surgery.
Our study focussed on the satisfaction of patients who underwent upper blepharoplasty
for areola reconstruction as part of general breast reconstruction after surgical
resection and on cosmesis after surgery.
Material and Methods
We report here on eight patients who had upper blepharoplasty for areola
reconstruction between 1 December 2010 and 31 January 2012. All patients were s/p
breast reconstruction after mastectomy for breast cancer. After receiving a patient
information leaflet, all patients were requested to present themselves to our
Department for clinical examination between April and June 2012. The patients had
previously received a questionnaire developed specifically for our study to record
their subjective assessment of the surgical outcome (breast and upper eyelids). The
questionnaire aimed to investigate the satisfaction of patients with the surgical
outcome of nipple reconstruction and with the appearance of the upper eyelids after
surgery and included detailed questions on patient satisfaction with the
reconstructed nipple with regard to skin pigmentation, shape, size and overall
symmetry. Patients were additionally asked whether the surgical results corresponded
to their preoperative subjective wishes/ideas and whether they would opt for this
form of areola reconstruction again. All patients were carefully measured and the
operated areas were closely inspected. The investigation protocol consisted of
inspection of the operated areas for signs of infection, scarring and pigmentation,
as well as the measurement of three fixed distances for both breasts
(breast–jugulum, inframamary fold–breast, [central] sternum–breast) to assess
symmetry. A scoring system with points was used to assess the answers to the
individual questions in the questionnaire, the inspection criteria and the
measurements ([Table 1]). In seven patients, the
reconstructed breast-areola complex and the eye area (eyes closed and eyes open)
were documented photographically using close-up and long-shot images ([Figs. 1] to [4]). The selection
of patient photographs for publication was random. Subsequently, 3 gynaecological
and obstetric surgeons from the department which carried out the study assessed the
photographs of the reconstructed breast of patients (information given included the
time when surgery was performed but not the patientsʼ previous medical history) with
regard to cosmesis using a points system (5 = best cosmetic result, 0 = worst
cosmetic result). All findings in this study are presented purely descriptively.
Fig. 1 53-year-old patient, 20 months postoperatively, s/p nipple
reconstruction of the right breast using a star flap and bilateral upper
blepharoplasty for areola reconstruction.
Fig. 2 53-year-old patient, 20 months postoperatively, s/p nipple
reconstruction of the right breast using a star flap and bilateral upper
blepharoplasty for areola reconstruction after mastectomy of the right breast
for breast cancer. The patient had previously rejected tattooing of the areola
to achieve a colour match. Status post periareolar lift on the left side.
Fig. 3 70-year-old patient, 23 months postoperatively, s/p nipple
reconstruction of the left breast using a star flap and bilateral upper
blepharoplasty for areola reconstruction.
Fig. 4 70-year-old patient, 23 months postoperatively, s/p nipple
reconstruction of the left breast using a star flap and bilateral upper
blepharoplasty for areola reconstruction of the left breast after previous
mastectomy for breast cancer. Status post periareolar lift on the right
side.
Table 1 Scoring systems. Score 1 is used to assess patient
satisfaction and Score 2 to assess the objective outcome after
surgery.
|
Scoring systems
|
Criterion
|
Point scores
|
|
1st score
|
Patient satisfaction
|
0–3 points: very dissatisfied
|
4–6 points: moderately satisfied
|
7–9 points: very satisfied
|
|
2nd score
|
Objectively verifiable result (inspection, measurements)
|
0–3 points: very poor cosmetic result
|
4–8 points: moderate cosmetic result
|
9–12 points: very good cosmetic result
|
Results
Mean age of the patients included in this study was 53 years. On average, upper
blepharoplasty for areola reconstruction took 69 minutes. No relevant surgical
complications such as secondary bleeding or impaired healing occurred either in the
area where blepharoplasty was done or at the site of the reconstructed areola.
Patients recorded their subjective satisfaction with the surgical method using a
questionnaire (0 = very dissatisfied to 9 = very satisfied). The mean satisfaction
score was 7.9 ± 0.8 standard deviation (range 7–9).
An examination score was compiled to create an objective criterion for cosmetic
outcome with a particular focus on symmetry (0 = very poor cosmetic result to 9 =
very good cosmetic result). The average score was 9.1 ± 1.5 (6–11). A very good
cosmetic result (9–11 points) was achieved in 6 patients and a moderate cosmetic
result was achieved in 2 patients (6 and 8 points, respectively) ([Table 2]).
Table 2 Patient characteristics. Table 2 lists patient
characteristics, the subjective and objective scores for the individual
patients and information on the surgical procedure(s).
|
Patients
|
Age (years)
|
Measurement score
|
Satisfaction score
|
Time between first operation and NAC reconstruction (years)
|
Duration of surgery (minutes)
|
|
1
|
52
|
10
|
8
|
1
|
58
|
|
2
|
69
|
6
|
8
|
1
|
55
|
|
3
|
43
|
9
|
9
|
1
|
67
|
|
4
|
50
|
11
|
7
|
0.5
|
76
|
|
5
|
54
|
9
|
7
|
0.25
|
68
|
|
6
|
50
|
10
|
9
|
4
|
75
|
|
7
|
58
|
10
|
8
|
29
|
70
|
|
8
|
52
|
8
|
7
|
2.5
|
84
|
Assessment by the panel of 3 physicians resulted in a mean value of 3.8 ± 0.9 (2–5)
(0 = worst cosmetic result to 5 = best cosmetic result).
Discussion
Blepharoplasty is one of the most common plastic surgery procedures performed
worldwide. The main goal of the operation, if it is carried out as a single
intervention, is visible facial rejuvenation, but the intervention can also lead to
functional and cosmetic improvement of the periorbital region [6]. Complications arising from this procedure are rare and generally
transient and mild, usually consisting of haematomas and chemosis. In a case series
of 10 patients, Beier et al. reported a very low complication rate with good to very
good cosmetic results for areola reconstruction using local flap plasty or nipple
sharing together with full-thickness skin grafts from the upper eyelids [7]. In 2009, Kruavit reported a complication rate of 3.8 %
(only mild complications) after blepharoplasty procedures in 6215 patients over a
period of 18 years. No serious complications were reported in the study [8]. However, the literature does include reports on a
number of complications. They can include blindness but also complications requiring
repeat surgical intervention such as eversion of the eyelid and eyelid or brow
ptosis [9]. In a retrospective study of 200 patients who
underwent blepharoplasty between January 2007 and January 2009, Patrocinio et al.
reported that most complications can be avoided if the surgical procedure is
preceded by careful preparation, including a detailed patient history
(co-morbidities, current medication, previous medical conditions affecting the eye
area) and careful physical examination. In addition, it is important to explore any
patient-specific psychological aspects preoperatively, for example the patientʼs
preoperative expectations about the outcome after surgery [10]. Both the diagnosis and the surgical procedure should be done by a
surgeon trained in aesthetic plastic surgery to minimise the complication rate and
morbidity associated with the intervention. When potential patients are selected,
it
is also important to inquire into their previous medical history with regard to
deficits in wound healing or scarring, as atrophic scarring tends to be associated
with a better cosmesis.
Reconstruction of the nipple-areola complex is the final surgical procedure of breast
reconstruction surgery. The aim is to complete the external physical appearance and
fully adapt the reconstructed breast to the contralateral breast; it is therefore
extremely important for patients. Many different surgical procedures are used for
nipple reconstruction, all of which aim to create and maintain adequate nipple
projection [11]. The challenge of nipple reconstruction
is to ensure that the reconstructed nipple is correctly positioned and symmetrical
to the contralateral side and that the scar is inconspicuous [12].
Surgery can be used to reconstruct both the nipple and the areola. While skin flaps
made of local tissue are usually used for nipple reconstruction [13], there are many well-tried procedures available for
areola reconstruction which use skin grafts obtained from the contralateral areola,
from the groin, the upper thigh or the vulva. With all skin grafts, pigmentation of
the grafted areola usually differs from pigmentation of the contralateral side, and
pigmentation between the areola and nipple also differs. Even when a skin graft is
obtained from the contralateral areola, a loss of pigmentation is often detectable
in the long term which, in many cases, will require tattooing at a later stage to
achieve a colour match [5].
Conclusion
The skin of the upper eyelid resembles that of the skin of the areola in its
appearance, consistency and pigmentation, making it suitable for use in areola
reconstruction. Tissue removed from the upper eyelid during blepharoplasty can be
used as a skin graft in areola reconstruction. To obtain enough skin from the upper
eyelid to create an areola, bilateral upper blepharoplasty is necessary. The
technique combines surgical areola reconstruction with rejuvenating facial plastic
surgery and generally has a high patient satisfaction score. The high levels of
patient satisfaction together with the aesthetically pleasing outcome noted for the
method presented in here warrant further prospective studies with greater numbers
of
patients.
