الفهرس 
Anatomy of Nipple-Areola ComplexOnly 14 pages are availabe for public view
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Abstract
The nipple-areolar complex may be affected by many disorders, many of which have similar appearances. The detection of these disorders of the nipple-areolar region may be challenging because of the complex anatomy of this region thus, understanding of anatomic variants, benign and pathologic processes, and the imaging features specific to each is the necessary basis for a comprehensive and appropriate imaging assessment, diagnosis, and, if necessary, intervention.
These disorders of the nipple-areolar complex are unique or differ in important ways from those that occur elsewhere in the breast, and they require a diagnostically specific imaging evaluation. Also, a clinical evaluation by the patient’s surgeon should be part of the diagnostic work-up.
The standard dual-view mammography may be necessary to visualize or exclude an underlying mass or other abnormality. But when routine mammographic findings are negative and clinical findings arouse suspicion about the presence of a malignancy, US and MR imaging may facilitate the diagnosis. US may be performed to further characterize a mammographic or clinical finding particularly intraductal papillary lesions. Higher sensitivity was demonstrated with MR imaging than with mammography for the diagnosis and assessment of nipple and retroareolar tumors.
The diseases of nipple areola complex may be classified as congenital or acquired. Congenital disorders as athelia, supernumerary nipples, bifid nipple and inverted nipple. While acquired disorders as Paget’s disease, bowen disease, adenoma of the nipple, melanoma of the nipple and eczema.
Surgical management for these congenital nipple areola disorders differ according to each disorder. For surgical management of athelia, nipple reconstruction is done, for supernumery nipples, surgical removal of the extra nipple is done, while for inverted nipple, surgical correction is done.
Paget’s disease is a chronic, eczematous rash on the nipple and adjacent areolar skin. Proper recognition of this disorder is required to initiate an appropriate workup for differentiating it from other diseases. Its surgical management varies according to the disease invasiveness. So modified radical mastectomy and lymph node clearance are appropriate therapies for patients with invasive breast carcinoma, while Conservative management and radiation therapy are therapies for patients with disease limited to the nipple. Also, central quadrantectomy with rotation-advancement of a dermaglandular flap is used in management of paget disease. Skin sparing mastectomy is indicated in case of small breast, where it is followed by reconstruction.
Adenoma of the nipple is treated by complete surgical excision. While Bowen disease is treated medically by topical therapy as 5-Fluorouracil, and Imiquimod 5% cream, or surgical management in the form of Simple excision. Melanoma is treated through excision with surgical margins for primary melanoma and elective lymph node dissection.
Reconstruction of the nipple-areola complex is indicated to complete breast reconstruction and to restore the patient’s body image. Following mastectomy for breast cancer, NAC reconstruction is mostly the final aspect of breast reconstruction. Other conditions requiring nipple-areola complex reconstruction include congenital or developmental pathology.
Ideal reconstruction of the NAC requires symmetry in position, size, shape, texture, pigmentation and permanent projection. It can be safely performed on an outpatient basis under local anaesthesia.
NAC reconstruction is postponed till the final and stable setting of the reconstructed breast mound, optimally 3-4 months following breast reconstruction.
In unilateral reconstruction, the contralateral NAC serves as a template, while in bilateral reconstruction, the NAC location is planned according to relative anatomical landmarks and aesthetic preferences of the patient.
Loss of projection of the reconstructed nipple should always be anticipated due to contraction, and so overcorrection of 25-50% of the desired result is advisory in NAC reconstruction with local flaps.
Reconstruction of areola usually does not pose difficulties, while creation of a natural 3-dimensional nipple with lasting projection remains a challenge.
Options for areola reconstruction involve skin grafting, NAC saving or banking, dermabrasion and tattoing. The major advantage of skin grafting is the resultant irregular surface, which resembles the normal areola, but its disadvantages which involve hyperpigmentation and donor site morbidity made skin grafting not preferable. Tattoing is preferable nowadays because of the simplicity of the procedure, requiring neither hospitalization nor general anaesthesia, relatively inexpensive, and there is no donor site morbidity.
While options for nipple reconstruction involve grafting and local flaps which may be centrally based flaps or subdermal pedicle flaps. These subdermal pedicle flaps may be single pedicled as skate flap, star flap, bell flap, c-v flap, and arrow flap, or it may be double pedicled as s-flap, double opposing tab flap, and twin flap.
Grafting for nipple reconstruction with soft tissue alone is followed by loss of projection of the nipple, and in order to solve this problem cartilage graft has been used to provide structural support for the reconstructed nipple.
Subdermal pedicle flaps are better than centrally based flaps, as the centrally based flaps are subjected to the greatest retraction forces, which act on the entire base of the flap. While in subdermal pedicle flaps these forces are significantly reduced, and thus protected from retraction. Also subdermal pedicle flaps are nourished through the rich subdermal plexus and thus have better blood supply compared to centrally based flaps.
Double pedicled flaps allow using two flaps which adds total bulk to the nipple reconstruction and increases the chance of flap survival. However, opposition and fixation of the two flaps creates a certain amount of tension on the flaps, which subjects the whole structure to a greater amount of retraction forces from the surrounding tissues than with single pedicle flaps.
The skate flap is a reliable technique for reconstruction of a nipple. It is considered by many to be the optimal procedure that can provide a reasonable projection even after long term follow up.
The star flap is a modification of the skate flap. It creates a projecting structure that is self supporting and stable. The C-V flap is also evolved from the skate flap and has many modifications like designing V flaps twice the projection of the normal nipple and a smaller C flap to prevent the reconstructed nipple from DROPping.
The bell flap was introduced as a new technique for nipple reconstruction in which the obtained nipple-areola complex is smaller in diameter than the donor site; so a permanent purse string suture is applied in the subdermal plane to shrink the donor site.
The double pedicled flaps are centred on the mastectomy scar, which may cross the base of the nipple flap in single pedicle flaps, thereby compromising its blood supply. Both flaps are directed parallel to the mastectomy scar and oriented in opposing directions, so that flap bases are not crossed by the scar.
Multiple procedures for NAC reconstruction have been described, but none has been universally favoured. Currently, subdermal single and double-pedicled flap techniques for nipple reconstruction combined with skin grafting and tattoo for areola reconstruction are the first-choice. In order to avoid donor site morbidity, some authors refuse skin grafting and use only tattoo for the simulation of the areola.
In general, nipple areola reconstruction represents a final, positive step in a sometimes difficult process from diagnosis to treatment and reconstruction for many nipple areola complex disorders.