Arrow Flap and Rib Cartilage Graft for Nipple-Areola Complex Restoration

  • Aldo B. GuerraEmail author
  • Stephen E. Metzinger
  • Robert J. Allen


Restoration of the nipple-areola complex is a key component of breast reconstruction. The authors describe a reliable method of nipple-areola reconstruction using a combination of a dermal flap shaped like an arrow and a cartilage graft which provides a strong underlying scaffold support. The authors observed that techniques using isolated soft tissue dermal flaps can eventually fail due to secondary scar contracture with loss of neo-nipple projection. The cartilage graft is harvested at the initial breast flap transfer when exposing the internal mammary vessels. The arrow flap offers additional advantages against scar contracture due to its elegant design which allows the final incisions to resemble a W-plasty configuration on the new nipple vertical limb. The combination of arrow flap and rib graft leads to a reliable nipple reconstruction.


  1. 1.
    Little JW III. Nipple-areola reconstruction. Clin Plast Surg. 1984;11:351–64.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Yueh JH, Houlihan MJ, Slavin SA, Lee BT, Pories SE, Morris DJ. Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation. Ann Plast Surg. 2009;62:586–90.CrossRefPubMedGoogle Scholar
  3. 3.
    Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769–76.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Momoh AO, Colakoglu S, de Blacam C, Yueh JH, Lin SJ, Tobias AM, Lee BT. The impact of nipple reconstruction on patient satisfaction in breast reconstruction. Ann Plast Surg. 2012;69:389–93.CrossRefPubMedGoogle Scholar
  5. 5.
    Wellisch DK, Schain WS, Noone RB, Little JW III. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80:699–704.CrossRefPubMedGoogle Scholar
  6. 6.
    Anton MR, Eskenazi LB, Hartrampf CR Jr. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg. 1991;5:67–74.Google Scholar
  7. 7.
    Eskenazi LB. A one-stage nipple reconstruction with the “modified star” flap and immediate tattoo: a review of 100 cases. Plast Reconstr Surg. 1993;92:671–80.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hartampf CR Jr, Culbertson JH. A dermal-fat flap for nipple reconstruction. Plast Reconstr Surg. 1984;73:982–6.CrossRefGoogle Scholar
  9. 9.
    Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing tab flap. Plast Reconstr Surg. 1989;84:520–5.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg. 2003;50:31–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207–12.CrossRefPubMedGoogle Scholar
  13. 13.
    Schoeller T, Schubert HM, Pülzl P, et al. Nipple reconstruction using a modified arrow flap technique. Breast. 2006;15:762–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg. 1958;10:257–98.CrossRefGoogle Scholar
  15. 15.
    Broadbent TR, Woolf RM, Metz PS. Restoring the mammary areola by a skin graft from the upper inner thigh. Br J Plast Surg. 1977;30:220–2.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Bosch G, Ramirez M. Reconstruction of the nipple: a new technique. Plast Reconstr Surg. 1984;73:977–81.CrossRefPubMedGoogle Scholar
  17. 17.
    Jones G, Bostwick J III. Nipple-areola reconstruction. Oper Tech Plast Reconstr Surg. 1994;1:35–9.CrossRefGoogle Scholar
  18. 18.
    Thomas SV, Gellis MB, Pool R. Nipple reconstruction with a new local tissue flap. Plast Reconstr Surg. 1996;97:1053–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Schwager RG, Smith JW, Gray GF, Goulian D Jr. Inversion of the human female nipple, with a simple method of treatment. Plast Reconstr Surg. 1974;54:564–9.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Pribaz JJ, Pousti T. Correction of recurrent nipple inversion with cartilage graft. Ann Plast Surg. 1998;40:14–7.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Winocour S, Saksena A, Oh C, Wu P, Laungani A, Baltzer H, Saint-Cyr M. A systematic review of comparison of autologous, allogenic, and synthetic augmentation grafts for nipple reconstruction. Plast Reconstr Surg. 2016;137:14e–23e.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Brent B, Bostwick J. Nipple-areola reconstruction with auricular tissues. Plast Reconstr Surg. 1977;60:353–61.PubMedGoogle Scholar
  23. 23.
    Tanabe HY, Tai YT, Kiyokawa K, Yamauchi T. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. Plast Reconstr Surg. 1997;100:431–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Collis N, Garrido A. Maintenance of nipple projection using auricular cartilage. Plast Reconstr Surg. 2000;105:2276–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Heitland A, Markowicz M, Koellensperger E, Allen R, Pallua N. Long-term nipple shrinkage following augmentation by an autologous rib cartilage transplant in free DIEP-flaps. J Plast Reconstr Aesthet Surg. 2006;59:1063–7.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Becker H. The use of intradermal tattoo to enhance the final result of nipple-areola reconstruction. Plast Reconstr Surg. 1986;77:673–6.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    O’Neill AC, Hayward V, Zhong T, Hofer SO. Usability of the internal mammary recipient vessels in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg. 2016;99:907–11.CrossRefGoogle Scholar
  28. 28.
    Davidson JA. A technique to aid in rib cartilage excision for access to the internal mammary vessels. Plast Reconstr Surg. 2003;111:506–7.CrossRefGoogle Scholar
  29. 29.
    Schoeller T, Schubert HM, Wechselberger G. Rib cartilage replacement to prevent contour deformity after internal mammary vessel access. J Plast Reconstr Aesthet Surg. 2008;61:464–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Fayman MS, Beeton A, Potgieter E. Barotrauma: an unrecognized mechanism for pneumothorax in breast augmentation. Plast Reconstr Surg. 2005;116:1825–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Mayridis S, Gnauk HG, Schumacher M, Wagner R. Bilateral pneumothoraces complicating reduction mammoplasty: a case report. BMC Surg. 2013;13:29.CrossRefGoogle Scholar
  32. 32.
    Osborn JM, Stevenson TR. Pneumothorax as a complication of breast augmentation. Plast Reconstr Surg. 2005;116:1122–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Fayman MS. Air drainage: an essential technique for preventing breast augmentation-related pneumothorax. Aesthet Plast Surg. 2007;31:19–22.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Aldo B. Guerra
    • 1
    Email author
  • Stephen E. Metzinger
    • 2
  • Robert J. Allen
    • 3
  1. 1.Guerra Plastic Surgery CenterScottsdaleUSA
  2. 2.Aesthetic Surgical AssociatesMetairieUSA
  3. 3.The Center for Microsurgical Breast ReconstructionMetairieUSA

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