Background Numerous techniques have been used to achieve long-term projection of the nipple following nipple-areola reconstruction. However, the reconstructed nipple loses projection over time. We describe a technique that uses local flaps to improve the lost projection of reconstructed nipples. 

Methods Between November 2013 and March 2015, nine patients (11 nipples) underwent revisional nipple reconstruction for lost projection. Only C-H nipple reconstructions were included in this study. The medical history of each patient was reviewed and photographs were taken in front and lateral views. All patients attended routine follow-up visits. Deepithelialized triangular flaps were made on all four sides of the nipple and buried in the opposite corners in order to augment the volume of the nipple. Anchoring sutures were used to attach each triangular flap on the side opposite their point of origin, and the resulting defects were closed directly. 

Results This procedure was used successfully in nine patients (11 nipples). Adequate projection was achieved in all patients and no complications occurred. The average nipple height was 3 mm before operation, 7 mm one day after operation, 5 mm at the six-month follow-up, and 5 mm at the 12-month follow-up. The average nipple-areolar angle was 164 degrees before the operation, 111 degrees one day after the operation, 130 degrees at the six-month follow-up, and 133 degrees at the 12-month follow-up. 

Conclusions The method described provides a solution to the loss of projection in reconstructed nipples. We recommend this technique because it leads to better projection, greater volume, and a more natural shape

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339
O
riginal Article
INTRODUCTION
Nipple-areola reconstruction is the final stage of breast recon-
struction, playing a crucial role in providing the breast with a 
natural appearance, especially when the patient is undressed. 
Over the past four decades, many different techniques have been 
used to reconstruct the nipple following mastectomy. Some meth-
ods, such as nipple banking [1], nipple sharing, and nipple re-
construction with only a tattoo [2] are no longer used. Local 
pull-out flaps are currently considered to be more reliable and 
A Revision Restoring Projection after Nipple 
Reconstruction by Burying Four Triangular 
Dermal Flaps
Ji Hun Kim, Hee Chang Ahn
Department of Plastic and Reconstructive Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
Background Numerous techniques have been used to achieve long-term projection of the 
nipple following nipple-areola reconstruction. However, the reconstructed nipple loses projec-
tion over time. We describe a technique that uses local flaps to improve the lost projection of 
reconstructed nipples.
Methods Between November 2013 and March 2015, nine patients (11 nipples) underwent 
revisional nipple reconstruction for lost projection. Only C–H nipple reconstructions were 
included in this study. The medical history of each patient was reviewed and photographs 
were taken in front and lateral views. All patients attended routine follow-up visits. De-
epithelialized triangular flaps were made on all four sides of the nipple and buried in the 
opposite corners in order to augment the volume of the nipple. Anchoring sutures were used 
to attach each triangular flap on the side opposite their point of origin, and the resulting 
defects were closed directly.
Results This procedure was used successfully in nine patients (11 nipples). Adequate projection 
was achieved in all patients and no complications occurred. The average nipple height was 3 
mm before operation, 7 mm one day after operation, 5 mm at the six-month follow-up, and 
5 mm at the 12-month follow-up. The average nipple-areolar angle was 164° before the 
operation, 111° one day after the operation, 130° at the six-month follow-up, and 133° at the 
12-month follow-up.
Conclusions The method described provides a solution to the loss of projection in reconstructed 
nipples. We recommend this technique because it leads to better projection, greater volume, 
and a more natural shape. 
Keywords Nipples / Mammoplasty / Surgical flaps
Correspondence: Hee Chang Ahn
Department of Plastic and 
Reconstructive Surgery, Hanyang 
University Seoul Hospital, Hanyang 
University College of Medicine,  
222 Wangsimni-ro, Sungdong-gu, 
Seoul 04763, Korea
Tel: +82-2-2290-8560
Fax: +82-2-2295-7671
E-mail: ahnhc@hanyang.ac.kr
No potential conflict of interest relevant 
to this article was reported.
Received: 28 Oct 2015 • Revised: 1 Apr 2016 • Accepted: 12 Apr 2016
pISSN: 2234-6163 • eISSN: 2234-6171 • http://dx.doi.org/10.5999/aps.2016.43.4.339 • Arch Plast Surg 2016;43:339-343
Kim JH et al. Secondary nipple reconstruction
340
are the surgical technique of choice for nipple reconstruction 
[1,3-5]. However, the major disadvantage of reconstructing a 
nipple using local tissue is the long-term loss of nipple projec-
tion. Although the initial projection is adequate, all reconstruct-
ed nipples lose some projection over time. Indeed, in one study, 
lack of projection was found to be the most common factor for 
dissatisfaction in over 50% of patients who expressed dissatis-
faction with the outcomes of breast reconstruction surgery [6].
In order to overcome the tendency of reconstructed nipples to 
flatten, a variety of methods and materials have been used to 
augment secondary nipple projection [7,8]. However, almost all 
of these techniques have poor experimental support and result 
in donor site morbidity. 
Many articles have reported that dermal flaps can be used to 
correct inverted nipples [9,10], but we have found no studies 
using dermal flaps to correct flattened nipples, and it occurred 
to us that dermal flaps might be used in such cases. The purpose 
of this report is to introduce a technique for secondary nipple 
projection involving the anchoring of four triangular dermal 
flaps. This technique achieves increased projection and volume, 
as well as providing the reconstructed nipple with a better shape.
METHODS
Between November 2013 and March 2015, re-projection sur-
gery was performed on nine patients (11 reconstructed nipples) 
to treat lost projection in reconstructed nipples. Patients’ dissat-
isfaction was the only surgical indication. The operations were 
performed by a single surgeon. The medical history of each pa-
tient was reviewed and photographs were taken in front and lat-
eral views. The height of each nipple and the angle between the 
nipple and the areola of both sides were measured before the 
operation, one day after the operation, six months after the op-
eration, and 12 months after the operation. Nipple height was 
defined as the length from the base of the nipple to the top of 
the nipple. A caliper was used to measure the nipple height. The 
height was measured perpendicular to the base of the nipple. 
The angle between the nipple and the areola was measured at 
the widest area with a protractor. All patients attended routine 
follow-up visits. Only C–H nipple reconstructions using trans-
verse rectus abdominis muscle flaps were included in this study. 
The C–H flap, which is a modification of the C–V flap, is named 
after the shape of the letters ‘C’ and ‘H’. Tip necrosis is a com-
mon complication of the C–V flap. Furthermore, the shape of 
the nipple changes after the necrotic tissue of the tip heals. A C–
H flap is another option for nipple reconstruction, because tip 
necrosis does not occur. After nipple reconstruction with a C–
H flap, a larger dog-ear is created compared to the C–V flap nip-
ple reconstruction technique. However, after the dog-ear is cor-
rected, it can be used for a dermal fat graft in the reconstructed 
nipple (Fig. 1). A dermal fat graft is not only useful for a small 
amount of volume augmentation, but also for preventing the 
loss of projection over time [11]. 
The operation was performed under local anesthesia. Four tri-
angular flaps were designed on the nipple-areola complex. Four 
more triangular designs were made on the nipple to reduce the 
dog-ear and to narrow the base of the nipple (Fig. 2). The inci-
sions were made over the design. Afterwards, the skin of the 
nipple-areola complex was dissected, and the epidermis was 
separated from the dermis over the planned flap area. De-epi-
thelialized triangular flaps were created on all four sides of the 
areola, and a tunnel was formed in the deep plane below the 
nipple. The flaps were passed through the tunnels and buried in 
the four opposite corners in order to augment the volume of the 
nipple. Anchoring sutures were used to attach each triangular 
flap on the opposite side in order to narrow the base of the nip-
ple, and the defects in the four areas were closed directly (Fig. 2).
RESULTS
Eleven cases in nine patients were evaluated in this study. The 
patients were 45–58 years of age (mean, 50.9 years). The aver-
(A) The incision line of the C-H flap is drawn. (B) The C-H flap is elevated. (C) The new nipple is reconstructed and the donor site is closed with a 
dog-ear correction. (D) Final shape of the nipple. The suture line resembles the letters ‘C’ and ‘H’.
Fig. 1. Nipple reconstruction with a C–H flap
A B C D
Vol. 43 / No. 4 / July 2016
341
age period between primary and secondary reconstruction of 
the nipple was 13.67 months (range, 8–20 months). The aver-
age nipple height was 3 mm before secondary nipple reconstruc-
tion, 7 mm one day postoperatively, 5 mm at the six-month fol-
low-up, and 5 mm at the 12-month follow-up. The average height 
of the patients’ natural nipples was 6 mm (range, 4–10 mm). 
The average angle between the areola and nipple was 164° be-
fore secondary nipple reconstruction, 111° one day postopera-
tively, 130° at the six-month follow-up, and 133° at the 12-month 
follow-up (Fig. 3). The average angle between the areola and 
nipple of the patients’ natural nipples was 101°. 
Patients were followed for 6–21 months postoperatively, with 
a median follow-up of 17 months. Two cases were followed for 
less than 12 months; therefore, only nine cases were included in 
the average figures for the 12-month follow-up. 
No complications occurred in any patient included in this study.
DISCUSSION
One of the main purposes of nipple reconstruction is to create a 
three-dimensional nipple from a two-dimensional surface. How-
ever, a natural tendency exists for the reconstructed nipple to 
flatten and for the skin surface to return to its normal contour. 
Multiple causes of nipple flattening have been identified, includ-
ing inadequate subcutaneous fat, internal and external pressure, 
poor flap design, delayed healing, and tissue memory [12]. More-
over, wearing a bra may result in external pressure on the surface 
of the breast, contributing to nipple flattening. The flattening ra-
tio of reconstructed nipples is dependent on the quality of the 
skin, the type of breast reconstruction, and the surgical tech-
nique [13]. Many methods have been developed to overcome 
flattening after nipple reconstruction, but flattening remains a 
major concern. Secondary nipple reconstruction for nipple re-
projection is needed to correct flattened reconstructed nipples, 
because loss of nipple projection is the reason for dissatisfaction 
in over 50% of dissatisfied patients [6]. However, few studies 
have addressed secondary nipple reconstruction for nipple re-
projection. In one such study, Alloderm regenerative tissue ma-
trix (LifeCell, Bridgewater, NJ, USA) was used to improve nip-
ple projection in the reconstructed breast [12]. 
The importance of secondary nipple reconstruction has been 
overlooked, because it is mistakenly thought to be similar to pri-
mary nipple reconstruction. The role of secondary nipple re-
construction is to project a flattened nipple, not to correct the 
Fig. 2. Design of the four triangular flaps
(A) Designs of the four triangular flaps and the four triangular dog-ear corrections. De-epithelialization was performed over the designs. (B) The 
four triangular de-epithelialized dermal flaps were elevated. (C) A tunnel was created under the nipple with a Metzenbaum Scissor. The figure 
only shows two flaps for better description. (D) The four de-epithelialized dermal flaps were passed through tunnels, buried in the four corners. 
The figure only shows two flaps for a better description. (E) The four buried triangular de-epithelialized dermal flaps were anchored on the oppo-
site of their origin. The donor sites were closed directly. The figure only shows two flaps for a better description. (F) Final shape after procedure.
A
D
B
E
C
F
Kim JH et al. Secondary nipple reconstruction
342
absence of a nipple. Only volume augmentation and correction 
of the nipple-areolar angle can improve the contour of the nip-
ple. Methods that correct inverted nipples include suturing tech-
niques [14], dermal flaps [15], and the use of dermis analogs 
[16]. Various types of dermal flaps have been used in the correc-
tion of inverted nipples, and we hypothesized that such flaps 
could be applied to secondary nipple reconstruction in the same 
way. In the correction of inverted nipples, limited-size dermal 
flaps are buried and anchored, because lactation must be pre-
served. However, in secondary reconstruction of the nipple, it is 
not necessary to preserve the lactation function, meaning that a 
greater volume of dermal flaps can be buried and strong anchor-
ing sutures can be used to obtain a more acute nipple-areolar 
angle. 
Park et al. [17] reported that the average height of the nipple 
was 5 mm in Korean women between 41 and 50 years of age. In 
this study, the average height of the natural nipple was 6 mm, 
and the average height of the re-projected nipple was 5 mm. The 
average height of the re-projected nipple was similar to the aver-
age Korean nipple height, in this case, the contralateral side. As 
far as we know, this is the first study measuring the angle between 
the nipple and areola. The angle between the nipple and areola 
of a reconstructed nipple tends to widen over time. Thus, nar-
rowing the base of the nipple creates a more natural contour. 
In this study, all patients were satisfied with the results. Although 
there was only an average 2 mm projection improvement in pa-
tients, by percentage, it was a 67% increase. The nipple shape 
appeared more natural postoperatively because the angle be-
tween the nipple and areola was decreased, in addition to the 
improvement in projection.
In this study, nipple projection gradually decreased over time, 
but tapered to a stable plateau after approximately six months to 
one year. Our study had a relatively short follow-up period, but 
other studies have also shown a stable plateau approximately 
one year after reconstruction [13,18]. The nipple-areolar angle 
likewise gradually increased over time, but stabilized after six 
months to one year. Two of our cases were followed for less than 
one year, but the other nine cases had successful results at the 
one year follow-up. 
The limitation of this technique is the potential for scarifica-
tion in four directions around the nipple. The shape of the tat-
tooed nipple-areola complex can change after this revisional nip-
ple restoration technique and so may need re-tattooing. Howev-
er, the change was very subtle in all cases. No re-tattooing was 
provided after this procedure. 
Many methods have been used in successful primary recon-
struction of the nipple, but few reports have described success-
ful secondary nipple reconstruction. The method reported here 
provides a solution to the loss of projection in reconstructed 
nipples. The use of four triangular dermal flaps and anchoring 
sutures on the opposite side of the flaps results in better projec-
tion and greater volume augmentation, improving the appear-
ance and natural shape of the nipple. This method has proven to 
be reliable, effective, and safe, with long-lasting results, and may 
emerge as the method of choice for secondary nipple recon-
struction.
 
Fig. 3. Preoperative and postoperative photographs
(A) Preoperative frontal photograph. (B) Preoperative lateral photo-
graph. (C) Frontal photograph one day after the operation. (D) Lat-
eral photograph one day after the operation. (E) Frontal photograph 
12 months after the operation. (F) Lateral photograph 12 months 
after the operation.
A
C
E
B
D
F
Vol. 43 / No. 4 / July 2016
343
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A Revision Restoring Projection after Nipple Reconstruction by Burying Four Triangular Dermal Flaps

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A Revision Restoring Projection after Nipple Reconstruction by Burying Four Triangular Dermal Flaps

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