Discussion
NA is a very scarce, benign proliferative process of the nipple which
originates from the NAC, more often in women between the fourth and
fifth decade of their life. Clinically, it often presents as a palpable
nipple nodule, a visible nipple skin erosive lesion, with or without
discharge from the surface of the nipple skin. Thorough diagnostic
assessment is needed to eliminate the possibility of malignant
pathologies resembling NA and surgical resection is necessary for its
treatment.
Several surgical approaches and reconstruction options for the remaining
areola post-excision have been proposed in the available literature,
such as purse-string for nipple adenoma, nipple elevation and
nipple-areola reconstruction [7, 12-14]. In such techniques, NAC
creation is the last step in the breast reconstruction process and is
vital as it greatly affects patients psychologically. The main challenge
is to maintain the projection of the reconstructed nipple over time when
the original was removed. The local graft reconstruction together with
tattooing is the most popular technique, with individualized treatment
options accounting for patient anatomical characteristics and aesthetic
preferences, with results unfortunately not always proving satisfactory.
To avoid this challenging reconstruction step, other, more conservative
methods have also been proposed. Lee et al[15] utilized Moh’s
Micrographic Surgery (MMS) and proposed that, if applied early, it could
facilitate the excision of the tumor with the preservation of the
nipple. Similarly, Bae et al[16] performed cryosurgery in their
patient, a technique that is gaining ground as a minimally invasive
treatment of NA as well, with remarkable outcomes as far as aesthetics
are concerned.
In this report, we presented a Double Purse-String (DPS) technique,
which allows for the complete surgical excision of the nipple while
preserving the surrounding relatively large areola using a DPS suture of
the wound. Subsequently the suture can be used to reshape the areola,
adjust the size, avoid tension, prevent flattening or dissatisfying
defects and offer adequate projection of the nipple; thus adapting to
the morphology of the contralateral healthy nipple. In this way,
patients with NA maintain
sensation,
which promotes their overall feeling of post-operative satisfaction and
offers psychological benefits to the patients who can opt for tattooing
3D complementation of the areola following recovery as well.
To our knowledge this is the first case of a PDS technique being used in
the treatment of NA. The main strength of our proposed method is that a
symmetric nipple-areola complex was created that matched the
contralateral nipple in size, color, position and projection, giving it
a pleasing and natural appearance, achieving a sustained projection of
the areola and minimizing complications such as irregularities and
hypertrophic scar. Another advantage is that the DPS technique can be
performed in cases of aggressive NA as well, by any breast surgeon. In
contrast, other, less invasive techniques, require expertise and can
only be applied in benign and not locally advanced lesions.
Additionally, such techniques carry the admittedly low, but existent
risk of recurrence due to incomplete resection, a phenomenon observed by
Perzin et al [17], who noted 7% recurrence rate in cases treated
via local excision, as well as of malignancy arising from NA, a rare but
documented occurrence in eight cases [3].
In our point of view, treatment of the rare NA by the DPS technique is
an effective therapeutic intervention, not only due to the assured
complete resection of the tumor, but also because of the aesthetically
pleasing result that can be achieved; a result comparable to the more
advanced, less invasive surgical techniques, though without the higher
risk for post-operational residual tumor that these techniques confer.