Breast Reconstruction Under Local Anesthesia: Second-Stage Implant Exchange, Nipple Flap Reconstruction, and Nipple Flap Tattoo

  • Dimitri J. KoumanisEmail author
  • Jessie Bujouves


Implant-based reconstruction is strictly performed in three stages in the authors’ practice. The first stage is the tissue expander and acellular dermal matrix sling procedure performed immediately after the mastectomies. The second-stage reconstruction involves the removal of the tissue expander with a small incision, replacement with a permanent silicone gel implant, and possible revisions of the breast flaps breast pocket if needed. Finally, the third stage involves nipple flap reconstruction. Patients typically wait a few months post surgeries before undergoing medical tattooing of the areola and nipple to give it a three-dimensional look. The authors discuss the techniques used for each stage, the possible complications, and the complications of anesthesia. Star flap method, out of all stages of breast implant reconstruction, is the most amenable to local anesthetic techniques due to its minimalist approach.


  1. 1.
    Phillips BT, Bishawi M, Dagum AB, Khan SU, Bui DT. A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence? Plast Reconstr Surg. 2013;131(1):1–13.CrossRefPubMedGoogle Scholar
  2. 2.
    Bogue DP, Mungara AK, Thompson M, Cederna PS. Modified technique for nipple-areolar reconstruction: a case series. Plast Reconstr Surg. 2003;112(5):1274–8.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Huber KM, Zemina KL, Tugertimur B, Killebrew SR, Wilson AR, DallaRosa JV, Prabhakaran S, Dayicioglu D. Outcomes of breast reconstruction after mastectomy using tissue expander and implant reconstruction. Ann Plast Surg. 2016;76(Suppl 4):S316–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Nicholson RM, Leinster S, Sassoon EM. A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction. Breast. 2007;16(4):396–410.CrossRefPubMedGoogle Scholar
  5. 5.
    Draper LB, Bui DT, Chiu ES, Mehrara BJ, Pusic AL, Cordeiro PG, Disa JJ. Nipple-areola reconstruction following chest-wall irradiation for breast cancer: is it safe? Ann Plast Surg. 2005;55(1):12–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Disa JJ, McCarthy CM, Mehrara BJ, Pusic AL, Hu QY, Cordeiro PG. Postmastectomy reconstruction: an approach to patient selection. Plast Reconstr Surg. 2009;124(1):43–52.CrossRefPubMedGoogle Scholar
  7. 7.
    Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1983;1(8322):459–62.CrossRefPubMedGoogle Scholar
  8. 8.
    Stevens LA, McGrath MH, Druss RG, Kister SJ, Gump FE, Forde KA. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg. 1984;73(4):619–28.CrossRefPubMedGoogle Scholar
  9. 9.
    Wellisch DK, Schain WS, Noone RB, Little JW III. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg. 1985;76(5):713–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Rosenqvist S, Sandelin K, Wickman M. Patients’ psychological and cosmetic experience after immediate breast reconstruction. Eur J Surg Oncol. 1996;22(3):262–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Elder EE, Brandberg Y, Björklund T, Rylander R, Lagergren J, Jurell G, Wickman M, Sandelin K. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast. 2005;14(3):201–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Colque A, Eisemann ML. Breast augmentation and augmentation-mastopexy with local anesthesia and intravenous sedation. Aesthet Surg J. 2012;32(3):303–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Yang JD, Ryu JY, Ryu DW, Kwon OH, Bae SG, Lee JW, Choi KY, Chung HY, Cho BC. Our experiences in nipple reconstruction using the Hammond flap. Arch Plast Surg. 2014;41(5):550–5.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D’Aniello C, Nisi G. Nipple-areola complex reconstruction techniques: a literature review. Eur J Surg Oncol. 2016;42(4):441–65.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Adams WM. Labial transplant for correction of loss of the nipple. Plast Reconstr Surg. 1949;4(3):295–8.CrossRefGoogle Scholar
  16. 16.
    Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg. 2006;59(1):40–53.CrossRefPubMedGoogle Scholar
  17. 17.
    Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009;62(5):591–5.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Berson MI. Construction of pseudoareola. Surgery. 1946;20(6):808.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Barton FE Jr. Latissimus dermal-epidermal nipple reconstruction. Plast Reconstr Surg. 1982;70(2):234–7.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Silversmith PE. Nipple reconstruction by quadrapod flaps. Plast Reconstr Surg. 1983;72(3):422.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Chang WH. Nipple reconstruction with a T flap. Plast Reconstr Surg. 1984;73(1):140–3.CrossRefPubMedGoogle Scholar
  22. 22.
    Halvorson EG, Cormican M, West ME, Myers V. Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg. 2014;133(5):1073–5.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    McKay DR. Costs of regional and general anesthesia: what the plastic surgeon needs to know. Clin Plast Surg. 2013;40(4):529–35.CrossRefPubMedGoogle Scholar
  24. 24.
    Koumanis DJ, Colque A, Eisemann ML, Smith J. Breast surgery under local anesthesia: second-stage implant exchange, nipple flap reconstruction, and breast augmentation. Clin Plast Surg. 2013;40(4):583–91.CrossRefPubMedGoogle Scholar
  25. 25.
    Mohamed SA, Parodi PC. A modified technique for nipple-areola complex reconstruction. Indian J Plast Surg. 2011;44(1):76–80.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Macadam SA, Ho AL, Cook EF Jr, Lennox PA, Pusic AL. Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients. Plast Reconstr Surg. 2010;125(3):761–71.CrossRefPubMedGoogle Scholar
  27. 27.
    Paek LS, Giot JP, Tétreault-Paquin JO, St-Jacques S, Nelea M, Danino MA. The impact of postoperative expansion initiation timing on breast expander capsular characteristics: a prospective combined clinical and scanning electron microscopy study. Plast Reconstr Surg. 2015;135(4):967–74.CrossRefPubMedGoogle Scholar
  28. 28.
    Cordeiro PG, Albornoz CR, McCormick B, Hudis CA, Hu Q, Heerdt A, Matros E. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135(6):1509–17.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Krueger EA, Wilkins EG, Strawderman M, Cederna P, Goldfarb S, Vicini FA, Pierce LJ. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys. 2001;49(3):713–21.CrossRefPubMedGoogle Scholar
  30. 30.
    Motwani SB, Strom EA, Schechter NR, Butler CE, Lee GK, Langstein HN, Kronowitz SJ, Meric-Bernstam F, Ibrahim NK, Buchholz TA. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys. 2006;66(1):76–82.CrossRefPubMedGoogle Scholar
  31. 31.
    Nava MB, Pennati AE, Lozza L, Spano A, Zambetti M, Catanuto G. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg. 2011;128(2):353–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Nahabedian MY. Minimizing incisional dehiscence following 2-stage prosthetic breast reconstruction in the setting of radiation therapy. Gland Surg. 2013;2(3):133–6.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Phillips BT, Fourman MS, Bishawi M, Zegers M, O’Hea BJ, Ganz JC, Huston TL, Dagum AB, Khan SU, Bui DT. Are prophylactic postoperative antibiotics necessary for immediate breast reconstruction? Results of a prospective randomized clinical trial. J Am Coll Surg. 2016;222(6):1116–24.CrossRefPubMedGoogle Scholar
  34. 34.
    Clayton JL, Bazakas A, Lee CN, Hultman CS, Halvorson EG. Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg. 2012;130(3):495–502.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Phillips BT, Halvorson EG. Antibiotic prophylaxis following implant-based breast reconstruction: what is the evidence? Plast Reconstr Surg. 2016;138(4):751–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Adams WP Jr, Conner WC, Barton FE Jr, Rohrich RJ. Optimizing breast pocket irrigation: an in vitro study and clinical implications. Plast Reconstr Surg. 2000;105(1):334–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Delay E, Mojallal A, Vasseur C, Delaporte T. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006;118(6):1303–12.CrossRefPubMedGoogle Scholar
  38. 38.
    Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg. 1997;50(5):331–4.CrossRefPubMedGoogle Scholar
  39. 39.
    Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108(2):361–9.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, Schusterman MA. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997;99(6):1602–5.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Lesavoy M, Liu TS. The diamond double-opposing V-Y flap: a reliable, simple, and versatile technique for nipple reconstruction. Plast Reconstr Surg. 2010;125(6):1643–8.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110(3):780–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Anton MA, Eskenazi LB, Hartrampf CR Jr. Nipple reconstruction with local flaps: star and wrap flaps. Semin Plast Surg. 1991;5(1):67–78.CrossRefGoogle Scholar
  44. 44.
    Mathes SJ, Ueno CM. Reconstruction of the nipple areola complex. In: Mathes SJ, Hentz VR, editors. Plastic surgery. Philadelphia, PA: Saunders Elsevier; 2006. p. 791–818.Google Scholar
  45. 45.
    Gurunluoglu R, Shafighi M, Williams SA, Kimm GE. Incorporation of a preexisting scar in the star-flap technique for nipple reconstruction. Ann Plast Surg. 2012;68(1):17–21.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Mets B, Janicki PK, James MF, Erskine R, Sasman B. Lidocaine and bupivacaine cardiorespiratory toxicity is additive: a study in rats. Anesth Analg. 1992;75(4):611–4.CrossRefPubMedGoogle Scholar
  47. 47.
    Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51(4):285–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Marx GF. Cardiotoxicity of local anesthetics–the plot thickens. Anesthesiology. 1984;60(1):3–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Li J, Iorga A, Sharma S, Youn JY, Partow-Navid R, Umar S, Cai H, Rahman S, Eghbali M. Intralipid, a clinically safe compound, protects the heart against ischemia-reperfusion injury more efficiently than cyclosporine-a. Anesthesiology. 2012;117(4):836–46.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Picard J, Meek T. Lipid emulsion to treat overdose of local anaesthetic: the gift of the glob. Anaesthesia. 2006;61(2):107–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88(4):1071–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Richter DF, Reichenberger MA, Faymonville C. Comparison of the nipple projection after reconstruction with three different methods. Handchir Mikrochir Plast Chir. 2004;36(6):374–8.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE. Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg. 2002;110(2):457–63.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Boccola MA, Savage J, Rozen WM, Ashton MW, Milner C, Rahdon R, Whitaker IS. Surgical correction and reconstruction of the nipple-areola complex: current review of techniques. J Reconstr Microsurg. 2010;26(9):589–600.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Moyer HR, Ghazi B, Saunders N, Losken A. Contamination in smooth gel breast implant placement: testing a funnel versus digital insertion technique in a cadaver model. Aesthet Surg J. 2012;32(2):194–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Surg. 2006;117(1):30–6.PubMedGoogle Scholar
  57. 57.
    Van Laeken N, Genoway K. Nipple reconstruction using a two-step purse-string suture technique. Can J Plast Surg. 2011;19(2):56–9.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Mulroy MF. Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures. Reg Anesth Pain Med. 2002;27(6):556–61.CrossRefPubMedGoogle Scholar
  59. 59.
    Barash PG, Cullen BF, Stoelting RK, editors. Clinical anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 459–62.Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Capital Area Plastic Surgery of New YorkSaratoga SpringsUSA
  2. 2.LondonCanada

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