Annals of the Royal College of Surgeons of England (1991) vol. 73, 67-69
An improved nipple prosthesis Richard Sainsbury
MD FRCS
Consultant Surgeon
Valerie A Walker
RGN
Breast Nurse Specialist
Paul M Smith Dental Technical Officer
Huddersfield Royal Infirmary, Huddersfield, West Yorkshire
Key words: Nipple-areola prosthesis; Breast reconstruction
A nipple-areola reconstruction or prosthesis completes the of breast reconstruction. Reconstructions are technicaily difficult and have poor long-term results, whereas commercial nipple prostheses are unsatisfactory in matching the normal colour and shape. We describe a simple technique for the manufacture of a custom made nipple-areola prosthesis.
placing a nipple that looks realistic. To avoid these problems various artificial (stick-on) nipple prostheses have been developed. Some of these are available commercially, but are often unrealistic in size, shape and colour (Fig. 1) as well as being expensive. We report a technique of preparing a customised nipple by taking a plaster-of-Paris impression of the normal nipple and making a silastic prosthesis which can be glued in place.
General surgeons are increasingly offering their patients breast reconstruction, either at the time of mastectomy or at a later date. This may be carried out by creation of a subcutaneous or subpectoral pocket with placement of a silastic prosthesis either immediately or after a period of tissue expansion, or by the use of a myocutaneous flap such as the latissimus dorsi or transverse rectus myocutaneous flap (TRAM). All the above techniques aim to provide a breast mound with a volume approximately equal to the remaining breast. It is seldom possible to match the ptosis of a normal breast and most surgeons (and their patients) are happy with a breast that fills the brassiere (1). The practice of nipple-areola reconstruction (NAR) varies greatly, with a quoted use varying from 0 to 94% (2,3). Many surgeons do not offer it at all, discouraging those patients who ask for it, or claiming that their patients are satisfied with the breast mound and wish for nothing more. Many patients do not wish to undergo further surgery (4). Many surgical techniques of NAR have been tried; most are technically difficult and have poor long-term results (1). There is a definite art in constructing and
Materials and methods
process
Correspondence to: Mr R Sainsbury, Consultant Surgeon, Huddersfield Royal Infirmary, Acre Street, Huddersfield, West Yorkshire HD3 3EA
We use a plaster-of-Paris technique (in preference to the injection alginate method originally described by Roberts et al. (5)) to make a copy of the opposite nipple-areola
complex (NAC). The patient's clothes are protected by a towel and a plaster-of-Paris mix is prepared. It is applied with a spatula to cover the NAC (Fig. 2). The plaster dries within minutes and the cast is carefully removed (Fig. 3). A colour match is then obtained by comparison with a set of control shades (Fig. 4). The silastic nipple is then made directly from the plaster impression by investing the impression in a two-part flask using the lost wax technique. The material used for the new nipple is a silicone elastomer (Silskin®, Chas. Thackery, Leeds). The process takes 3 h in a dry heat furnace with the flask under pressure. This technique is available in any dental laboratory. The new NAC is trimmed and fitted. It is held in place with a silastic glue (Dow Corning) and is positioned by the patient (Fig. 5). (It can also be stuck on the outside of an external breast prosthesis if required.) During the preparation of the nipple, the application of the plaster causes a degree of nipple erection producing a satisfactory final shape. No problems have been encountered with the nipple contracting during preparation of the mould.
68
R Sainsbury et al.
Figure 1. A commercial nipple compared to a custom made nipple showing difference in colour and shape.
Figure 3. The plaster impression.
Figure 2. Plaster-of-Paris being applied to the nipple to make an impression.
Figure 4. A colour match is obtained by comparison with a set of control patches.
(a)
(b)
Figure 5. The nipple can be stuck in place by using either (a) spray, or (b) painted adhesive.
An improved nipple prosthesis
69
Discussion
v~~~ l.
Figure 6. Bilateral reconstruction showing nipples in place.
This technique is easy to master and impressions can be taken at ordinary clinic visits or while the patient is on the ward. Any maxillofacial laboratory can prepare the nipple. It provides the final touches to the reconstructed breast and offers considerable advantages over the commercial varieties, giving better shape and colour. The commercial prostheses are not available on NHS prescription and cost between £7 and £10 plus VAT if bought directly from the manufacturer. They cost much more if bought privately (6). It obviates the need for further surgery and should be offered to all patients undergoing breast reconstruction. We thank Mr David Sharpe, Consultant Plastic Surgeon, for introducing us to this technique.
References Results All patients undergoing reconstruction are offered this technique and so far all have welcomed it. Many wear their nipples continuously (up to a month at a time), swim in them and play sports. All comment that it is nice to have a 'complete' shape again. They are encouraged to remove the nipple at least once a month to clean the skin underneath it. An informal survey has shown that between 70% and 80% of paients wear their nipples on a regular basis. Some of the remainder put the nipple on for 'special occasions'. Less than 5% have dispensed with the nipple
altogether. Bilateral reconstructions pose no problem (Fig. 6). The patient chooses a nipple shape from a stock selection of extras made from each mould.
I Bostwick J. Reconstruction of the nipple areola. Aesthetic and Reconstructive Breast Surgery. St Louis: C V Mosby,
1983:675-720. 2 Goldwin RM. Breast reconstruction after mastectomy. N Engl J Med 1987;317:1711-14. 3 Chisholm EM, Marr S, Macfie J, Broughton AC, Brennan TG. Post mastectomy breast reconstruction using the inflatable tissue expander. Brj Surg 1986;73:817-20. 4 Ward CM. The uses of external nipple-areola prostheses following reconstruction of a breast mound after mastectomy. BrJ Plast Surg 1985;38:51-4. 5 Roberts AC, Coleman DJ, Sharpe DT. Custom made nipple-areola prostheses in breast reconstruction. BrJ Plast
Surg 1988;41:586-7. 6 Anon. Restricted access to prosthetic nipples. Therapy Weekly. London: Macmillan Press, 1989;Nov 9:24.
Received 12 July 1990
An improved nipple prosthesis Richard Sainsbury
MD FRCS
Consultant Surgeon
Valerie A Walker
RGN
Breast Nurse Specialist
Paul M Smith Dental Technical Officer
Huddersfield Royal Infirmary, Huddersfield, West Yorkshire
Key words: Nipple-areola prosthesis; Breast reconstruction
A nipple-areola reconstruction or prosthesis completes the of breast reconstruction. Reconstructions are technicaily difficult and have poor long-term results, whereas commercial nipple prostheses are unsatisfactory in matching the normal colour and shape. We describe a simple technique for the manufacture of a custom made nipple-areola prosthesis.
placing a nipple that looks realistic. To avoid these problems various artificial (stick-on) nipple prostheses have been developed. Some of these are available commercially, but are often unrealistic in size, shape and colour (Fig. 1) as well as being expensive. We report a technique of preparing a customised nipple by taking a plaster-of-Paris impression of the normal nipple and making a silastic prosthesis which can be glued in place.
General surgeons are increasingly offering their patients breast reconstruction, either at the time of mastectomy or at a later date. This may be carried out by creation of a subcutaneous or subpectoral pocket with placement of a silastic prosthesis either immediately or after a period of tissue expansion, or by the use of a myocutaneous flap such as the latissimus dorsi or transverse rectus myocutaneous flap (TRAM). All the above techniques aim to provide a breast mound with a volume approximately equal to the remaining breast. It is seldom possible to match the ptosis of a normal breast and most surgeons (and their patients) are happy with a breast that fills the brassiere (1). The practice of nipple-areola reconstruction (NAR) varies greatly, with a quoted use varying from 0 to 94% (2,3). Many surgeons do not offer it at all, discouraging those patients who ask for it, or claiming that their patients are satisfied with the breast mound and wish for nothing more. Many patients do not wish to undergo further surgery (4). Many surgical techniques of NAR have been tried; most are technically difficult and have poor long-term results (1). There is a definite art in constructing and
Materials and methods
process
Correspondence to: Mr R Sainsbury, Consultant Surgeon, Huddersfield Royal Infirmary, Acre Street, Huddersfield, West Yorkshire HD3 3EA
We use a plaster-of-Paris technique (in preference to the injection alginate method originally described by Roberts et al. (5)) to make a copy of the opposite nipple-areola
complex (NAC). The patient's clothes are protected by a towel and a plaster-of-Paris mix is prepared. It is applied with a spatula to cover the NAC (Fig. 2). The plaster dries within minutes and the cast is carefully removed (Fig. 3). A colour match is then obtained by comparison with a set of control shades (Fig. 4). The silastic nipple is then made directly from the plaster impression by investing the impression in a two-part flask using the lost wax technique. The material used for the new nipple is a silicone elastomer (Silskin®, Chas. Thackery, Leeds). The process takes 3 h in a dry heat furnace with the flask under pressure. This technique is available in any dental laboratory. The new NAC is trimmed and fitted. It is held in place with a silastic glue (Dow Corning) and is positioned by the patient (Fig. 5). (It can also be stuck on the outside of an external breast prosthesis if required.) During the preparation of the nipple, the application of the plaster causes a degree of nipple erection producing a satisfactory final shape. No problems have been encountered with the nipple contracting during preparation of the mould.
68
R Sainsbury et al.
Figure 1. A commercial nipple compared to a custom made nipple showing difference in colour and shape.
Figure 3. The plaster impression.
Figure 2. Plaster-of-Paris being applied to the nipple to make an impression.
Figure 4. A colour match is obtained by comparison with a set of control patches.
(a)
(b)
Figure 5. The nipple can be stuck in place by using either (a) spray, or (b) painted adhesive.
An improved nipple prosthesis
69
Discussion
v~~~ l.
Figure 6. Bilateral reconstruction showing nipples in place.
This technique is easy to master and impressions can be taken at ordinary clinic visits or while the patient is on the ward. Any maxillofacial laboratory can prepare the nipple. It provides the final touches to the reconstructed breast and offers considerable advantages over the commercial varieties, giving better shape and colour. The commercial prostheses are not available on NHS prescription and cost between £7 and £10 plus VAT if bought directly from the manufacturer. They cost much more if bought privately (6). It obviates the need for further surgery and should be offered to all patients undergoing breast reconstruction. We thank Mr David Sharpe, Consultant Plastic Surgeon, for introducing us to this technique.
References Results All patients undergoing reconstruction are offered this technique and so far all have welcomed it. Many wear their nipples continuously (up to a month at a time), swim in them and play sports. All comment that it is nice to have a 'complete' shape again. They are encouraged to remove the nipple at least once a month to clean the skin underneath it. An informal survey has shown that between 70% and 80% of paients wear their nipples on a regular basis. Some of the remainder put the nipple on for 'special occasions'. Less than 5% have dispensed with the nipple
altogether. Bilateral reconstructions pose no problem (Fig. 6). The patient chooses a nipple shape from a stock selection of extras made from each mould.
I Bostwick J. Reconstruction of the nipple areola. Aesthetic and Reconstructive Breast Surgery. St Louis: C V Mosby,
1983:675-720. 2 Goldwin RM. Breast reconstruction after mastectomy. N Engl J Med 1987;317:1711-14. 3 Chisholm EM, Marr S, Macfie J, Broughton AC, Brennan TG. Post mastectomy breast reconstruction using the inflatable tissue expander. Brj Surg 1986;73:817-20. 4 Ward CM. The uses of external nipple-areola prostheses following reconstruction of a breast mound after mastectomy. BrJ Plast Surg 1985;38:51-4. 5 Roberts AC, Coleman DJ, Sharpe DT. Custom made nipple-areola prostheses in breast reconstruction. BrJ Plast
Surg 1988;41:586-7. 6 Anon. Restricted access to prosthetic nipples. Therapy Weekly. London: Macmillan Press, 1989;Nov 9:24.
Received 12 July 1990
