Nipple projection evolution using the modified arrow flap:
prospective study on 25 consecutive nipple reconstructions
Horácio Zenha Costa
Mário Jorge Freire dos Santos
Received: 1 June 2014 /Accepted: 26 June 2014 / Published online: 31 July 2014
Springer-Verlag Berlin Heidelberg 2014
Background Nipple–areola complex reconstruction repre-
sents the final stage of breast reconstruction. It is considered
one of the most important landmarks of the entire process. It is
known that nipples reconstructed with local flaps slowly and
inexorably flatten with time. The authors undertook this pro-
spective study to evaluate the effectiveness of a modified
arrow flap technique for nipple reconstruction.
Methods A series of 25 consecutive nipple reconstructions
were performed on post-mastectomy defects reconstructed
with tissue expander and implant or autologous tissues. All
patients have been followed for at least 12 months, and the
involution of the nipple projection was assessed through dig-
ital caliper measuring.
Results No immediate complications were observed. The av-
erage immediate postoperative projection was 12.9 mm. The
average residual projection at 3, 6, and 12 months was 69, 47,
and 35 %, respectively.
Conclusions The modified arrow flap has proved to have an
acceptable residual projection with pleasing clinical outcome.
It is a reliable procedure, easy to learn, and reproduce.
Level of Evidence: Level IV, therapeutic study.
Nipple–areola complex (NAC) reconstruction represents the
final stage of breast reconstruction. Although it is considered a
technically easy procedure, it is one of the most important
aesthetical landmarks of the reconstructed breast and one that
will at last restore the patient’s self-image of normality.
The presence of a nipple and areola highly correlates with
patient satisfaction with breast reconstruction .
Numerous nipple reconstruction techniques have been de-
scribed, but all have to deal with eventual loss of long-term
projection. Classical techniques like nipple sharing or
nipple banking  are no longer used and have been relegated
in favor of local “pull-out” flaps [3, 4] which have shown to be
more reliable and represent the current surgical technique of
choice for nipple reconstruction.
In this article, the aim of this study is to evaluate the
technique of nipple reconstruction using a modification of
the arrow flap described by Thomas et al. bypresenting
a long-term assessment of nipple projection.
Materials and methods
The study presents a series of 25 consecutive nipple recon-
structions in patients with post-mastectomy defects who
underwent breast reconstruction either with expander and
implant or with autologous tissues. All surgeries were per-
formed on an outpatient clinic. Follow-up lasted for up to
12 months during which periodic measurements of the nipples
were made, always by the same observer through the use of a
digital caliper with the aim of assessing its involution.
R. Carvalho (*)
H. Z. Costa
M. J. Freire dos Santos
Serviço de Cirurgia Plástica e Queimados, Centro Hospitalar e
Universitário de Coimbra, Praceta Prof. Mota Pinto,
3000-075 Coimbra, Portugal
Eur J Plast Surg (2014) 37:539–542