ORIGINAL ARTICLE Improving Long-Term Projection in Nipple Reconstruction Using Human Acellular Dermal Matrix An Animal Model L. H. Holton, MD,* Hafez Haerian, BA,* Ronald P. Silverman, MD,* Thomas Chung, DO,* Jennifer H. Elisseeff, PhD,† Nelson H. Goldberg, MD,* and Sheri Slezak, MD* Abstract: Reconstructed nipples rapidly lose projection. We de- scribe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction. Key Words: acellular dermal matrix, nipple projection, micronized acellular dermal matrix, nipple reconstruction (Ann Plast Surg 2005;55: 304 –309) B reast cancer is the most common cancer in women. 1 The American Cancer Society estimates that more than 211,000 new cases of breast cancer will be diagnosed in American women in 2003. 2 A majority of women with breast cancer have traditionally opted for modified radical mastec- tomy for local control of their disease. 3 Essentially, all postmastectomy patients are fraught with distress from the diagnosis of cancer and affected by the adverse body image caused by the loss of their breast. 4,5 Breast reconstruction is an integral component of the physical and emotional recovery for many of these women, 4,5 and studies clearly demonstrate that patient satisfaction after breast reconstruction correlates highly with the presence of a nipple and areola. 6 Although surgeons have developed numerous tech- niques for reconstructing the nipple–areola complex, no cur- rent method reliably yields a good esthetic result with low morbidity and durable nipple projection. Although the ma- jority of commonly used methods are simple for the surgeon, well-tolerated by the patient, and provide acceptable initial projection, most studies demonstrate that nipple projection is ultimately suboptimal within several months. 7–11 In a recent retrospective study examining patient satisfaction after nip- ple–areola reconstruction, the factors patients disliked most about their reconstruction was the lack of projection. 12 The only recent techniques able to provide lasting nipple projec- tion have required surgeons to augment local tissue flaps with graft material. 13 Although these efforts have generally worked, they are dependent on the use of tissue harvested from distant body sites, thus exposing patients to increased operative time and unnecessary harvest site morbidity. Ef- forts to develop a simple, 1-stage method for nipple recon- struction that yields a nipple with lasting projection will benefit both surgeons and their patients. As noted, there are many techniques for nipple–areola reconstruction available to the surgeon. When choosing a method of reconstruction, surgeons must consider ease of procedure, patient morbidity, cost, and cosmetic result, which should include the long-term projection of the new nipple. There are several general categories of nipple–areola recon- struction technique, including free composite grafts, prosthet- ics, and local tissue flaps. Grafts use tissue harvested from Received January 6, 2005; accepted for publication May 2, 2005. From the *University of Maryland Medical Center, Division of Plastic and Reconstructive Surgery, Baltimore, Maryland; and the †Whiting School of Engineering, Whitaker Biomedical Engineering Institute, Johns Hopkins University, Baltimore, Maryland. Drs. Silverman and Goldberg have received honoraria from LifeCell Corpo- ration as speakers. This research was supported by a grant form LifeCell Corporation. Reprints: Ronald P. Silverman, MD, University of Maryland Medical Center, Division of Plastic and Reconstructive Surgery, 22 South Greene Street, Baltimore, MD 21201. E-mail: rsilverman@smail.umaryland.edu. Copyright © 2005 by Lippincott Williams & Wilkins ISSN: 0148-7043/05/5503-0304 DOI: 10.1097/01.sap.0000171679.78456.62 Annals of Plastic Surgery • Volume 55, Number 3, September 2005 304