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.