Case 12: Flower Flap – A Novel Papilla Reconstruction Technique Using Local Flaps and Skin Graft

Keywords: Flower Flap, Papilla reconstruction, nipple reconstruction, breast revision, full-thickness skin graft, dog ear correction

Authors: Anna Louise Norling, MD, Nanja Gotland Sundstrup, MD, Matilda Svenning Hunt, MD and Pia Cajsa Leth Andersen, MD. Institution: Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hospital, Denmark

Abstract

A 47-year-old woman underwent bilateral papillae reconstruction using a novel reconstruction technique involving four local flaps and a full-thickness skin graft including subcutaneous tissue from excised dog ears, due to scar correction, following a DIEP flap breast reconstruction. This technique preserved breast projection, avoided additional scarring, and improved breast contour. Initial epidermolysis occurred, as expected with a thick graft, but the grafts survived. At one month follow-up, the papillae showed resolving discoloration. This simple and reliable method facilitates simultaneous nipple reconstruction and aesthetic breast contouring with minimal donor-site morbidity.

Patient medical history

A 47-year-old woman with a history of DCIS in the left breast and a family history of breast cancer (BRCA-negative) initially underwent bilateral subcutaneous mastectomy with NAC removal and implant-based reconstruction in 2021. Due to dissatisfaction with the result, she had bilateral DIEP flap reconstruction in May 2023. In July 2024, a revision was performed to improve the breast shape, including correction of dog ears and redundant skin on the DIEP flaps, as well as lateral liposuction. At the 3-month follow-up, the breasts remained laterally full with a square appearance. A new revision was planned to refine the contour and simultaneously reconstruct the nipple using a novel technique combining four small local flaps and a full-thickness skin graft with subcutaneous tissue.

Breast augmentation post-surgery scars and healing process

Before and After

The patient was a well-preserved woman with good-quality skin. Clinical examination revealed signs of previous breast reconstruction, including horizontal mastectomy scars. The breast shape was squared with a flattened projection. Excess skin was present, forming a medial dog ear on the right breast and lateral dog ears on both sides, with prominent lateral fullness extending to the mid-axillary line.

Pre-operative considerations

To complete the breast reconstruction, papilla reconstruction was indicated. Several techniques are available, including local flaps and skin grafts, each with specific advantages and drawbacks. In Denmark, the “Tennessee flap,” a modified version of the “C-H flap,” is frequently used. This flap is typically designed with a height of 1–1.3 cm but is known to shrink significantly over time. Although simple and safe, it relies solely on local skin, often resulting in compromised breast projection and a flattened contour. These changes can complicate accurate placement of the reconstructed papilla. Moreover, the technique introduces two additional scars adjacent to the papilla. Existing surgical scars may also affect flap viability, as raising local flaps too close to scar tissue increases the risk of necrosis and reconstruction failure.
In this case, the patient’s squared breasts and flattened projection made the Tennessee flap suboptimal. She also exhibited lateral skin excess and fullness, which required correction to achieve a more natural contour. These features made her a suitable candidate for the “flower flap” reconstruction—a new technique combining four small local flaps and a full-thickness skin graft that includes some subcutaneous tissue. This method produces a low papilla (approximately 3-5 mm), which undergoes minimal shrinkage, preserves breast projection, and utilizes skin from dog ear excisions.
To address lateral breast fullness, the lateral scars needed to be extended. The patient’s preferences were considered, and she accepted the scar elongation as a trade-off for reduced fullness. The medial dog ear on the right breast could be corrected without further scar extension. Papilla placement was determined collaboratively with the patient in front of a mirror, taking planned skin corrections into account.
A thick skin graft containing subcutaneous tissue increases the risk of graft failure but provides additional height. Since the graft was harvested from skin that would otherwise be discarded, the consequences of failure were minimal. Additionally, the patient expressed interest in correcting dog ears on the abdominal scar. Although not part of this procedure, this site could later be used as a graft donor if needed.
Breast surgery planning with marker drawings.
1

Incision lines

Incision lines were drawn to address lateral fullness and dog ears, shaping the breasts accordingly.

2

Placement of the papillae

Papilla prosthetics were tried on in front of a mirror with the patient to determine optimal nipple placement based on the planned breast contour.

3

Marking of the Papillae

The site for papillae reconstruction was marked.

4

Local anesthesia

Local anesthesia was administered for dog ear excision.

5

Dog ear excision

Dog ears were excised and closed up with primary sutures using Vicryl 3-0 for the subdermis and Caprosyn 4-0 intradermally.

6

Excised skin and subcutaneous tissue

The excised skin and subcutaneous tissue(the medial dog ear and the lateral dog ear on the left breast) were collected.

7

Shaping and trimming the papillae

Portions of the excised tissue, typically discarded, were used to create new papillae.
The grafts were shaped into 1 cm diameter circles, with excess subcutaneous tissue trimmed while retaining some to increase height of the papillae.

8

The final grafts

The final grafts consisted of full-thickness skin with subcutaneous tissue.

9

Local flaps incision lines

The incision lines for the four small triangular local flaps were marked.

10

Raising the local flaps

The flaps were raised with underlying subcutaneous tissue, creating a central wound bed for graft placement. The raised local flaps were assessed for adequate mobility.

11

Suture of the graft

The grafts were sutured in place using Prolene 5-0. Sutures were placed at the four corners of the local flaps and the corresponding areas on the graft, with additional sutures along the grooves between the flaps.

12

Immediate postoperative evaluation

Immediate postoperative evaluation showed the height and appearance of the reconstructed papillae.

13

Compression dressing

A compression dressing of Jelonet, gauze, and Micropore was applied, with no need for sutures.

14

Follow-up POD 7

On postoperative day 7 (POD 7), the dressing was removed. As expected, the graft appeared dark with epidermolysis, typical for a skin graft that includes subcutaneous tissue.

15

Follow-up POD 15

By POD 15, the grafts were clearing, with graft survival evident.

16

Follow-up POD 31

On POD 31, the papillae remained mildly discolored but continued to improve with expected normalization anticipated within the following month.

Pearls

• This technique is straightforward and well-suited for outpatient or clinical settings.
• Papilla placement is easier to predict because the method does not alter breast contour or projection.
• No additional scars are created near the papilla.
• Donor site morbidity is minimal; skin excised for cosmetic reasons (e.g., dog ears) can be repurposed for the reconstruction, improving aesthetics.
• Since discarded skin is used for grafting, the consequences of graft failure are minimal, allowing easy reattempts.

Pitfalls

• Thick skin grafts with subcutaneous tissue carry a risk of ischemia and graft failure.
• Epidermolysis and initial graft darkening are expected. Without prior awareness, this may be mistaken for graft failure.
• The papilla height achieved is limited (3–5 mm) and may not match a contralateral native papilla if present.

Post-operative plan

• Compression dressing is removed on postoperative day 7, along with suture removal, during a nurse-led consultation.
• A second follow-up is conducted at two weeks postoperatively by a nurse to evaluate graft survival and healing progress.
• A final evaluation with the operating surgeon is scheduled at three months to assess the long-term aesthetic outcome.

References

  • Krogsgaard, S. H. H., Carstensen, L. F., Thomsen, J. B., & Rose, M. (2019). Nipple Reconstruction: A Novel Triple Flap Design. Plastic and Reconstructive Surgery, Global Open, 7(5), Article e2262. https://doi.org/10.1097/GOX.0000000000002262
  • Sisti A, Grimaldi L, Tassinari J, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol. 2016;42(4):441-465. doi:10.1016/j.ejso.2016.01.003
  • Yoo H, Park S, Chang H. Nipple reconstruction using modified C-V flap with purse-string sutures for maintenance of long-term nipple projection. J Plast Reconstr Aesthet Surg. 2023;84:62-70. doi:10.1016/j.bjps.2023.04.061
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  • Komiya T, Iwahira Y, Ishikawa T, Matsumura H. Long-Term Outcome of Nipple Projection Maintenance After Reconstruction with Clover Flap Technique. Aesth Plast Surg. 2021;45:1487–1494. doi:10.1007/s00266-021-02170-1
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  • Colwell AS, Christensen JM. Nipple Reconstruction with C-V Flap Using Dermofat Graft. Plast Reconstr Surg.2010;126:1292-1298. doi:10.1097/PRS.0b013e3181f3b744

Contents

Case 12: Flower Flap – A Novel Papilla Reconstruction Technique Using Local Flaps and Skin Graft