Case 12: Flower Flap - A Novel Papilla Reconstruction Technique Using Local Flaps and Skin Graft
Anna Louise Norling1, Nanja Gotland Sundstrup1, Matilda Svenning Hunt1
- 1Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hospital, Denmark
Abstract
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. Before and After Patient examination The patient was a well-preserved woman with good-quality skin. Clinical examination r
BeforeAfterA 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.
Incision lines were drawn to address lateral fullness and dog ears, shaping the breasts accordingly.
Papilla prosthetics were tried on in front of a mirror with the patient to determine optimal nipple placement based on the planned breast contour.
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The site for papillae reconstruction was marked.
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Local anesthesia was administered for dog ear excision.
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Dog ears were excised and closed up with primary sutures using Vicryl 3-0 for the subdermis and Caprosyn 4-0 intradermally.
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The excised skin and subcutaneous tissue(the medial dog ear and the lateral dog ear on the left breast) were collected.
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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.
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The final grafts consisted of full-thickness skin with subcutaneous tissue.
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The incision lines for the four small triangular local flaps were marked.
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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.
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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.
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Immediate postoperative evaluation showed the height and appearance of the reconstructed papillae.
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A compression dressing of Jelonet, gauze, and Micropore was applied, with no need for sutures.
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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.
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By POD 15, the grafts were clearing, with graft survival evident.
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On POD 31, the papillae remained mildly discolored but continued to improve with expected normalization anticipated within the following month.
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How to cite this article
Anna Louise Norling, Nanja Gotland Sundstrup, Matilda Svenning Hunt. Case 12: Flower Flap - A Novel Papilla Reconstruction Technique Using Local Flaps and Skin Graft. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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