Case 17 2026: Papilla Reconstruction Using the Tennessee Flap Following DIEP Flap Breast Reconstruction
Mikkel Halborg Sørensen1, Nanja Gotland Sundstrup1, Christian Lyngsaa Lang1
- 1Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hospital, Denmark
Abstract
Keywords: Tennessee flap, modified C-H flap, nipple reconstruction, invasive ductal carcinoma, DIEP flap, secondary breast reconstruction Authors: Mikkel Halborg Sørensen, MD; Nanja Gotland Sundstrup, MD; Christian Lyngsaa Lang, MD Institution: Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hospital, Denmark Abstract A 50-year-old woman with a history of invasive ductal carcinoma (IDC) underwent right-sided papilla reconstruction following secondary deep inferior epigastric perforator (DIEP) flap breast reconstruction. A Tennessee flap technique was used in conjunction with correction of lateral volume of the DIEP flap. The technique provided projection and predictable positioning relative to the contralateral nipple-areola complex. The procedure was performed under local anesthesia in an outpatient setting. The immediate postoperative appearance was satisfactory, and wound healing proceeded without complications. This case higlights the continued utility of the Tennessee flap as a simple, safe, and reproducible technique for delayed nipple reconstruction. Patient medical history A 50-year-old woman with a history of IDC underwent right-sided subcutaneous mastectomy in 2017. In 2025, she underwent unilateral delayed autologous breast reconstruction using a DIEP flap. In 2026, completion of the reconstructive process was planned with papilla reconstruction. The patient was in good general health, non-smoking, and without known comorbidities. Before and After Patient examination Clinical examination demonstrated a well-integrated right-sided DIEP flap, good symmetry compared to the contralateral breast, even though the flap was too voluminous at the lateral side. Absence of nipple-areola complex (NAC) on the reconstructed side and a contralateral areola with soft and not sharply demarcated borders. A well-healed lower abdominal donor-site scar from the DIEP flap harvest was present. Pre-operative considerations In Denmark, the Tennessee
BeforeAfterA 50-year-old woman with a history of IDC underwent right-sided subcutaneous mastectomy in 2017. In 2025, she underwent unilateral delayed autologous breast reconstruction using a DIEP flap. In 2026, completion of the reconstructive process was planned with papilla reconstruction. The patient was in good general health, non-smoking, and without known comorbidities.
Incision lines were drawn outlining:
•tThe lateral excision and contouring of the DIEP flap.
•tThe Tennessee flap design for papilla reconstruction
Local anesthesia was administered using lidocaine.
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The flap incisions were performed according to the marked design
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Initial elevation of the dermal flaps was performed in the subdermal plane.
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Further flap elevation was performed while preserving dermal thickness to maintain vascularity from the subdermal plexus.
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The dermal flaps were fully elevated and mobilized in preparation for formation of the neo-papilla.
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The central limb of the flap was folded to initiate projection of the reconstructed papilla.
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The lateral wings were wrapped around the central limb and secured with sutures to shape the neo-papilla, followed by skin closure.
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Immediate postoperative appearance following papilla reconstruction.
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Dressing removal and suture removal at postoperative day 7–10. Clinical evaluation of projection and wound healing. Areola tattooing planned after complete healing, typically 3 months. Final evaluation at 3 months to assess projection maintenance and symmetry.
At suture removal 10 days post-operative (picture), healing was uneventful. The papilla maintained adequate projection with no signs of ischemia or wound complications.
How to cite this article
Mikkel Halborg Sørensen, Nanja Gotland Sundstrup, Christian Lyngsaa Lang. Case 17 2026: Papilla Reconstruction Using the Tennessee Flap Following DIEP Flap Breast Reconstruction. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 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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