Nipple Areola Reconstruction

Creating the nipple areola is the final component to making your breast reconstruction complete. There have been numerous approaches to nipple reconstruction over the last 30 years, and with several options available, surgeons can utilize whichever method is most suitable for their patients. There is no one absolute best method of nipple reconstruction for all patients. Some patients are comfortable without having a nipple, and do not wish to have further surgery. Others choose the non-surgical option of tattooing without reconstruction. This allows color pigmentation to simulate the nipple areola without the contour of an actual nipple. Still, the reconstruction of the nipple areola helps to put the finishing touches on the new breast after a long journey in reconstruction.

After optimal symmetry between the breasts has been achieved, the nipple areola reconstruction can be done. There are a number of factors that help determine which method of nipple reconstruction is right for you. These include the quality of tissue on the reconstructed breast, and whether you are having nipple reconstruction with or without a surrounding graft. Even more important, is your surgeon’s preference.

Historically, one technique included sharing a piece of the nipple from the opposite breast. This surgery is not used today, because it transfers breast tissue to the reconstruction that could potentially form a new cancer. Another method used in the past involved taking a full thickness skin graft from the labia to create a dark colored areola. This outdated technique leaves a scar in an undesirable location. Also, these grafts may be hair bearing, and areolar pigment is easier achieved with medical tattooing.

In modern approaches to nipple reconstruction, the nipple mound is created from skin taken as a local flap on the reconstructed breast. Various local flaps have been described, including the Skate flap, the C-V flap and the Star flap. Regardless of which approach your surgeon chooses, the outcome will be a nipple mound. The areola can then be either tattooed, or it can be reconstructed with a skin graft taken from elsewhere on the body. Common donor sites for the graft include the abdominal scar from a flap reconstruction, the inner thigh, or the buttock crease.

All nipple reconstructions lose some projection over time as part of the normal wound healing process. The risk of wound complications in nipple reconstruction is very low in patients with no history of prior radiation, but common in the radiated breast. In the case of failed nipple reconstruction, it may be necessary to revise the reconstruction with another local skin flap. Sometimes, the use of dermis or fat grafts, and fillers such as Radiesse, may be necessary to improve nipple projection. AlloDerm® has also been utilized by some surgeons at the time of nipple reconstruction to maximize projection and correct flattening.

Nipple reconstruction is done as an outpatient, ambulatory procedure. The rate of recovery depends on what other revisions are done simultaneously, and where the donor site for the areola graft is located. Once you have healed, you will have the tattooing done in your surgeon's office. Refer to the Nipple Areola Tattoo section for details on this procedure. Also you may refer to the Post-Operative Nipple Reconstruction section to learn about care after nipple surgery.

Procedure

The history of nipple reconstruction parallels that of breast reconstruction with autologous tissue, from the development of the latissimus dorsi flap by Tanzini in 1906 to modern transverse rectus abdominus myocutaneous (TRAM) and microvascular-free TRAM breast reconstruction.

Historically, nipple-areola complex reconstruction has been considered a secondary procedure to the more important breast mound reconstruction. To optimize positioning of the nipple, surgeons generally recommend waiting until complete settling of the reconstructed breast before performing nipple reconstruction. However, when nipple reconstruction is delayed for months to years, final reconstruction is often never completed, as patients often opt to minimize their exposure to further surgical procedures. Most recently, some have advocated immediate nipple reconstruction in free TRAM flap reconstructions to minimize operative procedures and to achieve earlier completion of the breast reconstruction.⁵
Nipple reconstruction techniques have evolved significantly over the years. From simple tattooing to the more technologically advanced, although rarely available, tissue engineering,⁶today's techniques are able to provide long-lasting, satisfactory reconstruction with minimal morbidity.

Indications

Nipple-areola reconstruction represents the completion of the breast restorative process and has significant psychological implications for women who undergo mastectomy. Nipple size, position, projection, and color are determining factors in the aesthetic symmetry of the reconstruction, qualifying an otherwise nondescript flesh mound as the new breast. Complete nipple-areola reconstruction with tattoo can visually draw attention away from the scars on the reconstructed breast mound. In addition, autologous flap breast reconstruction following skin-sparing mastectomy can usually be designed so that the entire flap skin paddle, along with the scar, is tattooed as an areola.

The benefit of nipple-areola reconstruction is supported by the findings of a retrospective psychological survey comparing the level of satisfaction of women who underwent breast reconstruction with or without nipple-areola reconstruction; a highly significant correlation was seen between level of satisfaction and presence of the nipple-areola complex. Artists and anatomists consider the nipple-areola complex an essential and defining component of the breast aesthetic unit, and the physical characteristics of the nipple gain importance as the breast mound decreases in size. Reconstruction of position, size, shape, and color of the native nipple-areola complex currently are attainable goals; functional restoration of erectile ability and erogenous sensation are goals for future reconstructive surgeons.

Relevant Anatomy

Nipple-areola anatomy is remarkably variable in dimension, texture, and color across ethnic groups and among individuals. Moreover, an appreciable difference often exists in the two nipple-areola complexes in the same patient. The presence of an elevated structure in the center of a pigmented area on the breast mound usually represents a nipple, yet wide variability exists as to what constitutes the normal dimensions of the complex. In general, an aesthetically balanced B-C cup breast has an areola diameter of 4.2-5 cm, with the nipple diameter and projection or height equal to one third to one fourth of the areola diameter.
The central position of the nipple cylinder in the areola also has significant variability, ranging from one fourth to one half of the radius off-center.
Nipple projection results from the primary location of the mammary ducts in the central portion of the nipple complex. This arrangement produces a semi-rigid structure with a significantly more fibrotic element than the soft and pliable surrounding areola. The contractile properties of the areola also contribute to the gradual change in nipple projection obtained with direct or neural stimuli.
Most methods of nipple reconstruction can be used whether the breast has been reconstructed with a flap or alloplastic materials. Flaps generally provide more mobile tissue and make it easier to achieve nipple bulk and projection. Previous scars from the mastectomy or previous biopsies need to be accounted for in terms of flap design so as not to compromise blood supply to the reconstructed nipple.