eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Nipple-Areola Reconstruction

Author: Yoon Sun Chun, MD, Clinical Instructor, Department of Surgery, Harvard Medical School; Associate Surgeon, Department of Surgery, Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital; Staff Surgeon, Department of Surgery, Division of Plastic and Reconstructive Surgery, Faulkner Hospital
Coauthor(s): Dennis P Orgill, MD, PhD, Professor of Surgery, Harvard Medical School; Associate Chief of Plastic Surgery, Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Aug 20, 2009

Introduction

Breast cancer is second only to skin cancer as the most common cancer in women. According to the American Cancer society, an estimated 193,000 women in the United States will be diagnosed with breast cancer in 2009.1 Many of these patients will undergo breast conservation therapy. In 2008, according to the American Society of Plastic Surgery, approximately 80,000 women underwent breast reconstruction, most with expanders and implants and about 24,000 with some type of flap reconstruction.2

Following mastectomy, breast reconstruction can provide significant psychosocial benefits for women. Because the reconstructed nipple is not easily moved, nipple reconstruction is usually reserved as the final step in breast reconstruction and is critical for providing an aesthetically pleasing breast.3 Patients with loss of the nipple and areola from cancer excision, trauma, or congenital absence continue to experience psychological distress even long after breast mound reconstruction has taken place. Studies have shown that recreation of the nipple-areola complex has a high correlation with overall patient satisfaction and acceptance of body image.4 Thus, completion of the breast reconstruction by creating a nipple-areola complex that matches the contralateral nipple in terms of size, shape, projection, and position adds significantly to the reconstructive result.

Numerous techniques have been developed to reconstruct the nipple following mastectomy. These include intradermal tattooing, variations of local tissue flaps, skin grafts, cartilage grafts, tissue-engineered structures, and nipple-sharing techniques. The most common problem following nipple reconstruction is a decrease in projection, or nipple flattening. Thus, methods of secondary nipple reconstruction as well as restoration of nipple projection have been reported.

For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

History of the 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,6 today'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.

Contraindications

No general contraindications exist to reconstruction of the nipple-areola complex. However, evaluation of each patient's specific medical condition and surgical requirements may delay or contraindicate the procedure on a case-by-case basis.

More on Breast Reconstruction, Nipple-Areola Reconstruction

Overview: Breast Reconstruction, Nipple-Areola Reconstruction
Treatment: Breast Reconstruction, Nipple-Areola Reconstruction
Follow-up: Breast Reconstruction, Nipple-Areola Reconstruction
Multimedia: Breast Reconstruction, Nipple-Areola Reconstruction
References
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References

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  2. National Clearinghouse of Plastic Surgery Statistics. 2008 Reconstructive Breast Patients. 2009 Report of the 2008 Statistics. American Society of Plastic Surgeons Web site. Available at http://www.plasticsurgery.org/Media/stats/2008-US-cosmetic-reconstructive-plastic-surgery-minimally-invasive-statistics.pdf. Accessed August 20, 2009.

  3. Few JW, Marcus JR, Casas LA. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg. Oct 1999;104(5):1321-4. [Medline].

  4. Evans KK, Rasko Y, Lenert J. The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction: early results. Ann Plast Surg. Jul 2005;55(1):25-9; discussion 29. [Medline].

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Further Reading

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Keywords

breast reconstruction, nipple-areola complex, breast cancer, athelia, transverse rectus abdominus myocutaneous reconstruction, TRAM reconstruction, microvascular-free TRAM breast reconstruction, mastectomy, breast surgery, breast implant, nipple surgery, nipple reconstruction, areola reconstruction

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Contributor Information and Disclosures

Author

Yoon Sun Chun, MD, Clinical Instructor, Department of Surgery, Harvard Medical School; Associate Surgeon, Department of Surgery, Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital; Staff Surgeon, Department of Surgery, Division of Plastic and Reconstructive Surgery, Faulkner Hospital
Yoon Sun Chun, MD is a member of the following medical societies: American Medical Association, American Society of Plastic Surgeons, Association of Women Surgeons, Johns Hopkins Medical and Surgical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Dennis P Orgill, MD, PhD, Professor of Surgery, Harvard Medical School; Associate Chief of Plastic Surgery, Brigham and Women's Hospital
Dennis P Orgill, MD, PhD is a member of the following medical societies: American Burn Association, American Medical Association, American Society for Reconstructive Microsurgery, Massachusetts Medical Society, and Plastic Surgery Research Council
Disclosure: Kinetic Concepts, Inc. Grant/research funds Principle Investigator; Isologen Corporation Grant/research funds Principle Investigator; Massachusetts Institute of Technology Royalty None; Brigham and Women's Hospital Royalty None; Regenesis Corporation Scientific Advisory Board Consulting; Kinetic Concepts, Inc. Expert Witness None

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

James Neal Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
James Neal Long, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

 
 
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