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Nipple-Areola Reconstruction

  • Author: Yoon Sun Chun, MD; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Apr 29, 2015
 

Background

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 eMedicineHealth's Women's Health Center and Cancer Center. Also, see eMedicineHealth's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

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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.

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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.

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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.

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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. For example, if the breast mound reconstruction presents with poor skin/soft tissue quality (as with postmastectomy radiation), nipple-areola complex reconstruction may be associated with increased complication risks and compromise in overall reconstruction outcome.

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Contributor Information and Disclosures
Author

Yoon Sun Chun, MD Assistant Professor, 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, Massachusetts Medical Society, Association of Women Surgeons, Johns Hopkins Medical and Surgical Association

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 Society for Reconstructive Microsurgery, Plastic Surgery Research Council, American Medical Association, Massachusetts Medical Society

Disclosure: Received consulting fee from Integra LifeSciences, Inc for consulting; Received consulting fee from Integra LifeSciences, Inc. for program and training services agreement; Received grant/research funds from Integra LifeSciences, Inc. for clinical research; Received grant/research funds from KCI for basic science research; Received grant/research funds from KCI for clinical research; Received consulting fee from DSM for consulting; Received consulting fee from Musculoskeletal Transplant Foundatio.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS 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, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Pankaj Tiwari, MD Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

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.

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Diagram illustrating the layout of the bell flap. Note the triangles excised between the "handle" and the "bell" of the flap to allow for easier folding.
Diagram illustrating the layout of the skate flap. D is the diameter of the contralateral nipple, and the total length of the flap is twice the height (projection) of the contralateral nipple.
Diagram illustrating the layout of the double opposing tab flap. Note that the minimum recommended base width for the tabs is 18 mm. The 2 tabs are elevated and rotated to face each other as if 2 hands were joined in prayer.
Intraoperative sequence of nipple reconstruction with the bell flap: initial layout and dissection of the flap.
Intraoperative sequence of nipple reconstruction with the bell flap: elevation and initial apposition of the flap.
Intraoperative sequence of nipple reconstruction with the bell flap: final reconstruction.
Diagram illustrating the layout of modified star flap for nipple reconstruction. D is the diameter of the contralateral nipple. The 2 lateral arms wrap around to form a cylindrical structure and the central arm provides the top.
Intraoperative photograph of a nipple reconstruction using modified star flap. The 3-arm donor sites are closed primarily.
Postoperative photograph of the same patient.
 
 
 
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