- Author: Yoon Sun Chun, MD; Chief Editor: James Neal Long, MD, FACS more...
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. 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.
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. 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. 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.
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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.
Nipple reconstruction techniques have evolved significantly over the years. From simple tattooing to the more technologically advanced, although rarely available, tissue engineering, today's techniques are able to provide long-lasting, satisfactory reconstruction with minimal morbidity.
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.
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.
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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