Nipple-Areola Reconstruction Treatment & Management

No medical therapy is available for nipple and areola reconstruction. Nonsurgical options include areola tattooing and prosthetic devices.

Areola tattooing is a widespread method of areola reconstruction because of its simplicity. It is well tolerated by most patients. Tattooing is often used before or after nipple-areola reconstruction to obtain a good color match with the contralateral side. Some patients may opt for simple tattooing without surgical reconstruction, but this method produces a relatively unnatural appearance. The pigments used to obtain flesh colors are fairly stable over time, but, in some cases, early deterioration of the pigment components can lead to significant darkening of the pigment and unexpected color variations. Long-term fading is also common and may require re-tattooing of the nipple-areola reconstruction. ^[10] When tattooing is used prior to surgical reconstruction, careful planning of the tattooed area is necessary to ensure complete coverage of the future nipple-areola complex.

Currently, prosthetic devices are rarely used; most patients opt for more permanent options.

Areola reconstruction

Skin grafts

Because it is a 2-dimensional structure, the areola usually does not pose the same degree of difficulty in reconstruction as the nipple. Time-honored methods of reconstruction have included skin grafts obtained from the contralateral nipple-areola complex or the medial thigh-vulva area. These grafts are intended to provide pigmented tissue that closely resembles the native areola. Currently, with great improvements in tattoo technique and a seemingly endless variety of pigments available, it seems unjustifiable to expose a patient to the risks of possible donor site complications to obtain the same or less satisfactory results than those obtainable with tattooing.

Banking

The practice of banking portions of the excised areola to use as grafts in the reconstruction process is mentioned only to condemn it as oncologically unsound. These areola grafts used for areola reconstruction are unpredictable in terms of degree and direction of contraction and possible depigmentation. Typically, skin grafts are justified if they are needed to close the nipple donor site on the reconstructed nipple-areola complex, but, otherwise, little indication exists for their use.

Tattoo

Tattooing of the reconstructed breast in the area of the expected nipple-areola complex is simple, easy to perform, readily correctable, and requires no significant patient participation or convalescence. Reconstruction of the areola by tattooing can be staged and often requires some touch-up, but it allows a great degree of control over size, definition of contour, and color match with the contralateral side. However, results are usually less than satisfactory when used in the absence of nipple reconstruction.

Tattooing is strictly an optical effect, with no structural support and no way to reproduce the projection and texture typical of the natural nipple-areola complex. Thus, tattooing is best employed as one stage of a combined approach toward nipple reconstruction, whether performed prior to or after elevation of the nipple structure.

Many tattoo pigments are available, allowing precise color matching with the contralateral areola. A color shade a little darker than the desired color is selected to allow for some fading, which invariably occurs in the weeks postinjection. One or more applications may be necessary to obtain the desired result. Commercial surgical tattoo equipment is usually adequate to treat thick skin, such as the lower abdominal and back skin transferred with myocutaneous flaps, and proper injection technique is easily acquired with minimal practice. In some cases, to facilitate later touch-up and obtain a more natural color distribution, tattooing the skin prior to elevation of the nipple structure may be advisable.

Nipple reconstruction

The most challenging aspect of nipple reconstruction is the creation of a 3-dimensional projecting structure with texture, dimensions, and contour similar to the contralateral nipple. Moreover, the reconstruction must be lasting. Nipple reconstruction enhances the realism of breast reconstruction; the more projecting and 3-dimensional the structure, the more lifelike the reconstruction. Various options have included banking, nipple sharing, grafting, and local flaps.

Nipple sharing can potentially harm the only erogenous structure left in the woman's breast, as the surgeon must decrease the projection and alter the structure of the contralateral nipple to match the reconstructed one. Considering all the possible alternative options, this seems the least likely to be recommended.

A study by Haslik et al, however, found that of 26 patients who underwent the nipple-sharing procedure, 88% of them reported being either “very satisfied” or “somewhat satisfied” with nipple sensitivity, which decreased in the donor nipple from 1.2 g/mm² to 1.8 g/mm². The investigators also found that 88% of patients were very or somewhat satisfied with donor/reconstructed nipple symmetry and that 60% were very satisfied with the projection, appearance, naturalness, color, and shape of their nipples. ^[11]

Nipple reconstruction with local flaps is achieved with various techniques, each with its own proponents and benefits. These include the skate flap, ^[12] bell flap, ^[13] double opposing tab flap, ^[14] star flap, ^[3] top-hat flap, twin flap, ^[15] propeller flap, S flap, ^[16]  rolled dermal-fat flap, ^[17]  and C-V flap. ^{[18, 19]}  Autologous cartilage has also been employed, and the use of AlloDerm and filler injection to restore nipple projection has been reported. ^{[20, 21, 4]} Some have also advocated creating a more stable deepithelialized skin base for the reconstructed nipple to minimize loss of projection. Some of the most commonly used techniques are described below.

Immediate nipple reconstruction has also been described. At the time of free-TRAM reconstruction, excess tissue that would otherwise be discarded can be folded to create the 3-dimensional component of the nipple. When used with skin-sparing mastectomy, this can offer areolar fullness, as well. While this technique requires experience to determine the ultimate location of the nipple-areola complex, it does expedite the entire reconstructive process. Bilateral reconstruction significantly facilitates the symmetry of nipple location.

A study by Hyza et al, for example, discussed immediate nipple reconstruction in patients undergoing immediate breast reconstruction during skin-sparing mastectomy. The study involved 17 patients who underwent a modified Wise pattern skin-sparing mastectomy that employed three local flaps. The nipple was created by lifting and suturing together the dermal-fat flaps, with patients giving the shape and position of the nipple an average of 9.7 and 9.9 points, respectively, on a 10-point scale and 77% of patients reporting that they were very satisfied with nipple sensitivity. ^[22]

Stable breast mound reconstruction usually is obtained prior to nipple-areola reconstruction; therefore, nipple reconstruction is usually delayed approximately 3 months to allow for final settling of the new breast mound and to more precisely plan the new nipple position.

Anatomic symmetry is important. When a contralateral nipple is present, the surgeon is provided a natural template to use in guiding reconstruction. For a large contralateral areola, an areola reduction procedure can be considered. Size, color, and, most importantly, position of the new nipple must closely match the opposite side.

When a bilateral reconstruction is performed, the nipple-areola complex should be positioned along the breast meridian starting from the midclavicular point and extending to the breast fold to a point 11 cm from the midline. The complex should be placed at the most projecting point of the breast mound, approximately 21-23 cm from the sternal notch and 5-7 cm from the inframammary fold. These measurements are guidelines for the average case and must be reinterpreted in light of the specific anatomic configuration and aesthetic preferences of each patient and surgeon. For example, a significant range (5-9 cm) in distance between the areola and the inframammary fold is determined by the following factors:

• The size of the reconstructed breast

• The presence or absence of a well-defined fold

• The desired final breast appearance

A moulage of the planned nipple and areola location is advisable to allow the patient to approve the final position.

Skate flap

Draw a small circle the exact size of the contralateral nipple in the appropriate position on the reconstructed breast. Confirm positioning by sternal notch-nipple measurements but also confirm aesthetically. If the mastectomy scar crosses the area, draw the following lines so that the wings and body of the skate are designed away from the scar, as shown below.

The axis of the skate is designed to fall on the underside of the reconstructed nipple and is drawn twice as long as the contralateral nipple height to compensate for inevitable contraction (see the image above). The base of the skate is drawn 3 times the diameter of the contralateral nipple (D). The 2 lateral portions of the skate (wings) are then elevated in the deep subdermal layer up to the center of the flap (body), where the subcutaneous fat is preserved to add bulk to the structure.

The elevated nipple thus has a double blood supply from the superior skin pedicle and from the deeper subcutaneous fat-muscle at the base of the stalk. The flaps then are wrapped around the central stalk and sutured with fine absorbable sutures. The flaps' donor sites usually can be closed primarily; in some cases, a small skin graft may be required at the base of the nipple to prevent flattening of the structure with undue tension on the closure. Skin grafts are easily obtained from along the scar lines on the breast.

Bell flap

Design of this flap consists of a bell-shaped random pattern skin flap with a circular subcutaneous island flap. ^[13] See the image below.

The diameter of the circle is 15-20% larger than the contralateral areola. The base of the flap (blood supply) should have a minimal width of one fourth of the diameter of the circle. The free end of the flap (bottom of the bell) consists of an arc equalling one sixth of the circumference of the circle. See the image below.

Elevate the flap by incising the bell shape in the subcutaneous layer and extending the dissection in the deeper fat plane toward the center of the handle to preserve blood supply. See the image below.

After completing the elevation, fold the 2 sides of the bell on the handle to make up the lateral portion of the elevated nipple. Fold the flap upon itself with fine absorbable sutures. Incise the entire circumference in the subcutaneous plane, and approximate with fine sutures the two sides of the defect obtained by the elevation of the bell. As the obtained nipple-areola complex is smaller in diameter than the donor site, apply a permanent purse string suture in the subdermal plane to shrink the donor site down and allow tensionless approximation of the wound edges to the neo-areola.

See the image below.

Double opposing tab flap

Determine areola size by the contralateral areolar dimensions. Plan a transverse incision along the diameter of the circle equal to 3 times the height of the final nipple. Plan two semicircular incisions extending in a radial configuration from the middle incision in an S shape. The width of each flap base should be 18 mm. See the image below.

Raise the two flaps in the subdermal fat plane and then oppose and suture with fine absorbable sutures. The donor sites are closed primarily and the areola is tattooed.

Star flap

The modified star flap procedure involves marking the areola diameter equal to the contralateral areola. Within this circle, a 3-arm star is drawn. The base of the star is located at the margin of an ideal circle in the center of the areola, with the diameter equal to one fifth of the main areola diameter. See the image below.

The "arms" of the flap are elevated in the subcutaneous tissue, increasing in thickness to include the fat as the dissection progresses toward the middle of the flap. Once elevated, the 2 lateral arms are folded over from the base to form a cylindrical mound, and the central arm provides the top. This creates a projecting structure that is self-supporting and stable. See the image below.

The donor site is closed primarily and does not require a skin graft. Pigment tattooing is performed once the reconstruction is deemed stable. See the image below.

Spiral flap

The spiral flap uses the residual mastectomy scar to reconstruct a nipple. ^[23] This method can be used in tissue expander or prosthesis breast reconstruction in which the new nipple position lies near the center of the mastectomy scar.

A laterally based flap is elevated using the scar tissue medial to the new nipple position. The flap is approximately 5-6 cm long and 1 cm wide, and the base is 2 cm wide. The elevated flap is twisted in a spiral fashion on its main axis and sutured. The donor site is closed primarily.

Trapeze flap (modified Thomas technique)

A trapeze flap is designed with the greater base equal to 3 times the diameter of the contralateral nipple and the height equal to 2 times the height of the contralateral nipple. The greater base is divided into 3 parts, and the central third serves as the pedicle of the flap. ^[24]

The flap is elevated and the vertical banks are sutured to form a cylindrical structure. The top is closed by a purse-string suture technique. The flap donor site is closed primarily. A hemicircular patch corresponding to the base of the new nipple is de-epithelialized to provide a platform on which the nipple will rest, minimizing risk of invagination.

C-V flap

The C-V flap, developed in 1998, consists of two lateral V-shaped flaps and a central C-shaped flap, with the nipple’s projection determined by the V flap widths, and the nipple’s diameter determined by the diameter of the C flap, which forms the top of the nipple. The V flaps are elevated from subcutaneous tissue, and the C portion is a dermal flap. Although concern exists that nipple projection will not be maintained long-term with this technique, research suggests that autologous dermal fat grafting can be used to address this problem. Another concern with the C-V flap technique is that the presence of a nonideally located scar will lead to improper nipple position. ^{[18, 19]}

A study by Yang et al indicated that in patients who undergo C-V flap nipple reconstruction, nipple projection is better maintained in those in whom breast mound reconstruction has been performed with autologous musculocutaneous flaps rather than with tissue expansion/implantation. Flap reconstruction was achieved using a free transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi myocutaneous flap, with follow-up nipple measurement conducted an average of 10 months postsurgery. The investigators found that decrease in nipple circumference did not significantly differ between the flap and implant patients. ^[25]

A study by Jalini et al found high patient satisfaction with 33 C-V flap nipple reconstructions. Median nipple projection was 4.7 mm, comparable to the projection of the contralateral nipples, at 4.6-years mean follow-up. Median overall patient satisfaction with the reconstructions, measured using the visual analogue scale score, was 9. ^[26]

Support and protect the reconstructed nipple in the postoperative period. Dress the wound with antibiotic ointment and petroleum jelly dressing with a circular hole cut in the center. Then surround the nipple with petroleum jelly dressing and protect it with a standard maternity plastic nipple shield, a plastic medicine cup, or a syringe splint secured with adhesive tape. ^[27] Change this dressing often and maintain for 2 weeks postreconstruction. Recommend wearing an appropriately fitting noncompressing bra.

In cases of secondary treatment of failed nipple reconstructions, various treatment options are available, including repeating the original operation (particularly in the case of a skate flap) or inserting banked or autologous cartilage under a new skin flap to improve structural support and projection. The use of commercially available processed dermis (AlloDerm) as an insert or as an adjunct to re-elevation of a local flap can also improve the final outcome. ^[21]

Possible complications include partial and total loss of the nipple, epidermolysis, loss of nipple projection, and discoloration. Avoidance of smoking, accurate dissection, and the creation of a nipple that is initially 20-30% larger than the contralateral side minimize the chances of complications related to poor blood supply.

Loss of nipple projection commonly occurs a few years after reconstruction. This problem may be reduced with the use of bell and double opposing tab flaps; nevertheless, it remains a frequent finding. ^[14] Secondary nipple reconstruction can be performed by re-elevating the flap; inserting autologous dermal tissue, fat, or autologous or banked cartilage; and using filler injection or AlloDerm. Discoloration and uneven pigment distribution may occur over time and can usually be corrected with tattooing.

Successful nipple-areola reconstruction is expected to maintain nipple projection and areola size; however, longevity of this reconstruction is highly variable and is influenced by factors such as scar contracture, tissue thickness, radiation, and trauma. Tattooing is commonly repeated.

Nipple areola reconstruction is an essential component of complete and satisfactory breast reconstruction. This procedure can be performed with a minimum of patient discomfort, requires minimal postoperative care, and has a high degree of patient satisfaction. Various techniques are available that can be customized to meet specific patient requirements. Alloplastic materials such as porous polyethylene have been proposed for nipple reconstruction but have not been extensively tested in patients; concern exists about implant exposure.

The role of nipple-sparing mastectomy continues to evolve and presents a controversial debate, especially in the setting of therapeutic mastectomy. ^{[28, 29]} No reconstructed nipple-areola complex will match the physical properties of the natural nipple-areola complex. Thus, nipple-sparing mastectomy can potentially achieve more a natural, aesthetic breast reconstruction by preserving the natural nipple-areola complex and obviating the need for future nipple-areola reconstruction. However, long-term studies need to be performed and careful selection criteria should be met to ensure oncologic and surgical safety.

A literature review by Zaborowski et al indicated that in select patients with breast cancer, nipple-sparing mastectomy is an oncologically safe procedure. Patients in the study, which had a median follow-up period of 48 months, had invasive carcinoma or in situ disease, with the weighted mean rates of local recurrence and recurrence involving the nipple-areola complex determined to be 5.4% and 1.3%, respectively. A weighted mean distant failure rate of 4.8% was also found. ^[30]