“After all the devastating surgeries, after all the healing, you want to feel that you have your body back—as much as possible—and you want it as quickly as possible. With the DIEP flap and my nipple and areola intact, I feel closer to being myself again than I ever thought I could after this ordeal. There’s enough internal recovery to handle; it’s wonderful that the outside is so close to perfect.”
For many women like my patient above, undergoing breast reconstruction following mastectomy, the preservation of the nipple or the re-creation of a nipple through reconstruction becomes an important factor. The creation of a nipple-areola complex (NAC) is the final step in surgical restoration of the breast. Often considered a complement to breast reconstruction, NAC reconstruction is usually completed after an interval of several months, making use of tissue from the remaining breast skin or by taking part of the other nipple as a graft.
For women facing mastectomy and reconstruction today, the latest methods of breast reconstruction offer techniques that both preserve the native nipple and areola and remove the need for a second reconstructive procedure, re-creating an NAC as part of the initial reconstruction of the breast. For women facing an often difficult journey, the advances achieved in breast reconstructive surgery can offer those who choose this option confidence and hope as they enter a new phase in their lives.
Some women with breast cancer may be candidates for nipple-sparing mastectomy, which involves removal of the entire contents of the breast through an incision in the inframammary fold but preserves the areolar skin and the outer portion of the nipple.
Preservation of the nipple and the areola removes the need for a second reconstructive procedure. Candidates for preservation of the nipple and the areola include women with cancer that has not become invasive (such as ductal carcinoma in situ, or DCIS), those with small tumors that are at least 2 centimeters away from the NAC, and women with relatively small breasts and minimal droop (also known as ptosis).1,2
During nipple-sparing mastectomy, the nipple is cored out from the inside, and a separate specimen is often sent for immediate analysis under the microscope (frozen section pathology). If there is any concern about abnormal cells extending into the nipple, the nipple is removed. If the tissue is clear, the nipple is preserved and reconstruction takes place during the same operation (immediate breast reconstruction).
Immediate Implant Reconstruction with Nipple
Breast reconstruction after nipple-sparing mastectomy can involve either implants or autogenous tissue techniques (using the body’s own tissue). Traditional implant reconstruction involves two stages, in which the skin remaining after mastectomy is slowly expanded over months using a tissue expander. A permanent implant is placed as a second operation, and the nipple and the areola are reconstructed as a third procedure.
A new technique, immediate implant reconstruction, which is becoming increasingly available, does not require tissue expanders as a preliminary step and enables immediate reconstruction in a single operation.3
In immediate implant breast reconstruction, a permanent implant that is postoperatively adjustable is placed directly into the mastectomy pocket where the breast tissue was previously (Figure 1). The implant is partially inflated with saline at the time of surgery, and the incision beneath the breast is closed. The implant is attached to a small injection port, which is placed underneath the skin in a separate pocket. In this procedure the implant is placed beneath the breast skin, rather than beneath muscle, which results in less postoperative pain and discomfort than traditional techniques.
One to two weeks after surgery, when healing is under way and swelling has decreased, additional saline is added to the implant though a few injections into the port. The implant is fully inflated within a few weeks, and the port is later removed under local anesthesia in the office. The permanent implant remains in place, and the reconstruction is complete in a single stage.
Immediate implant reconstruction after nipple-sparing mastectomy has several advantages over traditional reconstruction: quicker recovery, less pain, no implant indentation with pectoralis major muscle motion, a natural breast shape, and no need to reconstruct the NAC.3
Due to oncologic (cancer-related) concerns, preservation of the NAC is not always possible or advised. When the nipple and the areola must be removed due to the type, size, or position of the cancer or because of the breast size or shape, NAC reconstruction is performed.
Reconstruction of the nipple and the areola truly is the “icing on the cake” of breast reconstruction. It is the final artistic finishing touch and can enable a woman to feel complete after she has undergone the initial stage of breast mound reconstruction.
The ideal NAC reconstruction creates a nipple prominence and an areolar circle that closely match the natural form, so when the eye falls on a breast in a swimsuit or fitted top (or when nude), the breast appears as natural and beautiful as possible.
How Is the Nipple Reconstructed?
Nipple and areola reconstruction generally takes place as a second outpatient procedure that takes one to two hours on average. The nipple may be reconstructed by a number of techniques, including using local tissues from the breast or tissue from other areas of the body.
Local flap nipple reconstruction. Local flap nipple reconstruction makes use of tissue from the remaining surrounding breast skin and subcutaneous fat. Wings (or local flaps) of tissue are elevated, rotated, and sutured in a formation that re-creates a nipple prominence resembling the other nipple. This leaves a small scar on the breast mound that is then covered up by the areola reconstruction.
Free nipple graft reconstruction. If only one breast is to be reconstructed and if the other nipple is of sufficient size, sometimes reconstruction can make use of the remaining nipple. This involves taking part of the normal nipple as a free composite graft and transplanting it to the reconstructed side. Below the graft, new blood vessels grow into the nipple piece and enable it to survive, similar to what occurs in a skin graft procedure.
Other nipple reconstruction techniques. Occasionally, other techniques are used for nipple reconstruction. These can include the use of autogenous tissue such as cartilage or dermis-fat grafts that are taken from elsewhere on the body and transplanted as a graft to the breast reconstruction.
How Is the Areola Reconstructed?
The areolar circle may be reconstructed by various means. Usually, a medical tattoo is performed at the same time as the nipple reconstruction. An alternative to this practice is reconstruction of the areola with skin grafts.
Medical tattoo. Like other types of tattooing, with a medical tattoo pigment is driven into the dermis (the bottom layer of the skin) by a rapidly oscillating tattoo needle (or needles). The body takes this pigment up permanently, resulting in a lasting tattoo that creates an areola. In a unilateral (single-sided) reconstruction, the other areolar color is matched as closely as possible. For bilateral (double) reconstructions, a pigment that corresponds with the body’s natural coloring is used. Photographs taken before the mastectomy are often helpful in selecting the best color match for a woman’s breasts.
The advantages of tattooing for areola reconstruction include simplicity, patient participation in choosing pigment, and avoidance of additional scars. Tattooing may be performed in the doctor’s office under local anesthesia, with minimal downtime. The disadvantages include mild fading of the pigmentation over time and the possible need for retattooing in the future.
Skin graft techniques. Alternatively, the areola can be reconstructed using the body’s own tissue. Skin grafts are traditionally harvested from the inner thigh, the labia, or the areola of the other breast, if it is enlarged. The darkly pigmented skin is transplanted to the reconstructed breast, and healing occurs via the same process as for a free nipple graft (blood vessel ingrowth over time).
Potential disadvantages of skin graft techniques include the creation of scars where the tissue is removed, the risk of incomplete survival of the skin graft, and a loss of pigment (hypopigmentation) or resultant darkening of the graft (hyperpigmentation) during healing. For these reasons tattooing is the most common technique for areola reconstruction.
Immediate NAC Reconstruction with theInner-thigh Flap
Whereas implant breast reconstruction makes use of an internal prosthesis, microsurgical breast reconstruction transplants the body’s own tissue to create a new breast (autogenous reconstruction). One of the newest types of autogenous tissue reconstructive procedures is the inner-thigh flap, or transverse upper gracilis (TUG) flap.
The TUG flap is taken from the upper inner-thigh area, in the same distribution as a cosmetic inner-thigh lift. It provides a permanent, warm, soft, and shapely breast reconstruction and also enables immediate nipple and areola reconstruction.
The tissue from the inner thigh is removed with some underlying skin fat and expendable gracilis muscle. The flap is then coned (sculpted) to create a shapely breast mound and moved to the chest area. Blood vessels are reconnected under a microscope to reestablish the circulation to the flap and ensure its survival.
When the flap is coned, a natural projection is created that simulates a nipple. Sutures are added to enhance this projection and create an immediate nipple reconstruction at the same time as the breast reconstruction.
In addition, because the skin of the inner-thigh region is naturally darker than the breast skin, an immediate areola reconstruction is also done. Further tattooing of this area is often not necessary, although it is offered as an office procedure if additional pigmentation is desired.
The inner-thigh flap makes use of the body’s own tissue for reconstruction of both the breast and the NAC in a single procedure. Candidates for TUG flap reconstruction include women desiring breast reconstruction using their own tissue who have sufficient upper inner-thigh tissue available for use.
The TUG flap requires a surgeon with microsurgical expertise, a five-day hospital stay on average, and a slightly longer recovery than implant reconstruction. The results are permanent, however, and no further surgeries are generally required after recovery. Reconstruction avoids the use of implants and their related risks and potential complications.
A Final Word
The goal of reconstructive surgery is to create a beautiful and well-proportioned breast for each woman undergoing mastectomy. Breast reconstruction is a very personal issue. The most appropriate procedure takes into account a woman’s anatomy, build, desires, and personal circumstances. In many cases a reconstructed breast can be attractive and beautiful, with and without clothing.
It is important for women to know that there are certain techniques in breast reconstruction that will give a woman the best chance of having a positive aesthetic result. It is also important for a woman seeking breast reconstruction to ensure that her surgeon is board certified in plastic surgery, is experienced in breast reconstruction, and has a good artistic sense. Finally, there should also be a good fit in personality and a keen sense of trust between doctor and patient. Breast reconstruction can and should be a positive experience for women facing breast cancer.
- Crowe JP Jr, Kim JA, Yetman R, Banbury J, Patrick RJ, Baynes D. Nipple-sparing mastectomy: Technique and results of 54 procedures. Archives of Surgery. 2004;139(2):148-50.
- Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure. Annals of Surgery. 2003;238(1):120-27.
- Eskenazi LB. New options for immediate reconstruction: Achieving optimal results with adjustable implants in a single stage. Plastic and Reconstructive Surgery. 2007;119(1):28-37.