Reconstruction of the nipple, or nipple–areola complex (NAC), marks the conclusion of the long and demanding treatment of breast cancer.
In addition to its aesthetic effect, reconstruction of the
nipple–areola complex (NAC) is also of
great psychological importance. This stage of treatment completes the recreation of the breast after the initial volume reconstruction and secondary shape correction to match the breast shape to the other side.
The timing of NAC reconstruction depends on the type of reconstruction, e.g. immediate or delayed reconstruction. In most cases, however, it is recommended
to wait for a period of 6–12 months until the reconstructed breast tissue has assumed its final shape in terms of ptosis and projection.
In preoperative planning, the correct position of the
NAC, and in particular of the nipple, is of the utmost importance. An asymmetrically positioned nipple can severely impair the visual impression of a breast reconstruction and lead to the patient being dissatisfied with the overall result.
The new
nipple position should therefore not be determined only in the operating theatre. It is best done with the patient’s involvement on the day before surgery in front of a mirror. The new position is chosen and marked while standing and then checked again in the supine position.
If an NAC is present on the other side, it can serve as a natural model; if necessary, a contralateral reduction can be carried out (during which areolar skin can also be harvested, for example). In bilateral reconstruction, the new
NACs should lie on the vertical meridian line of the breast from the midpoint of the clavicle, at a point approximately
11 cm from the midline . The horizontal level lies in the area of maximum projection of the breast mound, approximately
21–23 cm from the jugular notch and
5–7 cm from the inframammary fold.
The measured points are only guidelines; they must always be checked individually and adapted to the patient’s wishes or particular circumstances if necessary.
Because of the differences in shape and contour between the healthy and the reconstructed breast, the geometrically determined nipple position is not always the visually optimal point.
Techniques of nipple reconstruction
In practice, 3 methods are established for restoring a raised projection in the centre of the areola:
- Nipple sharing: transplantation of part of the divided nipple from the other side. Nipple sharing fulfils the reconstructive principle of “like with like”: the newly created nipple is very similar in colour and texture to the other side. The technique is also simple and the initial take rate is high; long-lasting projection is usually achieved. A disadvantage, however, is possible loss of sensation on the donor side, about which every patient must be informed before the operation.
- Skate flap / Fish tail flap / Star flap
In all nipple reconstruction techniques using
local flaps, projection is to be achieved by central support from subcutaneous fatty tissue. The preferred techniques are the star flap and the skate flap.
Reconstruction of the areola
In addition to nipple reconstruction, an areola that is as natural as possible is reconstructed. Various methods are available for this:
Tattooing
The most frequently used procedure today is tattooing of the areola; it is simple and quick, does not involve any further donor-site defects and allows the pigmentation to blend naturally from the areola into the surrounding breast skin. Darker pigmentation of the nipple compared with the surrounding areola can create the visual impression of greater size. A disadvantage is that touch-ups are frequently needed to achieve optimal colouring, and also in the long term as the original pigmentation fades.
Dermabrasion and spontaneous healing
The otherwise undesirable consequence of a pigment change after dermabrasion and spontaneous healing can be used here, as a darker shade generally results.
Skin grafting
The most important donor area for a free graft remains a
large areola on the other side, which is reduced by mastopexy or reduction mammaplasty. The graft is raised as a deep split-thickness skin graft from the edge of the areola and placed around the reconstructed nipple, so that a single circular scar results. Split-thickness grafts from the donor areola and techniques with spiral-shaped scarring look unnatural and should not be used.
An alternative is the groin region for harvesting a
full-thickness skin graft for areola reconstruction. However, unpredictable depigmentation frequently occurs, which must be corrected by tattooing. The
proximal inner thigh, which provides adequately pigmented skin grafts with an inconspicuous donor site, is well suited as a donor area.
Another solution is the bilateral harvesting of thin full-thickness skin grafts during
upper blepharoplasty, which can be offered to the patient if there is corresponding eyelid ptosis. The upper eyelid grafts are carefully thinned and then sutured onto the areola around the nipple as 2 half-moons. The slightly dark pigmentation of upper eyelid skin is often quite similar to that of the areola and rarely changes over time.
Disadvantages are the tendency to swelling if defatting is insufficient and the small yield of tissue, which is only sufficient for one-sided reconstruction.
Storage (“banking”) of the areola for later transplantation: areola banking is simple but
oncologically controversial and also frequently leads to loss of pigment and texture. It is therefore hardly used any more.
Sources and further information
