Nipple–areola reconstruction

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CHAPTER 58 Nipple–areola reconstruction

G. Patrick Maxwell, Allen Gabriel

History

Nipple–areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast with maximal realism when compared with the patient’s opposite breast. Essentially all post-mastectomy patients are fraught with distress brought on by the diagnosis of breast cancer and they suffer a severe alteration of body image and the resultant adverse psychological consequences. Nipple–areola reconstruction is an extremely vital part of breast reconstruction in the sense that it visually transforms the breast mound into a breast. The combination of nipple projection, areola color patch symmetry, and areola projection provides the reconstructed breast with the maximum degree of realism that any breast reconstruction can ever achieve. The evolution of nipple reconstruction techniques has enabled much progress toward this goal of realism.

Numbers of flap designs for nipple reconstruction have been well-described in the literature. There are several reasons why preferred techniques have changed throughout the years; most notably, these include a focus by surgeons on simplicity, reliability, and a reduction in the donor site. Several techniques have fallen into complete disfavor. Nipple banking (i.e. saving the native nipple for later transfer) is an absolutely inappropriate method for nipple reconstruction, as the risk of transferring cancerous cells back to the reconstructed breast has been previously documented. In the past, authors have advocated free grafting of composite tissue from sites such as the auricle, asserting that nipple projection is much better preserved over a long-term period. Here again, however, donor-site morbidity and a steep learning curve seem to underscore the unreasonable cost implicit in using such methods when other, more simple options for nipple reconstruction exist. Composite grafts from distant donor sites have also been previously used for nipple reconstruction but have not been nearly as successful.

All nipple reconstructions lose projection because of the natural processes of contraction inherent with wound healing. Postoperative care is fundamental for satisfactory results, and includes avoiding dressings that apply direct pressure on the nipple. A number of studies indicate that this loss of projection may be substantial, and therefore it is a common practice to overbuild the nipple relative to the opposite nipple projection in anticipation of decreased long-term nipple projection.

Reconstruction of the breast mound has consistently improved with multiple techniques that are selected on the basis of the extent of the defect and the patient’s and surgeon’s preferences. Nipple–areola reconstruction has also made significant strides in regard to multiple surgical options. Since 1944, when Adams described the reconstruction of the nipple–areola complex (NAC) with the nipple–areola graft, the techniques for NAC reconstruction have improved with grafts of a variety of donor areas and local flaps. The most popular techniques include the skate flap and the star flap. With improved techniques, nipple–areola reconstruction has become more popular in the past two decades as many patients consider the idea of a reconstructed breast without the NAC undesirable.

Physical evaluation

• Unilateral reconstruction, anatomic symmetry (opposite nipple position and size; opposite NAC texture and color and size), need for secondary contralateral surgery.

• Stability of breast mound.

• Previous breast mound scars (from mastectomy, biopsy, reconstruction).

• The vascularity and thickness of breast mound.

• Radiation history.

• The size of the reconstructed breast.

• The presence or absence of a well-defined fold.

• The desired final breast appearance.

• Medical history: specifically diabetes/vascular disease/smoking and other co-morbidities.

• Body and breast morphology (breast dimensional analysis).

• Size of opposite breast/plan of opposite breast (prophylactic mastectomy).

• Donor site morbidity and life responsibilities.

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 even 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.

The NAC is ideally located at the most prominent point of the breast or above the level of the projected inframammary crease. Average projection of the nipple is 5 mm. The areola projects slightly and has an average diameter of 35 to 45 mm. The areola texture can be smooth or rough at the location of the Montgomery tubercles. There is a wide variation in color, shape, size, and projection of the NAC as a result of race, the aging process, hormonal changes (pregnancy and menopause), and variation in weight.

Technical steps

The goal of this final stage of reconstruction is to transform the reconstructed mound into an attractive, natural, pleasing breast. This is a complex task especially in unilateral reconstructions as the opposite breast is soft, mobile, and ptotic. All patients need to be educated regarding the need of further revision to achieve symmetry and some may come close but never be completely symmetrical. Therefore during the decision making, the authors involve the patient to confirm the proposed NAC position and size, since ultimately patient satisfaction and acceptance are directly related to the patient’s sense of involvement and decision concerning her surgery.

In general, the authors like to delay the nipple–areola reconstructions as too many variables have an effect against achieving the best result. Nipple reconstruction should be performed as a final stage, after adjustments to the flap or implant and contralateral breast are completed. It is usually performed 2 to 3 months after the final breast shape is achieved. If subsequent surgical procedures are planned for the opposite breast for symmetry with the reconstructed breast, it is preferable to delay nipple reconstruction until the opposite breast surgery is performed. Some prefer to perform the nipple reconstruction and the contralateral matching surgery simultaneously. This again can be a complication with the multiple variables that are present in cases of a reduction mammaplasty or a mastopexy for the matching procedure. As the contralateral breast regains its final shape, the NAC may be lower than the reconstructed site; therefore a contralateral procedure should be performed first followed by NAC reconstruction as this may give the surgeon the opportunity to revise the opposite site again to achieve symmetry.

When the patient has agreed to proceed with nipple–areola reconstruction, the patient and the plastic surgeon must determine the optimal position. Specific identifiable landmarks help to determine the proper nipple areolar position visually and geometrically. These include the level of the nipple areola, the triangles with the sternal notch and the umbilicus and the nipple areolar position relative to each breast and to the inframammary fold (Fig. 58.1).

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Fig. 58.1 Identifiable landmarks used when determing the proper nipple areolar position. (a) distance of the nipple areola to the inframammary fold. (b) Sternal notchnipple areola to measure distance and geometry.

The nipple–areola position is determined visually with the patient in a standing position and the shoulder relaxed without abduction. In addition to measurement, visually the NAC is centered on the breast at the point of maximal convexity and projection, symmetric with the opposite NAC. This is why simultaneous contralateral surgery is not recommended as final shape and NAC position of the contralateral breast will change again.

On the other hand in a bilateral reconstruction, the nipple–areola complex should be positioned along the breast meridian starting from the mid-clavicular point and extending to the breast fold to a point 11 cm from the midline. Taking measurements with the patient in the sitting position, arms at sides; measurements are taken of the chest to determine nipple–areola distances from inframammary line, sternal notch, mid-clavicular line, and midline adjacent to the fourth intercostal space. Once again the NAC 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 dimensions are guides and averages, and each patient should be individualized and tailored to each patient’s breast dimensions. The final position should be confirmed visually and this may not always correlate to the measurements.

After the location is determined, the patient is asked to look in the mirror and approve the selected position. This will give the opportunity to the patient to select and ascertain the desired location just prior to surgery. Some also recommend taking a digital photograph and showing it to the patient.

Nipple–areola reconstruction is usually performed as a delayed procedure and can be either under local or general anesthesia and it is done on an outpatient basis. Several technical options are available for nipple and areolar creation. The method selected depends on the size and color of the opposite nipple and areola, the type of breast mound on which it is placed and the patient’s and surgeon’s preference (Table 58.1).

Table 58.1 Goals of nipple–areola reconstruction

• Position

• Symmetry

• Pigmentation

• Color

• Texture

• Size

• Projection

Nipple reconstruction

When the contralateral nipple is of adequate size (projected greater than diameter of areola and the patients are accepting, a composite graft can be taken from the opposite nipple (Fig. 58.2). It comes from the lower one half of the nipple or the tip, depending on its shape. This graft is sutured to the central portion of the de-epithelialized areola site and generally takes well. Most patients are not candidates for nipple-sharing reconstruction, and many patients fear donor site morbidity, including diminished projection of the donor site, risks of diminishing the sensitivity, and transfer of potentially malignant ductal tissue. Other composite graft donor sites, such as ear lobule and toe pulp, have been reported but they are generally not as satisfactory.

image

Fig. 58.2 Composite grafts for nipple reconstruction can be taken from either the lower aspect (A) or the tip (B) of the donor nipple.

When the opposite nipple is absent or lacks projection or the procedure is undesirable to the patient, grafting, flaps, and tattoos are the primary reconstructive choices. Reliable local flap techniques have been described that provide a nipple with reasonable projection. For this reason, most patients now undergo local flaps for nipple reconstruction followed by intradermal tattoo after the nipple flaps have healed. There are numerous flaps and modifications that are effective in establishing the NAC. Each technique offers advantages, but there are also disadvantages related to donor site vascularity and quality of tissue (flaps versus preserved breast skin envelope), maintenance of nipple mound size and projection, and potential complications.

In most techniques (with the exception of the double opposing tab flap), the key to success is designing the flap base away from the mastectomy incision. The flap should have adequate dimensions to provide adequate height for the nipple mound. In patients who have undergone breast reconstruction by a flap, the local flap for nipple–areola reconstruction will be based, when it is feasible, on site selection on the surface of the flap where healthy full-thickness tissue will be available for nipple reconstruction. In the patient who has undergone reconstruction by immediate implant or expander-implant, the skin envelope is thin and the resultant flaps are more likely to atrophy and to lose projection over time. In this group, subsequent contralateral full-thickness nipple graft, cartilage grafts have been proposed for providing secondary augmentation of the nipple. However with the advancement in technology and fillers, less invasive office procedures are now available to enhance secondary nipple augmentations. Dermal fillers have gained popularity in facial aesthetics and this can translate directly for secondary augmentation of reconstructed nipples. More permanent fillers such as Arcticoll may become popular in the first line of therapy in the future.

The other technique for nipple creation utilizes local flaps, the most popular of which is the skate flap technique with multiple modifications (Fig. 58.3). This flap is designed in a linear configuration radiating from the central base with large wings on each side. The base is oriented away from the mastectomy scar, and it can be oriented either transversely or vertically, with the flap oriented perpendicular to the base and extending within the planned areola site. In general, the base is oriented transversely and located either inferior or superior to the midaxis of the areola. The middle third of the base line represents the actual base of the flap and is usually 1.5 cm in width. The wings (approximately 1 cm in length) are elevated at the level of the deep dermis, and the linear portion includes deep fat. It is held at a 90 degree angle and wrapped with the wings themselves. The entire flap should be designed within the planned site of the areola to avoid visible scars outside the area of the subsequent pigmented areola. When the skate flap is designed on flap skin, less fat is required because dermis is thicker (especially on the latissimus dorsi skin island). When the skate flap is designed on a preserved breast skin envelope, the dermis is often thin, so fat down to the capsule (if there is underlying implant reconstruction) is elevated with the pedicle to ensure adequate bulk to the nipple. The two wings of the flap are now rotated 90 degrees to a position opposite the midpoint of the flap base. The distal tips of these flaps are sutured together to the midpoint of the hemi-circle. The two donor sites for the wings are closed directly. The wings are then approximated to form a nipple tube. The end of the tube will require dog-ear modification to establish a flat plane as opposed to a pointed tip of the nipple. The bases of the wings are sutured to complete the nipple reconstruction.

image

Fig. 58.3 Nipple reconstruction by the skate flap. A, 1: Area beyond tangent to nipple disk A denuded; lines from 3- and 9-o’clock of nipple disk to 6-o’clock of areolar pattern outline body of skate; 2: wings of skate elevated deep split-thickness up to body; 3: dissection changes from horizontal to vertical as dermis and fat are cut through to form composite body; 4: body dissected centrally and elevated; deep trough remains in dermal bed. B, 5: Areolar bed closed; areolar pattern distorts and wings of skate brought around body to each other; 6: completed nipple cone; areolar pattern revised, areolar doughnut graft added.

From Little JW. Nipple–areola reconstruction. In: Habal MB, et al. (eds) Advances in Plastic and Reconstructive Surgery Vol III, Year Book Medical Publishers: Chicago 1987 p 43.

Other skate variant flaps have also been described that are similar in principle, including the cervical-visor (C-V) flap, modified star flap (Fig. 58.4), Tennessee flap (Fig. 58.5), skate-flap purse-string nipple technique and others. The advantage of these flaps is that a full thickness graft or a skin graft is not needed for the closure and the volume of the flap is dependent on the volume of the underlying tissues, limiting this procedure in patients with thin skin subcutaneous tissue or, at times, radiated tissues.

image

Fig. 58.4 1–4, Planning, elevation, assembly, and donor site closure of the modified star flap.

From Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term projection: a comparison of three techniques. Plast Reconstr Surg 2002;110:780.

image

Fig 58.5 Planning, elevation, assembly and donor site closure of Tennessee flap.

The bell flap (Fig. 58.6) incorporated a pull-out flap that is elevated and folded on itself with primary closure of the flap donor area using a peri-areolar purse-string suture. The double opposing tab flap was devised by Kroll in the late 1980s. It is similar to the bell flap technique, consisting of an S-shaped pattern that gives it a cylindrical shape. In all these flaps the goal is to keep long-term projection therefore the nipple heights are designed 50 to 75% taller than the opposite nipple. Studies have shown that the maximum contraction occurs within the first 3–6 months and the near final height is achieved by 6 months. In a study performed by Shestak et al. (2002) analyzing the bell flap, skate flap, and star flap, the bell flap provided the least long-term projection where as the skate and its variant were considered superior in long-term projection.

image

Fig 58.6 1–5, Planning, elevation, assembly, and donor site closure of the bell flap.

From Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term projection: a comparison of three techniques. Plast Reconstr Surg 2002;110:780.

Because nipple projection can be difficult to achieve and to maintain, several techniques using autogenous and alloplastic materials have been developed to achieve this goal. If local tissue cannot provide adequate nipple projection or if there is gradual loss of projection after the nipple flap has healed, implants may be used to reinforce or to re-establish nipple projection, such as custom made external silicone ectoprosthesis, polyurethane-coated silicone gel implants. However, autogenous tissues are the preferred methods in enhancing long-term projection.

The most common techniques use costal cartilage combined with a local flap to improve the nipple projection. The uses of artificial bone and fat grafting have also been described with some success. Recently, the use of acellular dermis showed improved long-term nipple projection. Alloplastic materials are an option to enhance reconstruction; however when dealing with thinner tissues, these can be plagued with complications such as exposure of the material. Clearly, alloplastic materials should be considered as salvage procedures to maintain height of nipple in secondary reconstructions. With advances in dermal fillers, these may become the primary route for salvage procedures due to decreased morbidities that are associated with the local office procedures.

Areola reconstruction

Methods for recreating the areola range from simple tattooing to the more complex grafting techniques, which are performed approximately 2 to 3 months after the nipple reconstruction. The decision as to which technique is appropriate depends on a patient’s lifestyle and preferences (Fig. 58.7). Some patients desire the quickest, painless facsimile. Therefore patient individualization is again important while taking their life responsibilities in consideration.

image

Fig. 58.7 Sources for areola reconstruction.

The goals of size and pigmentation can be achieved with grafts, tattoos, or a combination of these techniques. Texture is best achieved with grafts because they provide a more natural, irregular surface.

The simplest procedure is tattooing which has become increasingly popular. Intradermal pigmentation placed by traditional tattoo methods and equipment can be used for nipple coloration, for areolar adjustments and coloration over previously placed grafts, or for areola creation directly on the breast mound without using a grafting technique. The disadvantage of tattooing alone is that the texture and projection are often lacking even tough acceptable color match is obtained. The initial tattoo must be darker than the desired final color because the result will fade with time. This phenomenon is related to the quantity of blood that is resorbed during the procedure associated with the ingestion of the pigments by the macrophages. Some patients may present with redness after the procedure associated with an edema and an itching sensation that remains for a few hours. Fading of the pigments is common; however, fading may be revised with touch-ups in approximately 3 months.

The next level of complexity for areola creation is established by grafting techniques. The entire marked circular area is de-epithelialized in nipple graft situations, where only the residual area within the circle is de-epithelialized for flap nipple techniques. The donor site for the areola graft is based on the color required to match the opposite areola, unless tattooing is part of the primary technique. When a tan areola is needed (as this is the case in white females), the upper inner thigh it the most frequent donor site. It is closed primarily to give a scar that is hidden in the perineal crease. The graft can also be taken more posteriorly toward the inner gluteal crease for a similar tan color. These donor site areas are the best autogenous grafts that have a pigment and texture similar to that of the natural areola. The pigment may lighten over a 10-year period and this may require secondary tattooing in the future.

Axillary dog ears, abdominal redundant skin, or any other easily accessible areas can be used regardless of color, since the tissue is being excised. The main drawback is that the skin is not pigmented and intradermal tattooing is necessary; even though initially the healing skin graft may look pink, the color will fade over a 2-month period. In all these situations, the graft is defatted and sutured to the de-epithelialized area on the breast mound. A small hole is made in the center through which the nipple is pulled. A bolster dressing placed over the graft for 5 days.

The use of opposite areola for areolar reconstruction has been reported, but the surgeon has to take into consideration that this necessitates simultaneous reduction mammaplasty or mastopexy.

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Fig. 58.C1 Case 1, A, Preoperative view. B, Postoperative view following nipple reconstruction using Tennessee flap and areola reconstruction by tattooing.

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Fig. 58.C2 Case 2, A, Preoperative view. B, Postoperative view following nipple reconstruction with Tennessee flap and areola reconstruction using medial thigh graft.

Postoperative care

After nipple reconstruction, an ointment is placed over the nipple, and 2 × 2 gauze squares, with central holes the size of the diameter of the new nipple, are placed over the breast in layers. A medicine cup may be used to reinforce the dressing and avoid compressibility of the new reconstructed nipple. The dressing should remain in place for 5 to 7 days. The dressing is removed in a subsequent visit in approximately 5 to 7 days, and the sutures are also removed. A new dressing is applied that is left in place for approximately 7 days.

Pressure to the nipple reconstruction site should be avoided for 6 weeks and a non-compressible fitting bra should be recommended.

For skin grafts, the graft should be covered with a bolster dressing to compress the graft, and avoiding motion at the recipient site. The bolster dressing should remain in place for at least 5 days and sutures should be removed in approximately 7 days. Following the bolster removal a double antibiotic or bacitracin ointment should be applied to the fresh incisions for 14 days.

After the tattoo procedure, there will be an excess of pigment deposited over the tattoo, which can be removed with moist gauze. The immediate dressing consists of either double antibiotic or bacitracin ointment and covered with gauze. The gauze should remain for 48 hours and removed and the area treated with antibiotic ointment for 14 days.

Complications

The most common complication is loss of projection. Projection usually decreases aggressively in the first three months and plateaus around 6 months. By that time the surgeon will know if the reconstruction was a success or a secondary procedure is mandated. The secondary procedure should be delayed for 6–9 months for tissue pliability and surgeon’s clinical judgment.

Other complications such as epidermolysis, partial or complete necrosis, and open wounds are problems associated with ischemia of the flap, separation of the tissues as a result of shearing forces during the manipulation of the tissues, or an error in planning the amount of soft tissue necessary to maintain the vascularization of the flaps. To avoid these problems, smoking cessation and avoidance are critical as well as a well-controlled glucose in diabetic patients. Reports have shown deleterious effects of wound healing in poorly controlled diabetes as low as 150 mg/dl.

Infection is not a common complication, and it is most often associated with use of synthetic material to perform the nipple reconstruction. Avoidance of direct pressure over the nipple for approximately 6 weeks and adherence to the postoperative regimen are also crucial for optimal results.

Pearls & pitfalls

Pearls

• Evaluate flap thickness prior to proceeding.

• Plan appropriate areolar diameter at time of nipple creation.

• Height of reconstructed nipple should be 50% larger than contralateral.

• Involve patient in preoperative marking for NAC positioning.

• Understand postoperative oncological plan.

Pitfalls

• Creation of short height nipple.

• No knowledge of oncological plan.

• Use of foreign body in thin radiated tissues to enhance projection.

• Misplacement of NAC.

• NAC color mismatch.

Summary of steps

1. The nipple–areola position is determined visually with the patient in a standing position and the shoulder relaxed without abduction.

2. Nipple–areola reconstruction is usually performed as a delayed procedure and can be either under local or general anesthesia and it is done on an outpatient basis.

3. Nipple reconstruction: When the contralateral nipple is of adequate size, a composite graft can be taken from the opposite nipple. It comes from the lower one half of the nipple or the tip, depending on its shape. This graft is sutured to the central portion of the de-epithelialized areola site and generally takes well.

4. When the opposite nipple is absent or lacks projection or the procedure is undesirable to the patient, grafting, flaps, and tattoos are the primary reconstructive choices.

5. The most popular local flap is the skate flap technique, with multiple modifications.

6. Implants may be used to reinforce or to re-establish nipple projection.

7. Areola reconstruction: Methods for recreating the areola range from simple tattooing to the more complex grafting techniques, which are performed approximately 2 to 3 months after the nipple reconstruction.

Further reading

Anton M, Eskenazi L, Hartrampf CR. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg. 1991;5:67.

Broadbent TR, Woolf RM, Metz PS. Restoring the mammary areola by a skin graft from the upper inner thigh. Br J Plast Surg. 1977;30:220.

Eng JS. Bell flap nipple reconstruction: a new wrinkle. Ann Plast Surg. 1996;36:485.

Gruber RP. Nipple–areola reconstruction: a review of techniques. Clin Plast Surg. 1979;6:71.

Hallock GG. Polyurethane nipple prosthesis. Ann Plast Surg. 1990;24:80.

Hartrampf CR. Nipple–areola reconstruction. In: Hartrampf CR, ed. Breast reconstruction with living tissue. Norfolk, VA: Hampton Press; 1991:32–45.

Jones G, Bostwick J, III. Nipple–areola reconstruction. Operative Techniques Plast Reconstr Surg. 1994;1:35.

Kroll SS. Nipple reconstruction with the double-opposing-tab flap. Plast Surg Forum. 1987;10:219.

Masser MR, Di Meo L, Hobby JA. Tattooing in reconstruction of the nipple and areola: a new method. Plast Reconstr Surg. 1989;84:677.

Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110:780.

Spear SL, Little JW, Convit R. Intradermal tattoo as an adjunct to nipple–areola reconstruction. Plast Reconstr Surg. 1989;83:907.

Ullmann Y, Pelled LJ, Laufer D, Blumenfeld L. Nipple–areola reconstruction with a custom-made silicone ectoprosthesis. Ann Plast Surg. 1992;28:485.

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