Maurice Nahabedian, MD, FACS
Director: Center for Reconstructive and Aesthetic Surgery of the Breast
Johns Hopkins Medical Institutions
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Over the years, a variety of techniques have been described to create the nipple-areolar complex following breast reconstruction. The most common methods in use today utilize the skin of the reconstructed breast in the form of local flaps. These include the Skate flap, C-V flap, and Star flap to name a few. All of these techniques are based on the principles of adjacent tissue rearrangement in order to create a 3-dimensional nipple. Other methods that are less commonly used include nipple sharing from the opposite breast and skin grafting. All of these methods can create a well-shaped nipple and all usually require a tattoo procedure to provide the color for the areola.
The technique that I use is a variation of the C-V flap that I refer to as the "elongated C-flap". My reasons for using this flap are principally related to its versatility and ease of use. The flap can be oriented in any direction or location on the breast that facilitates obtaining nipple symmetry. In addition, it can be positioned along a scar as long as it does not interfere with the blood supply to the nipple. As with all flaps, the viability and survival of the nipple depends on adequate blood supply. The blood supply for this flap is based upon the subdermal plexus of vessels from the portion of the skin that is not incised. The design of this flap and a clinical example is illustrated.
Planning for the nipple reconstruction usually begins at the 6-week point following the breast reconstruction. When the final contour and volume of the breast is stable, the operation is scheduled. This usually occurs at the 3-month point following breast reconstruction with flaps and at 6 months following 2-stage implant reconstruction. Adjuvant treatments such as chemotherapy and radiation can result in deferment of the nipple reconstruction. All operations are usually performed in the outpatient surgicenter. The procedure requires about 15 minutes for unilateral and 30 minutes for bilateral reconstructions. Local anesthesia is occasionally necessary especially for women who have had implant reconstruction. This is primarily dependant upon the degree of sensation of the reconstructed breast. Sedation is occasionally used to relieve any anxiety associated with this procedure. Following the incisions, the tissues are rearranged into the shape of a nipple and sutured. A combination of absorbable and nonabsorbable sutures is used for closure and to maintain the shape of the nipple. Once complete, bandages are applied and women are discharged to home usually within 30 minutes following the operation.
Postoperatively, women are instructed that they can shower the following day. There is essentially no downtime for this operation and women usually return to their normal activities the following day. Pain medication and antibiotics are usually not necessary except in women who have regained sensation or who have had implant reconstruction. The sutures are left in place for 2 weeks in order to maintain the shape and projection of the nipple. All women are instructed that the nipple will initially be longer and somewhat pointed. However after about 1 month, the reconstructed nipple will partially shrink and round out.
Creation of an areola is performed approximately 3 months following the nipple reconstruction. Permanent tattooing is performed in the office by specially trained nursing staff. There are a variety of colors that are available and the choice is based on the color of the opposite areola. This procedure requires approximately 20 to 30 minutes per nipple and may or may not require the use of a local anesthetic based on the degree of sensation. Women are instructed that these tattoos may fade over time and that a second tattoo procedure may be desired.
Complications following nipple reconstruction are uncommon. The most common occurrence is excessive flattening of the nipple Unfortunately, flattening is an outcome that is observed in all nipple reconstructions regardless of the technique used. It is expected that the nipple will shrink by approximately 50% following the initial creation. However in about 10-15% of reconstructions, the nipple will flatten excessively and need to be recreated. Fortunately, this is easily accomplished using this same technique. On occasion, the use of semisynthetic material such as alloderm may be used to improve the chances for long-term projection. It has been my observation that long-term projection of the reconstructed nipple occurs with greater frequency following breast reconstruction using flaps rather than implants. This is primarily because implants exert an additional upward force on to the skin surface, whereas flaps do not. Other complications include partial or total nipple necrosis that occurs in approximately 5% and 1% of reconstructions respectively. Nipple reconstruction following radiation therapy tends to result in a poor outcome more often and for this reason it is recommended that nipple reconstruction be performed prior to radiation when possible.
In conclusion, creation of a nipple-areolar complex provides the final touches to the breast reconstruction. It is considered by many to be an essential and important component of the breast. As with all reconstructive procedures related to the breast, the choices are all based on the physical and psychological needs of the women and for that reason, some women choose not to proceed with nipple reconstruction. However, of the 90% of women in my practice who do have nipple reconstruction, the results have been good to excellent in the majority and satisfaction following the procedure has been high.
(The content and opinions expressed in this article reflect that of the primary author and are subject to change over time.)