82007Nipple Reconstruction - ClLINICS

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Nipple ReconstructionMaurice Y. Nahabedian, MD, FACS

The challenge of nipple reconstruction is to cre-ate a three-dimensional structure from a two-dimensional surface. As we strive to improve ouroutcomes from nipple reconstruction, our options

continue to expand. Numerous techniques havebeen described. So many techniques have been de-

scribed, which suggests that no single technique isperfect. The principle limitation of all techniquesis premature or excessive flattening attributable pri-marily to scar contracture. Short- and long-termoutcome studies have been reported. Shestak andcolleagues [1] have demonstrated that local flaptechniques (Star, Skate, and Bell flaps) will flattenby 50% to 70% over 2 years. This was observed in

breasts reconstructed with flaps and with implants.Jabor and colleagues [2] have demonstrated thatthe principle determinant of patient dissatisfaction

was excessive flattening, followed by color, shape,size, texture, and position. Only 13% of all patientswere totally satisfied with their reconstructed nip-

pleareolar complex. Thus, the search for the idealnipple reconstruction continues.

There are two basic methods by which a nipplecan be surgically reconstructed: the use of local flaps

with or without the use of skin grafts, and as acomposite free nipple graft from the contralateral

breast. The options for local flaps are numerous

and include the CV, Tab, Skate, Star, Bell, and Arrowflaps, to name a few[1,35]. Skin grafts are used tomimic the areolar surface. The use of a free nipplegraft can be considered in women who have a con-

tralateral nipple with excessive projection. Nippleaugmentation using supplemental materials is pos-

sible with many of these local flap techniques. Var-ious materials are described that can be used at thetime of initial nipple reconstruction or as a second-ary procedure.

Given the broad scope of this topic and variousmethods available, this article reviews the authorspersonal approach for nipple reconstruction basedon over 500 procedures. The primary topics in-

clude surgical techniques of nipple reconstruction,methods of nipple augmentation, postoperativecare of the reconstructed nipple, areolar tattooing,

and complications.

Nipple reconstruction

The technique of nipple reconstruction that is most

commonly used in the authors practice is the CVflap. However, the majority of nipple reconstruc-tions that the author has performed have used theelongated C flap. Both of these flaps have theadvantage of not requiring the use of skin grafts.

C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 34 (2007) 131137

The author serves on the speakers bureau for LifeCell Corporation.Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington,DC 20007, USAE-mail address: [email protected]

- Nipple reconstructionPreoperative planningOperative technique (primary nipple

reconstruction)

Operative technique (secondary nipplereconstruction)

Method of nipple augmentationPostoperative care

Areolar tattooComplications

- Summary- References

131

0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2006.11.009

plasticsurgery.theclinics.com


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The areola is recreated using tattoos. The long-term

projection of the nipple using these flaps hasranged from 1 to 5 mm, but the majority of nipplesare within a range of 2 to 3 mm. Of the last 500 nip-ple reconstructions, 42 have required a second op-eration to increase nipple projection.

Preoperative planning

Planning for the nipple reconstruction is dependent

upon the type of breast reconstruction performedand the need for adjuvant treatments. In general,women who have had autologous reconstructioncan complete nipple reconstruction 3 months fol-lowing the reconstruction, whereas women whohave had expander/implant reconstruction cancomplete the process 3 months following thesecond stage. Women who have had adjuvant

treatments such as chemotherapy and radiationtherapy have deferred the nipple reconstructionuntil these treatments have been completed. The

outcome following radiation therapy to the

reconstructed breast has been less predictable and

associated with a higher incidence of delayed heal-ing and tissue necrosis. Nipple reconstruction at thetime of the breast reconstruction has not been per-formed in the authors practice, although there aresome who advocate this [6].

Operative technique (primary nipplereconstruction)

Operations are performed in an outpatient surgical

setting; however, these can also be performed in anoffice setting if feasible. On the day of surgery,patients are marked in the standing position. It isrecommended that the patient participate in deter-mining the optimal position of the nipple. Some

Fig. 1. An elongated C flap is outlined on a breast re-constructed with a muscle sparing free TRAM flap.The flap can be oriented in any direction, and the dis-tal aspect of the flap can be positioned along a scar ifnecessary.

Fig. 2. The elongated C flap is incised through thedermis and into the subcutaneous fat layer.

Fig. 4. Three dermal sutures are placed at this stage.The first suture is applied at the junction of the flapand upper skin edge. The second suture is appliedon the opposite side of the flap. These two sutures

are approximated to the opposite (nonflap side)edge of the pattern leaving a 1-cm gap in the centralthird. The third suture is a trifurcation stitch thatapproximates the dermal corners of the flap to themidpoint of the inferior skin edge.

Fig. 3. The flap is elevated. Minimal superior under-mining (flap side) is performed to minimize any vas-cular compromise to the flap. It is recommended toelevate 1 to 2 mm of subcutaneous fat with the flapto provide additional bulk when possible.

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patients are interested in symmetry on the horizon-tal plane, whereas others prefer the nipple to be op-timally positioned on the breast mound. Concernsrelated to the type of anesthetic are addressed be-fore entering the operating room. The breast recon-

structed with autologous tissue is often insensateespecially when the nipple is performed 3 monthsfollowing the breast reconstruction. Expander/im-plant reconstruction is often associated with somedegree of sensation at the time of nipple reconstruc-tion. Intravenous sedation can be used for bothmethods depending on the patients degree of

anxiety and sensation. Intravenous antibiotics arerecommended especially for women following im-plant reconstruction. Local anesthesia using 1%

lidocaine without epinephrine is necessary forwomen who have sensation of the breast mound.

The techniques that the author has used most of-ten include the CV flap and the elongated C flap.

The reasons for using these flaps are principallyrelated to their versatility and ease of use. The flapscan be oriented in any direction or location on the

breast that facilitates obtaining nipple symmetry. Inaddition, they can be positioned along a scar aslong as the design is oriented such that the bloodsupply enters away from the old scar (Fig. 1). The

viability and survival of the nipple depends on ad-

equate blood supply. The blood supply for theseflaps is based upon the subdermal plexus of vesselsfrom the portion of the skin that is not incised. Thelength of the flap ranges from 3 to 4 cm, and the

width of the flap ranges from 1 to 1.5 cm basedon the appearance of the contralateral nipple. The

technique for nipple reconstruction using the elon-

gated C flap is illustrated in Figs. 25. Following theincisions, the tissues are rearranged into the shapeof a nipple and sutured. A combination of absorb-

able and nonabsorbable sutures is used for closureand to maintain the shape. A 40 monocril suture isusually used in the dermal layer, and a 50 nylonsuture is used on the skin. The technique for nipplereconstruction using the CV flap is illustrated inFigs. 68. The projection of the reconstructed nip-

ple at completion ranges from 0.8 to 1.5 cm for

Fig. 5. Final closure of the flap using a running non-absorbable suture along the limbs and an interruptednonabsorbable suture along the flap.

Fig. 6. The CV flap is outlined. The dimensions andorientation possibilities are similar to the elongatedC flap.

Fig. 7. The CV flap has been elevated, and the firsttwo dermal sutures applied as described in Fig. 4.

Fig. 8. An alternate suture technique is performed inwhich the dermal corners for the flap (grasped withforceps in Fig. 7) are wrapped around each otherand sutured to the site of the preceding two sutures.

Nipple Reconstruction 133


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the elongated C flap (Fig. 9) and 0.8 to 1.2 mm fortheCVflap(Fig. 10). The initial projection of the re-constructed nipple often exceeds the projection ofthe natural nipple; however, over time, the recon-structed nipple will recontour and flatten by at least50%. This is usually evident 2 to 3 months follow-

ing the procedure. A protective shield filled with anantibiotic ointment is applied at the completion ofthe procedure (Fig. 11). Clinical examples are pro-

vided in Figs. 1216.

Operative technique (secondary nipplereconstruction)

Some women following primary nipple reconstruc-tion are not content with the final outcome. Usuallythis is due to flattening or poor projection but can

also be due to malposition, shape, and texture [2].Unfortunately, some degree of flattening is ob-served with all methods of nipple reconstructions

regardless of the technique used. It is expectedthat the nipple will shrink by at least 50% followingthe initial creation. However in approximately 10%

to 15% of reconstructions, the nipple will flattenbeyond expectations and need to be recreated(Fig. 17). Long-term projection of the reconstructednipple occurs with greater frequency followingbreast reconstruction using implants rather thanflaps. This is primarily because implants exert anadditional upward force onto the skin surface,

whereas flaps do not. Other reasons for excessive

Fig. 9. The typical appearance immediately followingnipple reconstruction using the elongated C flap. Theprojection is approximately 1 cm. The nipple ispointed initially, but this will begin to assumea more natural contour following removal of the

sutures at 2 weeks.

Fig. 10. The typical appearance immediately follow-ing nipple reconstruction using the CV flap. The pro-

jection is approximately 1 cm.

Fig. 12. Delayed breast reconstruction using a deepinferior epigastric perforator (DIEP) flap and nippleareolar reconstruction using an elongated C flap.One-year follow-up.

Fig. 11. Following the operation, the nipple shield isapplied and filled with an antibacterial ointment.The shield is removed on postoperative day 3, andpatients are instructed to shower.

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flattening include external pressure, poor design,thin skin and dermis, and lack of subcutaneous fat.

In these situations, the option of secondary nip-

ple reconstruction is discussed. When desired,a CV flap is always performed. The remnant of theflattened nipple is incorporated into the hood orC portion of the flap. The use of supplementalmaterial to increase the volume of the nipple andimprove the chances of long-term projection issometimes used. The author frequently uses an

acellular dermal matrix, but other material, such

as fat, dermis, cartilage, and bone, can be usedprimarily or secondarily[5,710].

Method of nipple augmentation

When considering nipple augmentation, patient ex-pectations must be appreciated. Some women have

little interest in visibly projecting nipples, whereasother patients have a strong interest. Although nip-ple augmentation can be performed at the initial

nipple reconstruction, the majority are performedsecondarily in the authors practice. In general,long-term projection has ranged from 4 to 5 mm

following augmentation.The method of nipple augmentation most com-

monly used in the authors practice is to use anacellular dermal matrix (AlloDerm, LifeCellCorporation, Branchburg, New Jersey). The detailsof this technique have been previously described;however, some of the salient features will be

emphasized [10]. It is recommended to obtain a

1 2cm piece of thick or extra thick AlloDerm,and use a segment that measures approximately3 6 mm (Fig. 18). Sometimes, the AlloDerm

can be folded for additional volume in caseswhereby there is enough tissue compliance(Fig. 19). The orientation of the basement mem-brane should be toward the skin flaps, althoughthis has not been critical in the authors experience.

The important concept when using supplemental

Fig. 13. Immediate unilateral two-stage breast recon-struction using expanders and implants followed bynippleareolar reconstruction using an elongated Cflap. Two-year follow-up.

Fig. 14. Immediate bilateral two-stage breast recon-struction using expanders and implants followed bynippleareolar reconstruction using an elongated Cflap. Two-year follow-up.

Fig. 15. Immediate right breast and delayed leftbreast reconstruction using DIEP flaps and bilateralnippleareolar reconstruction using CV flaps and Al-loDerm. One-year follow-up.

Fig. 16. Immediate left breast reconstruction usinga DIEP flap and nippleareolar reconstruction usingan elongated Cflap. Three-year follow-up.



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material is to place it between apposing skin flaps

(Fig. 20). The upper tip of the AlloDerm shouldbe sutured to the superior dermal edge of the localflap to prevent displacement or migration. It is notadvised to place the AlloDerm in a subcutaneouspocket under the nipple because this maneuverhas not resulted in enhanced projection.

Postoperative care

Postoperatively, women are permitted to showerthe following day. They are instructed to removethe nipple shield 2 days following the operationand then reuse it for 2 weeks to minimize externalcompression. Pain medication and antibiotics areusually prescribed. Some women, following flap

reconstruction, will not require analgesics becausethey have not yet regained sensation to the recon-structed breast. Sensation is common followingbreast reconstruction with implants. Sutures are re-moved 2 weeks following the operation to maintainthe shape and projection of the nipple. All women

are instructed that the nipple will initially be longer

and pointed when the elongated C flap is used.

However after approximately 1 month, the recon-structed nipple will partially shrink and roundout. There is essentially no downtime for this oper-ation, and women usually return to their normalactivities the following day.

Areolar tattoo

Creation of an areola is performed approximately3 months following the nipple reconstruction.Permanent tattooing is performed in the office byspecially trained nursing staff (Fig. 21). There are

various colors that are available, and the choiceis based on the color of the opposite areola(Fig. 22). This procedure requires approximately20 to 30 minutes per nipple and may or may not

require the use of a local anesthetic based on thedegree of sensation. Women are instructed thatthese tattoos may fade over time and that a second

tattoo procedure may be desired.

Fig. 17. Immediate right breast reconstruction usinga latissimus dorsi musculocutaneous flap and nipplereconstruction using an elongated C flap. The projec-tion of the nipple may decline and the areola tattoomay fade over time as depicted.

Fig. 18. A 1 2cm piece of thick AlloDerm.

Fig. 19. The AlloDerm is hydrated and then cut intoa 1-cm 6-mm piece. The dimensions may vary basedon the size of the skin flaps and available space. TheAlloDerm can be folded and sutured to maintain itsshape.

Fig. 20. The AlloDerm is positioned between appos-ing skin flaps.

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Complications

Complications following nipple reconstruction areuncommon. The most severe is partial or total nip-

ple necrosis that has occurred in less than 2% ofreconstructions (Fig. 23). This is more commonlyseen when the nipple reconstruction is performedfollowing radiation therapy. Thus, it is recommen-ded to perform nipple reconstruction before radia-tion therapy when desired, possible, and feasible.

There have been several instances of nipple malpo-

sition requiring excision of the first nipple and re-construction of another nipple. Thus, women andsignificant others are asked to participate in the

decision of determining the location of the nippleon the reconstructed breast.

Summary

Creation of a nippleareolar complex provides thefinal touches to the breast reconstruction. It isconsidered by many women to be an essential

and important component of the breast. As withall reconstructive procedures related to the breast,the desire to pursue nipple reconstruction is based

on the physical and psychologic needs of the

woman. In the 80% of women in the authors prac-

ticewho do have nipple reconstruction, the resultshave been good to excellent in the majority, and sat-isfaction following the procedure has been high.

References

[1] Shestak KC, Gabriel A, Landecker A, et al. Assess-ment of long-term nipple projection: a compari-son of three techniques. Plast Reconstr Surg2002;110:7806.

[2] Jabor MA, Shayani M, Collins DR, et al. Nipple-areolar reconstruction: satisfactionand clinical de-

terminants. Plast Reconstr Surg 2002;110:45763.[3] Losken A, Mackay GJ, Bostwick J. Nipple recon-struction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:3619.

[4] Kroll SS, Reece GP, Miller MJ, et al. Comparisonof nipple projection with the modified doubleapposing tab and star flaps. Plast Reconstr Surg1997;99:16025.

[5] Guerra AB, Khoobehi K, Metzinger SE, et al. Newtechnique for nipple areola reconstruction: arrowflap and rib cartilage graft for long lasting nipplereconstruction. Ann Plast Surg 2003;50:317.

[6] Delay E, Mojallal A, Vasseur C, et al. Immediatenipple reconstruction during immediate autolo-gous latissimus breast reconstruction. Plast Re-constr Surg 2006;118:130312.

[7] Bernard RW, Beran SJ. Autologous fat graft innipple reconstruction. Plast Reconstr Surg 2003;112:9648.

[8] Yanaga H. Nipple-areola reconstruction witha dermal-fat flap: technical improvement fromrolled auricular cartilage to artificial bone. PlastReconstr Surg 2003;112:18639.

[9] Tanabe HY, Ti Y, Kiyokawa W, et al. Nipple-are-ola reconstruction with a dermal-fat flap and

rolled auricular cartilage. Plast Reconstr Surg1997;100:4318.

[10] Nahabedian MY. Secondary nipple reconstruc-tion with local flaps and AlloDerm. Plast Re-constr Surg 2005;115:205661.

Fig. 21. The areola can be tattooed in an office set-ting as shown.

Fig. 23. Necrosis of a reconstructed nipple followingDIEP flap breast reconstruction and radiation therapy.

Fig. 22. The appearance of the areola immediatelyfollowing the tattoo procedure.


82007Nipple Reconstruction - ClLINICS

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