Reconstruction of the

Nipple-Areola Complex

Dr,Ramprabhu
2 may 2015

Background
Breast reconstruction can provide significant
psychosocial benefits for women
NAC is an aesthetically important part of the
breast
NAC reconstruction is the final step in long and
traumatic process of breast reconstruction.

Increases subjective satisfaction and

acceptance of post-operative body image

Multitude of techniques developed

alongside breast mound reconstruction.

Anatomy

Anatomy
Significant variation is seen in size,
projection, shape, texture, colour between
individuals
Important features are:
Pigmented area in the most anterior part of
breast.
Central elevated structure within this areanipple
Nipple is ideally just above inframammary fold.

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
--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 nipple is supplied by branches of the 4th lateral

intercostal nerve(cutaneous nerve).
One branch of this nerve travels through the breast to
the nipple.
Another traverses medially on the chest wall before
ascending vertically towards the nipple.

Anatomy
For ideal aesthetics

Sternal notch to NAC distance

~21-23 cm
~5-7cm from inframammary fold
NAC diameter ~4.2-5cm
Nipple projection + diameter ~1/31/4 areolar diameter

Note: normal nipple projection

varies!
More important to match contra
lateral side!

Goals of nippleareola reconstruction

Position
Symmetry
Pigmentation
Color
Texture
Size
Projection

Timing
Reconstruction of the NAC is usually
performed at least 3 months after breast
reconstruction.
This is because it is difficult to correctly site
the NAC at the time of breast
reconstruction.

Options
Non-Surgical
NAC tattooing
Prosthesis

Surgical
Graft
Nipple sharing
Skin
Autologous dermo-fat /
Alloderm
Cartilage

Local flap

Prosthesis
Stock prostheses available
Can be made to match other side
Stick on
Fall off!
Much dissatisfaction on long term use.

Surgical options
More realistic in terms of nipple shape, size, contour.
Not yet able to reconstruct functional nipple!
Challenge in creating 3 dimensional structure from 2
dimensional surface
Loss of projection often occurs, may require 2nd procedure
Pre-op planning
If good symmetry match contra lateral NAC position
Otherwise
Cover contra lateral breast, mark nipple position where appears best.
Compare to other side and adjust if appropriate.
Note patients wishes.

Nipple Sharing
Uses contralateral nipple as
donor.
If enough projection,
transection of distal/inferior
30-50% of donor nipple
sufficient.

 Wedge excision (with small local flap).

Reduces/obliterates function of contra lateral normal

nipple.
Difficult to justify given other methods available.

Grafting
Skin graft for nipple with filler injection
Poor projection unless used with local flap,
cartilage or Alloderm
More diffuse nipple
Cartilage Autologous costal cartilage
Firm texture
May erode through skin
May be painful

Costal Cartilage graft

Post-op cartilage graft + tattooing

Local flaps
May lose projection over time so should be
planned 50-75% larger than contra lateral nipple.
Donor sites may be closed primarily or grafted.
Scars from donor site should be within future
areola reconstruction (4.2-5cm diameter)
Many techniques surgeon/patient preference.
Best orientation for scar.

Skate Flap(Little
in 1987 )
Flap(
Nipple reconstruction by the skate flap.
1: Area beyond tangent
to nipple disk A denuded; lines from 3- and 9oclock of nipple disk to 6-oclock 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.
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.

Skate Flap

Skate Flap

Skate Flap

Bell Flap(Eng 1996)

Diameter 15-20%
larger than other
nipple

Handle ~
diameter of circle

Bell Flap

Elongated C Flap

Elongated C Flap

Elongated C Flap

Cervical-visor (C-V) flap

Jones and Bostwick

CV Flap

Star flap

Base 3x diameter of contra lateral nipple

Anton, Eskenazi, and Hartrampf in 1991.

Star Flap

Double Opposing Tab Flap

(Kroll)

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.

Non hairy
skin lateral
to Labia
majora

Post operative 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. The dressing is taped to the
breast skin and should remain in place for 5 to 7 days.
The tattoo is usually delayed for 4 to 6 weeks, and pressure to the nipple
reconstruction site is avoided. With techniques that involve the use of a
graft, the bolster dressing is removed in 3 to 5 days.

Complications
Uncommon
Necrosis (partial/total)
Unsatisfactory positioning.
Loss of projection(most
common)
projection
Secondary procedures/revision

Necrosis

Postmastectomy reconstruction patients can be subdivided into three groups in

regard to nipple-areola reconstruction:
(1) patients who have no interest in further surgery, (external silicone
ectoprosthesis)
(2) patients who have unstable central mound skin or present with irradiation
injury to the central breast mound,(delayed reconstruction of the NAC) and
(3) patients with a stable skin envelope or flap at the central breast mound.(,
immediate or delayed nipple-areola reconstruction)