UNCORRECTEDPROOFNipple Reconstruction

Maurice Y. Nahabedian, MD½Q2� ½Q3�

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 optionscontinue 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. Shestak½Q5� [1]has demonstrated that local flap techniques (Star,Skate, and Bell flaps) will flatten by 50% to 70%over 2 years. This was observed in breasts recon-structed with flaps and with implants. Jabor½Q6� [2]has demonstrated that the principle determinantof patient dissatisfaction was excessive flattening,followed by color, shape, size, texture, and position.Only 13% of all patients were totally satisfied withtheir reconstructed nipple–areolar complex. Thus,the search for the ideal nipple reconstructioncontinues.

There are two basic methods by which a nipplecan be surgically reconstructed: the use of local flapswith or without the use of skin grafts, and as a com-posite free nipple graft from the contralateralbreast. The options for local flaps are numerous

and include the CV ½Q7�, Tab, Skate, Star, Bell, and Arrowflaps, to name a few [1,3–5]. 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 author’spersonal approach for nipple reconstruction basedon over 500 procedures. The primary topics includesurgical 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 mostcommonly used in the author’s practice is the CVflap. However, the majority of nipple reconstruc-tions that the author has performed have used the‘‘elongated C ½Q8�flap.’’ Both of these flaps have the ad-vantage of not requiring the use of skin grafts. The

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 - (2007) -–-

The author serves on the speakers’ bureau for LifeCell Corporation.Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington,DC 20007, USA½Q4�E-mail address: drnahabedian@aol.com

- Nipple reconstructionPreoperative planningOperative technique (primary nipple

reconstruction)Operative technique (secondary nipple

reconstruction)

Method of nipple augmentationPostoperative careAreolar tattooComplications

- Summary- References

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0094-1298/07/$ – see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2006.11.009plasticsurgery.theclinics.com

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areola is recreated using tattoos. The long-term pro-jection of the nipple using these flaps has rangedfrom 1 to 5 mm, but the majority of nipples arewithin a range of 2 to 3 mm. Of the last 500 nipplereconstructions, 42 have required a second opera-tion to increase nipple projection.

Preoperative planning

Planning for the nipple reconstruction is dependentupon 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 adjuvanttreatments such as chemotherapy and radiationtherapy have deferred the nipple reconstructionuntil these treatments have been completed. Theoutcome following radiation therapy to the

reconstructed breast has been less predictable andassociated 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 author’s practice, although there aresome who advocate this (reference ½Q9�).

Operative technique (primary nipplereconstruction)

Operations are performed in an outpatient surgicalsetting; 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

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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.

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

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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 suturesare 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.

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Fig. 3. The flap is elevated. Minimal superior under-mining (flap side) is performed to minimize and vas-cular compromise to the flap ½Q10�. 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 patient’s degree ofanxiety and sensation. Intravenous antibiotics arerecommended especially for women following im-plant reconstruction. Local anesthesia using 1% li-docaine 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). Theviability 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 thewidth of the flap ranges from 1 to 1.5 cm basedon the appearance of the contralateral nipple. Thetechnique for nipple reconstruction using the elon-gated C flap is illustrated in Figs. 2–5. 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 4–0 monocril suture isusually used in the dermal layer, and a 5–0 nylonsuture is used on the skin. The technique for nipplereconstruction using the CV flap is illustrated inFigs. 6–8. The projection of the reconstructed nip-ple at completion ranges from 0.8 to 1.5 cm for

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

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

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

[Q1]

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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.

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the elongated C flap (Fig. 9) and 0.8 to 1.2 mm forthe CV flap (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. 12–16.

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 canalso 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

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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 thesutures at 2 weeks.

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Fig. 10. The typical appearance immediately follow-ing nipple reconstruction using the CV flap. The pro-jection is approximately 1 cm.

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Fig. 12. Delayed breast reconstruction using a deepinferior epigastric perforator ½Q11�(DIEP) flap and nipple–areolar reconstruction using an elongated C flap.One-year follow-up.

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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 anacellular dermal matrix, but other material, suchas fat, dermis, cartilage, and bone, can be usedprimarily or secondarily [5–9].

Method of nipple augmentation

When considering nipple augmentation, patient ex-pectations must be appreciated. Some women havelittle 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 author’s practice. In general,long-term projection has ranged from 4 to 5 mmfollowing augmentation.

The method of nipple augmentation most com-monly used in the author’s 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 beemphasized [9]. It is recommended to obtain a1 � 2–cm piece of thick or extra thick AlloDerm,and use a segment that measures approximately3 � 6 mm (Fig. 18). Sometimes, the AlloDermcan 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 author’s experience.The important concept when using supplemental

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

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

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

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

Nipple Reconstruction 5

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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 flapreconstruction, 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 womenare 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 arevarious 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 notrequire the use of a local anesthetic based on thedegree of sensation. Women are instructed thatthese tattoos may fade over time and that a secondtattoo procedure may be desired.

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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.

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

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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.

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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% of re-constructions (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 thedecision of determining the location of the nippleon the reconstructed breast.

Summary

Creation of a nipple–areolar complex provides thefinal touches to the breast reconstruction. It isconsidered by many women to be an essentialand 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 thewoman. In the 80% of women in the author’s 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;110:780–6.

[2] Jabor MA, Shayani M, Collins DR, et al. Nipple-areolar reconstruction: satisfaction and clinicaldeterminants. Plast Reconstr Surg 2002;110:457–63.

[3] Losken A, Mackay GJ, Bostwick J. Nipple recon-struction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 2001;108:361–9.

[4] Kroll SS, Reece GP, Miller MJ, et al. Comparison ofnipple projection with the modified double ap-posing tab and star flaps. Plast Reconstr Surg1997;99:1602–5.

[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;50:31–7.

[6] Bernard RW, Beran SJ. Autologous fat graft in nip-ple reconstruction. Plast Reconstr Surg 2003;112:964–8.

[7] Yanaga H. Nipple-areola reconstruction with a der-mal-fat flap: technical improvement from rolledauricular cartilage to artificial bone. Plast ReconstrSurg 2003;112:1863–9.

[8] Tanabe HY, Ti Y, Kiyokawa W, et al. Nipple-areolareconstruction with a dermal-fat flap and rolledauricular cartilage. Plast Reconstr Surg 1997;100:431–8.

[9] Nahabedian MY. Secondary nipple reconstructionwith local flaps and AlloDerm. Plast Reconstr Surg2005;115:2056–61.

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

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

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

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