Current options for nipple reconstruction

Anatomy

The NAC is the key landmark of the breast and crucial to preoperative planning of a successful breast reconstruction in addition to other aesthetic components such as the inframammary fold, sternal notch, breast meridian. The NAC is typically present on the prominence of the breast mound as an elevated structure that usually projects 5–10 mm and as much as >1 cm from the pigmented skin surface known as the areola. In general, the average nipple and areola diameters are 1.3 and 4 cm, respectively. Traditionally, the aesthetic proportion between the size of the NAC and the breast have been suggested to be 1 : 3.4 for the areola : breast and 1 : 3 for the nipple : areola with the aesthetic positioning of the NAC at the point of maximal breast projection above the inframammary fold. Since the NAC is used to delineate the border between the upper and lower pole of the breast, an upper pole : lower pole ratio of 45:55 was found to score the highest in terms of ideal breast proportion. NAC positioning is also variably described to be 21–24 cm from the sternal notch or at the approximate level of the mid-humerus. In men, various NAC positioning systems have been proposed, from exact distance measurements to those based on morphometric ratios. Within the context of these general principles, there is wide variation in NAC appearance, dimensions, color, and texture across individuals and ethnic groups. Even within the same patient, the two NACs can be visibly different, and NAC placement and positioning should be individually discussed with each patient.

Preoperative planning

In unilateral cases, the contralateral NAC can be used as a comparative template to guide the size, positioning, and projection of the reconstructed nipple. Regardless over which technique is chosen, unilateral NAC reconstruction should aim to create a NAC that is significantly larger than the contralateral nipple to allow for the 40–50% reduction in projection that is typically observed from contraction during healing. If the contralateral nipple is relatively large, unilateral NAC reconstruction with composite nipple–areola grafting or “nipple-sharing” becomes a viable option. For bilateral NAC reconstruction, the optimal NAC position should be chosen based on other landmarks such as the prominence of the breast mound, sternal notch, chest midline, and the inframammary fold. An electrocardiogram lead with the central metal tab to simulate nipple position can be used to guide placement of the new NAC, with the patient standing in front of a full-length mirror. Once the patient and surgeon are satisfied with the placement and symmetry obtained, distances from key landmarks such as the sternal notch, sternal midline, and inframammary fold are recorded.

Timing of NAC reconstruction is usually performed after postoperative swelling and inflammation of surgical breast reconstruction as resolved, typically 3–6 months after the last operation to allow for NAC reconstruction onto a settled breast mound. While immediate NAC reconstruction at the time of breast reconstruction has been performed, this is typically in the setting of autologous flap reconstruction where additional thinning of the skin by local flaps will not threaten mastectomy flaps providing coverage over implants-based reconstruction Even so, immediate nipple reconstruction may not be optimal since autologous breast reconstruction often requires subsequent surgical revisions where NAC reconstruction can then be performed on a more stable breast mound.

Nipple–areolar complex preservation

The best reconstruction may be no reconstruction at all. As oncologic indications and limitations are better understood, nipple-sparing mastectomies can be the preferred surgical treatment of breast cancer if the tumor size, tumor-nipple distance, and tumor subtype are appropriate, along with other secondary factors. Nipple-sparing mastectomies allow the preservation of the NAC with subsequent improved quality of life scores as reported by BREAST-Q compared with traditional mastectomies regardless of type of breast reconstruction. As the primary consideration for breast reconstruction patients is definitively treating their breast cancer, recent studies have demonstrated long-term oncologic safety with a low incidence of NAC and locoregional cancer recurrence following nipple-sparing mastectomy with breast reconstruction. Of course, nipple-sparing mastectomies also come with the aesthetic risk of NAC necrosis given their maintenance on what can be a tenuous vascular supply of the mastectomy flaps. Fortunately, all-cause loss of the NAC is less than 7%, and in the event of nipple loss, many of these patients go on to pursue NAC reconstruction via one of the many techniques described below.