Nipple Areola Complex Reconstruction: An 8-Year Experience With Modified Technique and Systematic Review

Abstract

Background

Nipple areola complex reconstruction is often the last procedure offered to patients undergoing breast reconstruction. Although comparatively minor, this final step creates the focal point of the breast while signifying the end of an often long and difficult journey for patient and surgeon. The literature demonstrates that nipple areolar complex (NAC) reconstruction conveys a positive impact on overall body image while defining the final aesthetic outcome. This paper presents a novel technique for NAC reconstruction developed at a UK tertiary referral center. It is supported by a systematic review of the current literature.

Methods

Between 2014 and 2022, a new technique was used to reconstruct the NAC using a modification of the C-V flap with a full-thickness skin graft (FTSG) and later nipple tattoo, if required. Patients were followed up in clinic noting complications, satisfaction, and need for revision surgery. The study was completed by conducting a systematic review of the literature assessing areolar reconstruction with skin grafts, according to PRISMA guidelines.

Discussion

This technique provides excellent results in terms of patient satisfaction and objective outcomes (complication rate, need for revision procedures, and loss of projection requiring further surgery). This literature review reflects alternative techniques and highlights the advantages of using a modified C-V flap with FTSG, in terms of morbidity and patient satisfaction.

Conclusions

NAC reconstruction is the “cherry on top” at the end of the breast reconstructive journey. This paper advocates a technique that is reproducible, with minimal complications, excellent outcomes, and long-standing results.

Introduction

Nipple areolar complex (NAC) reconstruction is usually the final stage of the breast reconstruction journey. The aim is to achieve symmetry with the contralateral breast and to restore patient body image, especially in the case of bilateral reconstruction. The literature suggests that patients undergoing NAC reconstruction have higher general and aesthetic satisfaction when compared with breast reconstruction without NAC reconstruction.^1,2,3 This is relative to both unilateral and bilateral, autologous or heterologous procedures. The literature also supports offering patients the choice of NAC reconstruction; however, this should be broached early in the patient journey.⁴

In this paper we will outline our modified technique for nipple and areola reconstruction, alongside our outcomes and results. We will review the literature on this subject, mainly focused on grafting techniques for areola reconstruction and highlighting results and complications.

Patients and Technique

Reconstruction aims to produce a durable 3-dimensional structure. The procedure should be reliable, reproducible, and efficient and involve minimal complications or donor site morbidity.

This technique involves nipple reconstruction with a modified C-V flap similar to Losken et al; however, we add additional areola reconstruction using a full-thickness graft from the abdominal donor site scar as described in detail below.⁵

• Preoperatively, with patient standing upright, the new nipple position is marked and checked by the patient to ensure they are happy with the proposed location.

• The height and diameter of the new nipple is calculated based on the contralateral side. We add an additional 25% to each dimension to account for shrinkage during healing.

• In theater, local anesthetic with adrenaline is used to infiltrate each area (breast and abdomen), taking care to avoid the segment reserved for the blood supply to the base of the C-V flap. The nipple is centered using a suitable nipple marker. The area is then de-epithelialized, leaving the C-V flap (Figure 1), which is raised with some subdermal fat.

• A circular full-thickness skin graft is harvested from the lateral aspect of the abdominal scar, including and revising preexisting dog-ear deformity.

• The graft is prepared by de-epithelialising a central “button” measuring approximately 1 cm in diameter, as per Figure 1. A semicircular full-thickness window is also created.

• The graft is inset around the C-V flap, carefully tailoring the de-epithelialized area to rest beneath the nipple, forming a “dermal shelf.” This provides adequate projection in the long term.

• Grafts are secured using continuous suture with additional quilting to enhance graft “take” and provide a textured appearance. Often this results in a Montgomery tubercle effect.

• A noncompressive sponge and adhesive dressing are applied and remains in-situ for 1 week. Padding is worn in the bra to protect the projection for 5 weeks subsequently.

Exclusion Criteria: patients declining reconstruction, patient electing for tattoo only.

Figure 1.

Clinical photographs demonstrating a patient prepared for surgery with nipple and donor site marked. The modified C-V flap is also displayed attached to a deepithelialized superior pole. In the bottom left note the de-epithelialized central button that will be used as a dermal “shelf” to help projection of the neo-nipple.

The final outcome can be observed on the bottom right, with quilting sutures as discussed.

Results

Using the above technique, we performed 405 NAC reconstructions from 2014 to 2022. All procedures were undertaken as day cases, and 20% (n = 81) were bilateral. Photographs can be viewed in Figure 2, and final results shown after flap and tattoo.

Figure 2.

Two patients undergoing deep inferior epigastric perforator (DIEP) reconstruction with nipple areola complex (NAC) reconstruction. Above is a patient with skin-sparing mastectomy and immediate DIEP reconstruction. This was followed by symmetrization and NAC reconstruction. Below, a patient who underwent complete mastectomy and delayed reconstruction using a DIEP flap and subsequent symmetrization and NAC reconstruction.

Fifty-seven percent (n = 229) of cases were performed under general anesthetic, including all bilateral cases. Thirty-six percent (n = 145) of patients underwent unilateral reconstruction under general anesthetic, and this most often occurred because they were having additional procedures, such as lipomodeling or symmetrization. However, a cohort of patients elected to have general anesthetic by choice. Partial flap necrosis occurred in 0.2% (n = 1), and this was managed conservatively with dressings. We report zero incidence of donor site complications, and no patients went on to undergo revision surgery. Overall, on return to clinic patients reported positive esthetic outcomes in terms of NAC appearance, and all were pleased by the correction of dog-ear deformity when they had existed on the abdomen. In the longer term, no patient represented with loss of projection. Although the skin graft epidermis usually appears different in coloring from the rest of the breast tissue, tattooing was offered to all patients.

Systematic Review

NAC reconstruction was initially trialed in 1940, when Adams utilized a skin graft harvested from the labia minora.⁶ Subsequently, Millard suggested the “nipple-sharing” technique, which involved harvest of a skin graft from the contralateral areola.⁷ Recently, several techniques have been proposed, each with unique advantages and limitations.

Nowadays, NAC reconstruction is a technique involving local flaps and a combination of skin graft and tattoo for the areola.⁸ In terms of nipple creation, the literature outlines various local random pattern and composition flaps (epidermis and dermis with variable amounts of subcutaneous tissue). Each relies upon the vascular infrastructure of the subdermal plexus.⁹ The majority of the literature focuses on nipple configuration, as this is often the more challenging procedure for patients and surgeons. In contrast, areolar reconstruction has not been examined to the same extent, especially as tattooing has yielded strong results.¹⁰

Methods

In adherence with PRISMA guidance we carried out a systematic review. Two authors independently searched databases: Ovid & ScienceDirect. All duplicates were removed. Titles were screened independently, and papers were omitted according to our exclusion criteria. The next step was to review abstracts and further exclude inappropriate texts. Finally, all papers were screened by both reviewers and those which met our criteria were accepted. Disagreements were discussed with the senior author and included or excluded on a case-by-case basis.

We used the search terms reconstruction; breast; nipple; areola; graft; and NAC.

Inclusion criteria included English language; female; adult, all levels of evidence; NAC reconstruction of the breast with FTSG; graft donor site reported in text and case series.

Results

The initial data search revealed 459 papers. Please see Figure 3 for summation.

Figure 3.

This is a flow diagram demonstrating results from systematic review carried out as per PRISMA guidance. 459 papers were initially uncovered, and 49 duplicates were removed. 410 documents were screened for title and then abstract with 93 progressing to full text screening. 57 were deemed inappropriate for inclusion according to pre-set principles leaving 36 published studies for entry to our systematic review.

Thirty-six papers published between 1976 and 2019 are included in this review (Table). The total number of patients discussed within the literature numbers 1564.

Table.

Systematic Review Results Carried Out According to PRISA Guidelines

	Author	Year	Donor site	No. of Patients	Complications
1	Wiemer	1976	Labia minora/majora	4	Superficial epithelial loss of nipple button
2	Marshall	1977	Outer aspect of upper arm	6	Not recorded
3	Gruber	1977	Upper inner thigh	16	Hypopigmentation
4	Eder	1980	Contralateral areola; perineum	74	Not recorded
5	Serafin	1982	Medial thigh	30	Only nipple complication
6	Barton	1982	Inner thigh	25	1 total, 4 partial necrosis
7	Little	1983	Contralateral areola;inner thigh; retroauricular	62	Not recorded
8	Chang	1984	Inner thigh	13	1 partial loss of graft
9	Hartrampf	1984	Infragluteal fold;contralateral breast	31	1 avulsed skin graft
10	Kon	1984	Groin;upper inner thigh	12	Not recorded
11	Bosch	1984	Upper inner thigh;contralateral areola	9	Poor color matching
12	Cohen	1986	Groin	20	27% donor site irritation;5% (n = 1) infection;hyperpigmentation
13	Mukheriee	1987	Upper inner thigh; groin	51	Not recorded
14	Cronin	1988	Upper inner thigh	31	Not recorded
15	Amarante	1994	Inner thigh; labia minora; inner gluteal crease	6	Not recorded
16	Mandrekas	1997	Upper inner thigh	54	Not recorded
17	Tanabe	1997	Upper inner thigh	14	2 partial necrosis
18	Lossing	1998	Upper inner thigh	25	1 total, 4 partial loss
19	Liew	2001	Groin	278	5% epidermolysis
20	Skillman	2002	Neo-areola	2	Fading color
21	Yuksel	2003	Inner thigh; tram scar	12	None reported
22	Rubino	2003	Upper inner thigh	27	None reported
23	Panettieri	2005	Groin	70	None reported
24	Schoeller	2006	Breast skin	9	1 partial failure
25	Hamilton	2006	Groin crease	13	2 partial necrosis; 2 depigmentation
26	Costa	2009	Ipsilateral skin	122	None reported – better result than thigh graft
27	Costa	2009	Inner thigh	100	None reported
28	Zhong	2009	n/a	n/a	3.1%: donor site dehiscence 1.4%: infection 0.3%: epithelial inclusion cyst 2.1%: partial skin graft take 2.4%: other complication
29	Wirth	2010	Breast skin	88	69% partial or total failure of graft
30	Lee	2015	Ipsilateral or contralateral	23	None reported
31	Nagura Inomata	2016	Contralateral areola	58	Asymmetry in diameter
32	Juhn	2016	Ipsilateral areola	43	3 minor complications (haematoma, partial loss)
33	Satake	2017	Upper inner thigh	156	2 partial graft failure
34	Nedomanski	2017	Groin;contralateral areola	17	1 epidermolysis
35	Heo	2018	Upper inner thigh	23	None reported
36	Vozza	2019	Groin	40	10 % (1 hematoma, 1 dehiscence, 1 delayed healing)

In detail, 24 authors elected to harvest skin grafts from the upper inner thigh or groin and reported a low rate of hypopigmentation or poor color matching. Two patients were reported to have total necrosis, and 9 partial necrosis. Nine also reported rates of donor site dehiscence or irritation and donor site infection. Nine authors preferred the contralateral or ipsilateral areolar tissue as skin graft donor site and reported only minor complications.

Other authors reported the use of upper arm skin, labia minora, labia majora, infragluteal crease, and only one mentioned using the scar created following transverse rectus abdominus muscle flap. Nine papers reported that no complications were encountered, and 5 did not mention complications rates in their results.

Discussion

NAC reconstruction is fundamental to achieve a complete breast and capture the appearance many women strive toward: symmetry, areolar pigmentation, and sustained projection.⁵ The procedure is usually comparatively minor compared with prior treatment; however, it greatly influences patient satisfaction and psychological wellbeing.³ Though many techniques have been proposed, the reality is that NAC reconstruction is known to have unpredictable outcomes.⁴

As described, our technique involves a modified C-V flap to create the nipple and a FTSG to recreate the areola. Combining the 2 techniques has yielded pleasing, durable results primarily because it addresses the issues highlighted in the literature. The principle disappointment is loss of nipple projection. Many studies indicate that this begins around 3 months after surgery and then settles to reflect the final result at 1 year. However, overall loss of projection is variable, with numbers quoted between 17% and 70%.^11,12 In order to avoid this problem, various techniques and materials have been suggested, such as insertion of autologous tissue (fat, dermis, cartilage, bone) or the insertion of allogenic materials (polytetrafluoroethylene implants, Alloderm, artificial bone, and semipermanent injectable fillers “calcium hydroxyapatite”). Alas, none have emerged as a clear choice, and it has been noted that a higher rate of complications is associated with allogenic materials.^13,14

We believe to have successfully addressed this issue in a few steps. First, the initial nipple reconstruction is designed between 10% and 25% bigger than the contralateral side, to account for graft shrinkage secondary to contraction. The deepithelialized portion of the FTSG is carefully placed underneath the new nipple, creating a supportive “shelf” on which the nipple sits and avoids regression. Furthermore, grafting permits de-epithelialization at the base of the C-V flap, avoiding the need for direct closure. This greatly reduces the tissue tension forces responsible for loss of projection. It also avoids flattening the curvature of the reconstructed breast at the maximum point of projection.

Our literature review demonstrates a paucity of studies regarding areolar reconstruction when compared with nipple reconstruction. From Adams’ attempt to establish hyperpigmentation by using labia minora grafts in 1940, to Millard who introduced nipple sharing, the evolution of nipple reconstruction techniques was not matched when it came to areolae as most elect for FTSG.^6,7 The only variation between the publications reviewed was the donor site of the skin graft, which can be divided into 3 main categories: graft from ipsilateral breast, contralateral NAC, or distant donor site.

Authors advocating the contralateral NAC as a donor site found that the color match and texture were good. However, they faced the problem that few women wanted to disturb the “healthy” side.^15,18 In terms of distant donor site, the most popular was the medial upper thigh, followed by the groin, labia, gluteal fold, post-auricular space, axilla, discarded breast tissue, and much less commonly (one paper only) the abdominal scar after autologous reconstruction. The most significant change was the innovative introduction of tattoo in 1986 by Becker, later popularized by Spear.^19,20 The most popular modern technique is tattoo, although some authors, us included, believe that a skin graft with or without tattoo results in a more durable, aesthetically pleasing outcome.^12,13,15

An added benefit when using our technique is that it maintains the circular appearance of the areola, which does not warp into an oval shape over time. This is a common phenomenon associated with immediate autologous reconstruction after skin-sparing mastectomy. When one directly closes the defect having created a C-V flap, the distortion of the round skin paddle is inevitable. Use of a skin graft negates such measures and ensures a nicely rounded, circular neo-areola.

The literature reported complications in terms of graft take of the neo-areola. Sometimes there can be issues with healing; however, in our experience this settles with dressings. In general, reconstruction with FTSG is a safe procedure though not free from problems; therefore, we encourage open discussion with patients during the consent process. Four papers reported complications of the donor site when located on the groin or upper inner thigh.^21,24 It came as a surprise that other authors elected not to use the abdominal scar as a donor site as it very rarely results in complications in our experience. The abdominal skin also tends to undergo hyperpigmentation, reducing the need for additional tattoo in patients with a light contralateral NAC complexion. When additional tattooing is required, graft texture minimizes the “painting on canvas” effect of the tattoo-only secondary to a lack of palpable features.^22,25

Finally, the literature suggested that color fading and unexpected pigmentation were more commonly encountered in grafts taken from the thighs and the contralateral breast.^21,26,27

Limitations: Level 4 Evidence, no control group, no formal patient reported outcomes.

Conclusions

We present a combined technique for NAC reconstruction, involving modified C-V flap and a FTSG taken from the abdomen to reconstruct the areola. We have incorporated the concept of a dermal flap to improve nipple projection and multiple quilting sutures to recreate the irregular texture (tubercles) of a healthy breast. It is our practice to always counsel the patient regarding the use of tattoo alone, led by Breast Care Nurses, or in conjunction with formal NAC reconstruction. We understand that some authors feel it is unnecessary to perform a skin graft when recreating the areola. In our experience this technique offers a consistent and more natural outcome and addresses the limitations and complications commonly encountered. The donor site morbidity on the abdominal scar and the complications in our study were negligible, and patients with abdominal dog ears from previous surgery were delighted by the correction. We obtained strong results in terms of esthetics, low rate of complications, and patient satisfaction. Therefore, we advocate this procedure as part of our standard breast reconstruction pathway.