Reconstruction of the nipple-areola complex
Nipple-areola reconstruction is a component of breast reconstruction which is always to be considered a prime objective. Omitting this final step in reconstruction from an otherwise acceptable breast reconstruction does not lead to good aesthetic results because the symmetry – which is the primary aim of breast reconstruction – cannot be achieved in this case.
Nipple-areola reconstruction has to be explained to the patient as an integral component of the reconstruction concept. Volume reconstruction should be regarded as the first step and revision of the breast as well as adaptation of the opposite side and nipple reconstruction are to be seen as the secondary stage. The recreation of the areola is then the final stage in the total reconstruction process. If the patient views breast reconstruction as a whole process, she will better tolerate an initial asymmetry, accept necessary small revisions and is then prepared for the final stage, the nipple-areola reconstruction.
The nipple-areola complex is the aesthetic focus of the breast. Ideally the nipple is located on the site of the greatest projection of the breast mound. The areola, in the middle of which the nipple sits, normally projects slightly from the mound of the breast and in most women this areola forms a small pyramid with a raised area in comparison with the breast mound below.
In a breast reconstruction it is very difficult to achieve this pyramid-shaped nipple-areola complex. The reconstructed breast has a more rounded shape.
The right timing for the reconstruction of the nipple-areola complex remains controversial. Preferred times range from immediate reconstruction to reconstruction after 6-12 months. We ourselves carry out reconstruction about 6 months after breast reconstruction, as in our experience the shape, consistency and height of the breast does not change any more after this time and thus a permanently symmetrical result compared with the contralateral side can be attained.
Correctly positioning the nipple on the reconstructed breast is essential for the final aesthetic result. An inadequate or badly positioned nipple can completely disturb an otherwise good breast reconstruction outcome and lead to the patient being dissatisfied with the over all result. Determining the new nipple position should be carried out unhurriedly and not in the operating theatre. It is important that the patient is involved in deciding the position and for this reason determining an accurate nipple position cannot be carried out under full anaesthetic or sedation.
The position of the new nipple is determined together on the patient when she is standing, preferably in front of a mirror. Due to the unavoidable differences in shape and contour between the healthy and the reconstructed breast, the geometrically measured location of the nipple is not necessarily the best position optically. Therefore measured localisation is only one criterion and should not lead to any alteration in the aesthetically correct position.
Once the position of the nipple has been decided on the patient standing upright, it should be marked and not be changed in the operating theatre. When a patient is in a supine position the normal position of the nipple changes disproportionally to the reconstructed side due to the differences in shape, consistency and plasticity.
Innumerable techniques are described for nipple reconstruction. However, only a few have become established and well-proven as routine procedures.
Partial transplantation of the contralateral nipple
Amongst free transplant techniques “nipple sharing” has significant advantages. With “nipple sharing” the texture and colour of the nipple are retained and this technique also guarantees a high rate of initial adhesion of the graft as well as a permanent projection. Nevertheless this type of nipple reconstruction is often rejected by patients as they fear the loss of sensitivity in the healthy nipple as well as the scarring and the loss of projection.
Other free transplants have not become accepted as they also have considerable donor site morbidity. For these reasons labia minora, toe tissue or ear lobes are no longer used.