Creating the nipple and the areola complex (NAC) is the final stage of a breast reconstruction and is analogous to the epilogue of a story. Some patients are comfortable without having a nipple and do not wish to have further surgery, however the creation of the NAC is usually associated with a sense of “wholeness” and often improves the overall reconstructive result due to the Gestalt impression. Reconstruction of the structure is best considered it in 2 parts: The nipple itself and the surrounding coloured areola.
Nipple Reconstruction
There are numerous options which are available to patients. The simplest option is a non-surgical which involves a simple tattoo to simulate the nipple and the areola. There is no 3 dimensionality to this and it is just a picture of a nipple tattooed on the breast mound.
If available and applicable, a nipple sharing procedure is an occasionally used option. It involved excising a piece of the nipple from the opposite breast and transferring it as a composite graft. Other seldom used options include the use of earlobe, toe pulp and labia to create a 3 dimensional “bump” to simulate the nipple.
Most modern approaches to nipple reconstruction use the existing skin of the breast mound as small local flaps to create the “bump”. More than 90 different options have been described, but these fall into 2 broad groups : the central core techniques and the dermal flap techniques. The Skate flap, the C-V flap and the Star flap are examples of dermal flap techniques, and the Hallock H-flap and the Maltese cross are examples of central core techniques. My personal favourite technique is the C-V flap which is documented below. In general, this is placed in the existing mastectomy if applicable to limit additional scars, although technically, any piece of breast skin can be used and the reconstructed nipple can be placed anywhere on the mound.
All nipple reconstructions lose some projection over time as part of the normal wound healing process. Sometimes, the use of dermis or fat grafts, and dermal fillers may be necessary to improve nipple projection
Areolar Reconstruction
The reconstruction of the areola is done to simulate the colour disc of skin around the nipple. 2 options are available: Skin graft and tattoo. A skin graft can be harvested from any site as a disc and transferred to the nipple site. The donor site is usually closed as a linear scar. Common sites for skin graft harvest include the lower abdomen, inner thigh, buttock crease and labia. In general, more realistic results are achieved in more darkly pigmented patients.
Modern tattoo techniques have evolved to a high level of artistic virtuosity and very realistic colour matches are the norm. The process is completed as an outpatient and is usually quick and relatively pain-free. As with any tattoo, the pigment will fade in time and a small re-touch procedure may be required. My opinion is that modern tattoo techniques have far surpassed any surgical result for reconstruction of the areola and they are the gold standard. See the photos below.