Introduction to Nipple and Areola Reconstruction
Although not every patient opts for this procedure, nipple and areola reconstruction is often the final step involved in reconstructing the appearance and feel of the post-mastectomy breast. The advantages are obvious: A breast which more closely matches the remaining natural breast (in the case of a uni-lateral mastectomy), and the ability to maintain a more natural appearance, even when going braless. However, some patients do choose to forego this procedure because of its disadvantages, not the least of which is the simple fact that it is one more surgical procedure that some patients view as prolonging the process of “getting on with their lives.” With this additional procedure come a few unfavorable realities:
- Depending on the methods used, the patient may need to once again undergo general anesthesia.
- There is additional recovery time following the new procedure.
- It results in additional scars (at the site of the new areola/nipple, and/or at the donor site if grafting is used.
Typically, nipple and areola reconstruction is performed at about 3 to 6 months after the primary reconstruction. This allows for optimal healing and the dissipation of post-op swelling. However, the timing can vary considerably based on surgeon and patient preference, as well as the specific techniques used in both procedures.
Graft and Flap Reconstruction Techniques
The graft technique involves harvesting skin from a donor site separate from the reconstructed breast. The skin graft is then attached to the site of the newly constructed nipple and/or areola. Common donor sites for areola grafts include the abdominal scar from a flap reconstruction, the inner thigh, or the buttock crease. For nipple grafts, the three most common donor sites are the patient’s remaining nipple, the earlobe, and the labia. In general, the patient's remaining nipple is the preferred donor site, since it provides the best match in terms of skin texture and color. However, in the case of a bilateral mastectomy (or particularly small nipples), the other donor sites can be quite useful.
In the flap approach to nipple reconstruction, the nipple mound is created from a “flap” of skin taken directly from the skin adjacent to the site of the newly reconstructed nipple. This technique has the advantage of keeping the blood supply intact, and of confining any scarring to the area of the new nipple and areola (as opposed to creating a new scar at the donor site, as with a graft procedure).
Reconstruction Via Micropigmentation (Tattooing)
The tattooing procedure, called micropigmentation, is usually performed as the final stage of a complete breast reconstruction, only after the nipple itself has been reconstructed. This procedure is performed with equipment that is very similar to what one might find in use at a tattoo shop. Its main advantage is that it is a relatively quick and simple outpatient procedure which requires no more than local anesthesia, and does not create an additional scar. In fact, micropigmentation can be used to camouflage the color and even soften the texture of existing scars left behind after the initial breast reconstruction procedure.
Primarily, this technique is used to simulate the color, shape and texture of the area surrounding the nipple (called the areola). However, for those patients who do not wish to undergo further surgery after their primary breast reconstruction, the appearance of the nipple itself may be re-created using only tattooing. The obvious disadvantage of this method is that it can only create the optical illusion of texture and dimension, offering no nipple projection. In some cases, your surgeon may recommend the use of such fillers as Radiesse or Alloderm in order to enhance nipple projection. In this case, it may also be helpful to look specifically for a surgeon or micropigmentation technician who specializes in creating the most realistic-looking and three dimensional appearance.
Your surgeon or technician will mix various pigments to come up with just the right color to complement your skin tones and/or to match your remaining nipple. Achieving the perfect shades may require more than one visit, and as with any tattoo, the pigment will fade in time, necessitating a return visit for a color touch-up.
Risks & Complications
First, there is the possibility that the graft or flap may not survive in its new location. If this happens, further surgery will be necessary. In addition, if general anesthesia is required, there are the usual risks that go along with it, together with the risks and possible complications inherent to most surgical procedures, which include: unfavorable scarring, excessive bleeding or hematoma, skin loss (tissue death), blood clots, fat clots, skin discoloration or irregular pigmentation, anesthesia risks, persistent edema (swelling), asymmetry, changes in skin sensation, persistent pain, damage to deeper structures such as nerves, blood vessels, muscles, lungs, and abdominal organs, deep vein thrombosis, cardiac and pulmonary complications, unsatisfactory aesthetic results, and the need for additional surgery.
After surgery, call your surgeon immediately if any of the following occur: chest pain, shortness of breath, unusual heartbeats, excessive bleeding.
In most cases, reconstruction of the nipple and areola are considered to be the final step in post-mastectomy breast reconstruction. Therefore, by law, the costs would be covered by the patient’s insurance. However, you should always check with your insurance provider regarding the particulars of your coverage before scheduling any surgery.