Nipple and Areola Reconstruction

Mastectomy, or surgical removal of the breast, is often an important part of treatment for breast cancer. There are multiple types of mastectomy surgery, and each leaves a different amount of muscle, skin, and fat for potential breast reconstruction. There are different techniques available to address your nipple and areola as well.

This article discusses nipple and areola construction including the pros and cons of the possible procedures, surgical timeline, reconstruction techniques, risks and complications, costs, post-op care, and recovery from the procedure.

Overview

The first choice with reconstruction begins with your choice of surgery. You have several choices—whether you have a ​lumpectomy or mastectomy, whether you have immediate or delayed reconstruction, or opt for no reconstruction at all (sometimes called "going flat").

Depending on the location of your cancer, you might be a candidate for a nipple-sparing mastectomy. This procedure is becoming more common and some research has shown that it tends to have a higher initial satisfaction rate, with women who have this approach reporting a better quality of life. Breast cancer surgeons and other researchers continue to study the outcomes of different procedures so future recommendations may change.

Not all surgeons perform or are comfortable with a nipple-sparing mastectomy, and you may need to consider a second opinion at a larger cancer center if this is something you wish to consider. If you do not have a nipple-sparing mastectomy, you may choose to have nipple and areola reconstruction as a later procedure if desired.

Pros and Cons

As with many of the choices you have made with your breast cancer, there are several pros and cons to consider in choosing to have nipple and areola reconstruction. There is not a right and wrong decision to be made, only the decision that is right for you personally. Your healthcare team should have information about your specific situation and the options available to you.

The Pros

The advantages of nipple and areola reconstruction are basically that the appearance of your breast is as close as possible to the appearance prior to your diagnosis of breast cancer.

The Cons

There are also disadvantages of undergoing nipple reconstruction. These may include

• Reconstruction is yet one more surgical procedure. This carries the risks of general anesthesia, additional recovery time, and potentially, additional scars (at the site of the new areola/nipple, and the donor site if grafting is used.)
• Nipple reconstruction may prolong the process of "getting on with your life."
• A "con" that is not often mentioned, but is not uncommon, is that some women find it more uncomfortable to go braless after a nipple and areola reconstruction than if they did not have the reconstruction. In a well-done breast reconstruction, many women enjoy not having to wear a bra, and nipple reconstruction may interfere with that freedom (or they may resort to using band-aids and tape to cover their new nipples.) Unlike "natural" nipples, reconstructed nipples have one position and do not retract. Some women are embarrassed by the persistent elevation of a reconstructed nipple.

Surgical Timeline

Typically, nipple and areola reconstruction is performed about three to six 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. 

Your healthcare provider should discuss the expected timeline with you, and be sure to ask any questions you have about how to know the time is right to take the next step.

Reconstruction Techniques

There are several different ways for a provider to reconstruct a nipple and/or areola.

Many times, a skin graft or a flap is used to surgically create a mound of tissue to become a nipple. This is followed by "tattooing" when the reconstructed nipple has healed. The tattoo can add color and shading to resemble the original nipple.

Sometimes, tattooing alone is used to create the appearance of a nipple. This can be done to avoid further surgery.

Skin Graft Reconstruction

The graft technique for nipple and areola reconstruction 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 other body areas. For nipple grafts, the patient's remaining nipple is the preferred donor site, since it provides the best skin texture and color match. However, the other donor sites can be quite useful in the case of a bilateral mastectomy (or particularly small nipples).

Skin Flap Reconstruction

In the flap technique for 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. It also confines 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). The flap procedure is somewhat more reliable than the grafting procedure.

Medical Tattooing

The tattooing procedure, called micropigmentation, is usually performed as the final stage of complete breast reconstruction. If surgical reconstruction is selected, that must heal before the tattoo can be done.

This procedure is performed with equipment similar to that used in a tattoo shop. Its main advantage is that it is a relatively quick and simple outpatient procedure that requires no more than local anesthesia, and does not create an additional scar. In fact, micropigmentation can camouflage the color and even soften the texture of scars left behind after the initial breast reconstruction procedure.

Primarily, this technique simulates the color, shape, and texture of the area surrounding the nipple (called the areola).

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. Still, a 2016 study found that loss of projection of the nipple did not decrease satisfaction among women who had this technique. This is also the safest technique.

In some cases, your surgeon may recommend using such fillers as Radiesse or Alloderm 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 tattoo technician will mix various pigments to come up with 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. You may need to consider a return visit for a color touch-up.

Risks and Complications

Your healthcare provider will review the risks for any procedures you are considering. Surgery always has some risk. Some general risks related to nipple and areola reconstruction include:

• Graft failure (the new tissue dies)
• General anesthesia risks
• Scarring
• Bleeding
• Hematoma
• Blood clots
• Swelling and bruising
• Infection
• Numbness or changes in sensation
• Damage to nearby structures such as nerves, blood vessels, muscles, and more
• Unsatisfactory results
• The need for additional surgery
• Death

For those who have radiation therapy before reconstruction, the risk of side effects (nipple necrosis) is higher, and it's important to talk to your healthcare provider carefully if you are considering or have had radiation therapy.

Cost

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 a woman's health insurance.

However, you should always check with your insurance provider regarding the particulars of your coverage before scheduling any surgery. Some insurance plans dictate where you can go for surgery as well as specific types of procedures that are covered.

Post-Op Care

Following the procedure, a non-adherent gauze dressing and a generous amount of ointment will be placed onto your breast and held in place by surgical tape. The dressing will need to be changed every few hours for the first few days. Be sure to follow your provider's instructions for your situation.

If you have been tattooed as a part of your reconstruction, your tattoo will probably ooze a mixture of ink and blood. It is important not to let the tattoo get dry, or to allow excessive friction between clothing and the tattoo during this time.

Because of the blood, the tattoo’s color will appear much darker at first than it will be once it has healed. During the healing period, scabs will form and fall off, revealing the true color of the tattoo. Do not pick at the scab or try to remove it. If removed too early, the scab will take much of the tattooed pigment.

Recovery

Reconstruction of the nipple and areola is usually an outpatient procedure requiring less than an hour to complete. Most patients will have some mild pain or discomfort, which may be treated with mild pain-killer medications, and can return to their normal activities within a few days.

It is important to take care not to subject the procedure sites to excessive force, abrasion, or motion during the healing period. Any severe pain should be reported to your healthcare provider.

Scarring and Sensation

If your reconstruction is accomplished by tattooing alone, no new scarring is created.

If you have a flap reconstruction, the small scars are usually within the region of the nipple and are mostly hidden by the areola reconstruction.

If a grafting technique is used, a new scar will show up around the perimeter of the new areola. An additional scar is also created at the donor site.

Regardless of the method used for reconstruction, it is important to be prepared because the new nipple area will not have the same sensation as the nipple of the remaining breast (or the previous natural breasts).

Summary

Nipple and areola reconstruction can be part of breast reconstruction after cancer treatment. Depending on your breast shape and size, cancer treatment, and preferences, there may be several ways to create a nipple and areola for your reconstructed breasts. There are different levels of surgical procedures that can be used. Your healthcare team will discuss your options and the risks and benefits of any procedures you are considering.

A Word from Verywell

The choice of whether to have nipple reconstruction or not is completely up to you and there is not a right or wrong way. If you feel that you are simply done with surgery, or don't want to be bothered by further treatments (or nipples that don't retract) don't feel like you have to follow through on these "last steps" of reconstruction. And if you really want to have reconstruction and friends or family are second-guessing you, go ahead and do what works best for you alone.

As you think of your journey with breast cancer thus far, you may feel a bit overwhelmed and tired. It may be some minor consolation to realize that cancer changes people in good ways in well. Studies looking at "posttraumatic growth" in people with cancer have found that cancer survivors not only have a greater appreciation of life but tend to be more compassionate towards others.