Nipple-areola reconstruction technique depends on patient's needs

Toronto — Techniques for nipple-areola reconstruction vary depending on the needs of the patient, says a presenter here.

Speaking at the Toronto breast surgery symposium here in March, Dr. Kyle Wanzel, a plastic surgeon with the University of Toronto's department of plastic surgery and a practitioner at St. Joseph's Health Center, said there are several different ways to reconstruct both the nipple and the surrounding areola complex. All of these techniques should be explained when meeting with the patient, and it is also helpful to show photographs to illustrate outcomes with the different procedures, he says.

Nipple-areola reconstruction is typically done on an outpatient basis.

Indeed, research has found that patient satisfaction is very high with breast mound reconstruction. One study published in 2002 in Plastic Reconstructive Surgery found that 81 percent of subjects reported their breast mound reconstruction to be excellent.

Multiple studies have also found that nipple and areola reconstruction, the final stage in breast reconstruction, adds to patient satisfaction and an overall sense of well-being and femininity.

Several factors

Factors that a surgeon needs to consider when choosing a particular technique for nipple and areola reconstruction include projection of the nipple, color and texture match, shape, size and position on the reconstructed breast mound, Dr. Wanzel notes. Given the variability of dimension, texture and color of nipple-areola anatomy, nipple-areola reconstruction can present a surgical challenge.

"For example, to reconstruct the nipple, you can use a (local tissue) flap or a (skin) graft from a distant location chosen to best match the nipple color and/or texture," Dr. Wanzel says. "If you are doing a bilateral reconstruction, using local tissue flaps on each side works well since both nipples will look similar. However, in circumstances where there is a normal breast on one side, and you are reconstructing the nipple on the other side to match, sharing part of the remaining normal nipple may work out well because you are using like tissue."

When part of the remaining nipple is used to reconstruct a new nipple, the existing nipple is repaired by direct suture closure.

A theoretical concern in using tissue from the other nipple is the transfer of cells with carcinogenic potential from one breast to another, Dr. Wanzel says. "This is a theoretical risk and doesn't hinder most clinicians in their selection of the technique," he says.

With respect to a nipple share technique, the size of the remaining nipple and the patient's acceptance of a surgical procedure are often more important considerations.

Various flaps described over the years include the Skate flap, C-V flap, the Bell Flap, fishtail flap, Omega flap, the double opposing tab flap, Star Flap, top-hat flap, twin flap, propeller flap, S flap and a rolled derma-fat flap.

Skin graft sources

The skin grafts used to mimic the normal nipple can also come from multiple sources, such as the opposite nipple, the labia majora and minora, thigh or groin skin, skin from a breast reduction or lift on the normal side, the ear lobe or toe pulp.

Of note, flaps are moved with the blood supply intact, while grafts are removed from their own blood supply and depend on the growth of a new blood supply at the new site.

One of the advantages of using the local tissue flap procedure to reconstruct the nipple is avoiding donor site morbidity that can arise with the graft technique, Dr. Wanzel says. Scarring that can occur using the local tissue flap procedure is not extensive and remains in the area around the nipple, and can then easily be covered by either a skin graft or tattoo to reconstruct the areola complex. Tattooing is a technique used to ensure adequate color match. It can be performed easily, often under local or no anesthesia, but the effect is not necessarily long-lasting, as the color tends to fade with time.