Continuing Education Activity

Breast cancer is the most common cancer diagnosis in women, with surgical treatment being a tenant of its care. Following breast cancer resection, breast reconstruction is commonly performed to restore the breast to its native appearance. In the case of non-nipple-sparing mastectomy, cancer involvement of the nipple-areolar complex (NAC), or NAC complications following prior reconstruction, the NAC is absent on the reconstructed breast. Nipple-areolar complex reconstruction is thus undertaken via several techniques and is typically performed as the last step in breast reconstruction. This activity reviews the evaluation and treatment of NAC absence with subsequent NAC reconstruction and highlights the role of the multiple techniques to achieve a natural-appearing NAC reconstruction.

Objectives:

• Identify the anatomical structures pertinent to nipple-areolar complex reconstruction.
• Describe the proper timing of nipple-areolar complex reconstruction concerning adjuvant breast cancer therapies.
• Summarize the equipment and techniques frequently utilized for nipple-areolar reconstruction.
• Outline the common complications following nipple-areolar reconstruction.

Introduction

Breast cancer is the most common cancer diagnosis in women, with an annual incidence of approximately 1 in 10 women.[1] Treatment of breast cancer frequently involves surgery, which entails both oncologic resection and reconstruction if desired. Reconstructive surgery of the breasts often entails more than one stage to best recreate a natural-appearing breast(s) and correct asymmetries. In some cases, such as non-nipple-sparing mastectomy, cancer involvement of the nipple-areolar complex (NAC), or NAC complications following prior reconstruction, the NAC is absent on the reconstructed breast. If desired by the patient, NAC reconstruction is usually the final stage of breast reconstruction and can be accomplished via multiple different methods.[2][3] Various studies have demonstrated a correlation between patient satisfaction with breast reconstruction and the presence of a nipple and areola, helping combat the psychological consequences of a breast cancer diagnosis.[4][5][6] Thus, NAC reconstruction plays an important role in the acceptance of a reconstructed breast into a patient's self-body image. While there are benefits of NAC reconstruction, not all women desire NAC reconstruction.[3] It is, therefore, important for the provider to discuss NAC reconstruction openly with the patient and not predicate the completion of breast reconstruction on the recreation of the NAC. 

In general, the ideal NAC reconstruction recreates both the nipple and areola and achieves symmetry in position, size, shape, texture, pigmentation, and projection to the contralateral NAC. 

For the purpose of this topic, only NAC reconstruction following breast cancer surgery will be discussed, not purely cosmetic NAC surgery. Similar techniques may be utilized in the treatment of congenital NAC abnormalities (athelia) and burn deformities. 

Anatomy and Physiology

The vascular supply of the NAC has been elucidated by several anatomic studies that have shown vascular contributions from the subdermal plexus as well as vessels from the breast parenchyma, with large perforating vessels running along Wuringer's septum.[7][8] The NAC is consistently innervated by the anterior and lateral cutaneous branches of intercostal nerves three through five, with the fourth lateral cutaneous nerve branch providing the most consistent innervation.[8]

Certainly, the native NAC size, color, orientation, and shape vary from patient to patient. While NAC reconstruction allows the surgeon to create an NAC that is in harmony with the patient's aesthetic preferences, certain ideals of the NAC position have been outlined in the literature. Classically, the ideal NAC is described as sitting at the point of maximum projection of the breast tissue. A recent study demonstrated the aesthetically ideal NAC position is located in the middle of the breast mound vertically and slightly laterally in the horizontal plane (60:40, lateral: medial ratio).[9] The natural proportion between the areola and the breast is 1 to 3.4, and the nipple to areola is 1 to 3.[10] The reconstructed NAC should lie in the same transverse plane as the contralateral nipple (if present). 

Unfortunately, NAC reconstruction does not restore the breast's ability to produce milk. Similarly, many of the NAC reconstruction methods do not provide a sensate NAC. 

Indications

NAC reconstruction is driven by patient preference. Aside from the previously mentioned psychological benefits of NAC reconstruction, the recreation of the nipple and areola are aesthetic procedures.[4][5][6] They should be offered to all breast reconstruction patients as the final step in breast reconstruction.

The correct timing of NAC reconstruction is imperative for the optimal outcome and depends on the type of reconstruction as well as the need for adjuvant treatment(s). NAC reconstruction should only be undertaken after achieving a stable breast mound, typically 3 months after autologous breast reconstruction or 3 months after permanent implant placement in prosthetic-based reconstruction.[11] For a similar reason, NAC reconstruction should be delayed until after chemotherapy and radiation treatments are completed. Performing NAC reconstruction too soon can lead to inappropriate NAC positioning and ruin an otherwise superb result. 

Contraindications

Once again, NAC reconstruction should only be performed if it is desired by the patient. Other contraindications include performing NAC reconstruction before the breast reconstruction is complete, with final shape and volume still fluctuating.

Equipment

NAC reconstruction can typically be performed under IV sedation or using local anesthetic as autologous breast reconstruction skin flaps are often insensate. Likewise, breast envelopes following prosthetic reconstruction have varying degrees of sensation. A standard plastic surgery minor operations set (unless taking cartilage as composite grafts) will work appropriately. Sutures used to sew on grafts, or local flaps can be dissolvable or non-dissolvable and small caliber (3-0, 4-0, 5-0 suture). 

Personnel

NAC reconstruction is the culmination of an interprofessional team approach to patient care and often the final step in breast reconstruction. Procedurally, a plastic surgeon and surgical scrub team are all that is needed. 

Preparation

The most important aspects of preparation are elicitation of patient preferences in NAC reconstruction and assessing the contralateral native NAC (if present). While there are aesthetic ideals for the NAC position in the literature, it is useful to allow the patient to mark the position of the new NAC using an electrocardiogram lead pad in front of a mirror. In unilateral reconstruction, it is important to study the NAC on the unoperated breast to guide the positioning, orientation, size, and shape of the new nipple. 

Informed consent should discuss complications of NAC reconstruction, which include partial or total nipple necrosis and loss of nipple projection. 

Technique

There have been numerous surgical techniques for NAC reconstruction that have been described over time.[12][13] In general, surgical techniques involve using local skin flaps, composite grafts, nipple sharing, tattooing, or a combination of these techniques. 

Local flaps transfer adjacent skin and subcutaneous fat to create a projected nipple. Multiple techniques exist, with at least 30 unique techniques in the literature.[12] These techniques share the common characteristics of being based on random pattern skin and subcutaneous tissue flaps with blood supply from the subdermal plexus and/or subcutaneous pedicle. Commonly used local flaps include the skate flap, modified skate flap, star flap, fishtail flap, C-V Flap, S flap, Bell flap, Arrow flap, and Hammond flap.[12][14][15][16] The following review article has direct links to the index papers.[12] Unfortunately, all local flaps demonstrate some degree of loss of projection over time. The degree of loss of projection is estimated to be between 45 to 75%, with a majority of projection loss occurring within the first 2 months postoperatively.[12][17] For this reason, there is an over-correction of the reconstructed NAC with the immediate postoperative nipple approximately twice the desired final height.[18] Attempts at improving projection with autografts, allografts, and synthetic materials have been attempted with varying success.[19][20][21][22][23][24]

Nipple sharing is a technique considered for patients with excessive contralateral nipple projection who are willing to sacrifice contralateral projection for ipsilateral reconstruction. About 50% of contralateral nipple height is lost in nipple sharing techniques.[25][26] The contralateral nipple may be removed transversely or longitudinally and then grafted on the reconstructed NAC. Nipple sharing results in excellent color and texture match but does create an insult to the contralateral nipple. The donor nipple may have altered sensation, pain, and difficulty with breastfeeding.

Skin grafts can be used to reconstruct the areola or the NAC. Full-thickness skin grafts are harvested from other pigmented areas such as the axillary area or upper inner thigh. Dermabrasion has been described as an alternative to create hyperpigmented skin for the reconstructed NAC.[27]

Intradermal tattooing is commonly used as an alternative to the skin graft for reconstruction of the areola or to color the NAC after nipple reconstruction with a local flap. It is typically performed 3 to 4 months after nipple reconstruction after most nipple shrinkage has occurred.[28] The color immediately after the tattoo should be darker than desired as the color fades within the first few weeks. Furthermore, new 3D tattooing techniques can avoid the necessity of surgery. Traditionally, this technique is used if a lack of skin tissue is available for surgical reconstruction, in the presence of scars, following radiotherapy, for reconstruction and pigmentation of the areola complex or patient choice. 

Internal and/or external nipple prosthetics offer patients another minimally invasive NAC reconstruction option. In the case of external prosthetics, off-the-shelf and custom options exist. For a custom prosthetic, an impression is made of the contralateral NAC, from which mold and silicone prosthetic are created by a prosthetist.[29][30][31][32] The silicone NAC prosthetics have a lifelike appearance and are attached to the breast mound with silicone tape or other adhesives. They should be removed at regular intervals for the hygiene of the underlying skin. Internal prosthetics include silicone and polyurethane, in which gumdrop appearing implants are placed underneath well-vascularized nipple or local flaps.[33] Internal prosthetics carry the benefit of persistent projection but risk infection, extrusion, and capsule formation.[29]

Postoperatively, nipple-specific dressings and/shields are placed to protect the reconstructed NAC and avoid compression, trauma, and/or infection, leading to loss of NAC projection. Multiple dressings and shields have been described in the literature, including nipple-specific plastic guards, donut-shaped sponges, occlusive dressings with anti-biotics, silicone-based products, and modified ocular shields and protectors.[34][35][36][37][38]

Tissue engineering and regenerative medicine (TE&RM) nipple-areolar reconstruction with 3D-printed tissue scaffolds is presently being investigated as an NAC reconstruction method of the future.[39] While thus far only trialed in animal models, tissue-engineered construct (TEC) NAC reconstruction offers the benefit of minimal donor site morbidity, prolonged projection, and well-vascularized tissue.[40][41] Conceptually, the TEC consists of a 3D-printed nipple scaffold of natural biomaterials that are seeded with multipotent stem cells, which eventually differentiate into adipocytes. The TEC is then implanted subdermally in the desired NAC location with the aid of a pursestring suture for contour improvement. Current challenges in the TEC nipple-areolar complex arena include generating sufficient vascular networks to support the nipple scaffolding and assessing the oncologic safety of co-administration of growth factors to facilitate ingrowth.[39]

Complications

As previously mentioned, the main complication with local flaps is the loss of nipple projection with an anticipated loss of 45% to 75% projection. Blood supply to the reconstructed NAC is not always reliable in being located near or on prior scars; thus, the outcome may be unpredictable, and certain flap designs cannot be applied. Thus, inherently there is a risk for the flap and/or graft partial or complete failure. Finally, asymmetry and unacceptable cosmetic appearance to the patient are always risks to discuss preoperatively. 

Clinical Significance

Nipple-areolar complex reconstruction provides aesthetic and psychological benefits to the patient and can help increase acceptance of the reconstructed breast into the patient's self-image.[4][5][6] 

Enhancing Healthcare Team Outcomes

Breast cancer management is best managed in an interprofessional setting that involves the patient, nurse specialists, oncologists, radiologists, and surgeons. The patient should pursue NAC reconstruction once a stable breast reconstruction has been reached and after adjuvant therapies have been completed. The interprofessional team for NAC will include a surgeon, OR nurses, and surgical assistants. The patient's family clinician should also be kept in the information loop for subsequent monitoring between post-surgical follow-ups. With this type of interprofessional coordination, patients will have a better chance at a positive outcome. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

The reconstructive procedures mentioned above are often performed on an outpatient basis. Patients should be seen in close follow-up, typically 7 to 10 days following surgery.