Nipple and Areola Reconstruction After Breast Cancer

San Francisco Plastic Surgeon Dr. Karen Horton specializes in natural-looking breast reconstruction for patients who have undergone mastectomy surgery. Nipple reconstruction is typically performed several months after the initial breast reconstruction surgery. This procedure can restore the appearance of the nipple and areola, a final step that many women feel completes their reconstruction experience.

For women who do not have nipple-sparing mastectomy, reconstruction of the breast involves not only reconstruction of the breast mound, but recreation of the nipple and areolar complex (NAC). NAC reconstruction is done three to six months after breast reconstruction to allow for swelling to resolve and for the reconstruction to “settle” and assume its final contour before the nipple and areola are recreated.

NAC reconstruction is covered by insurance and is always recommended to our patients! The method we recommend for nipple reconstruction creates a soft, natural appearing nipple. The reconstructed nipple will not have erogenous sensation, nor will it become erect with cold or touch, but its creation completes the reconstruction and is always worth it!

Nipple and areolar reconstruction is truly the “icing on the cake” that acts as the finishing touch and makes the reconstruction appear truly natural when nude, beneath swim suits or in light clothing when the nipples are noticed.

How is the Nipple Reconstructed?

The nipple is reconstructed by using either a “local flap” or a “nipple-sharing” procedure.

Local Flap Reconstruction

For “local flaps”, small wings of skin and subcutaneous fat (from the breast skin or from a flap) are elevated and rotated to create a nipple prominence. See the accompanying images detailing step-by-step a local flap nipple reconstruction with areolar tattoo:

Step 1: Local flaps are drawn with the position of the new nipple at the center of a “modified star flap”.

Step 2: The nipple local flaps are pigmented with medical tattoo by your surgeon during the nipple reconstruction procedure.

Step 3: The wings of the local flap are then elevated into the fat beneath the skin – here, they are being held up by forceps for the photo. The donor sites of the local flaps have been closed with dissolving sutures.

Step 4: The wings of the nipple flap are rotated into place with the right and left wings making up the base, and the top wing creating the cap of the new nipple, which is being held up with a forceps.

Step 5: All wings of the local flap have been rearranged in place to reconstruct a nipple prominence using dissolving sutures.

Step 6: An areolar circle has been tattooed using the same medical pigment to match the other breast. Occasionally, a different color will be used for the nipple and the areola circle, based on the other breast or a woman’s natural coloring.

Please also see additional before and after photos of nipple and areola reconstruction in our Before and After Photo Gallery.

“Nipple Sharing” Procedure

Alternatively, a small piece from one nipple (the non-cancer side) can be transplanted as a “free nipple graft” to reconstruct the nipple on the reconstructed breast. Known as “nipple sharing”, this procedure produces the most natural appearing nipple. The “donor nipple” becomes slightly smaller (up to half size) afterward. Sensation and function should remain intact for the donor nipple, and a very small scar is created on its undersurface. See images of reconstructed nipples using both nipple sharing and free grafts in our Before and After Photo Gallery.

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How Is the Areola Reconstructed?

For the areola, a medical tattoo is used to create an areolar circle. Special reconstructive tattoo pigments correspond to the variety of shades women have naturally. The color will be carefully matched to your other nipple and areola. For delayed reconstructions, photos taken of your breasts before your mastectomy can also be used as a guide for the most accurate pigmentation.

Areola tattoo can be performed as an outpatient procedure under local anesthesia in the office, and is often done together with nipple reconstruction as a single procedure. Feel free to participate in selection of your tattoo color; we have color charts available in the office for reference.

An areola tattoo usually takes 30 minutes or less. The tattoo to the areola may fade with time (over 5-10 years). If the pigment fades significantly, it can always be touched up if needed by your surgeon in the office at your convenience.

For more information, please read our blog Nipples & Plastic Surgery – What is normal, what can be changed?

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