“Lets Dot the i “
Congratulations for making it this far in your reconstructive process. Creating the nipple and areola is the final component of making your breast reconstruction complete.
Historically numerous methods of nipple reconstruction have been described, from the tip of a toe, earlobe, labia part of the vagina to any type of implantable material. Luckily for us nipple areola reconstruction over the centuries have progress to a far less dramatic procedure.
There if no one absolute best method of nipple areola reconstruction. Some patients are comfortable without a nipple and elect not to have a reconstruction. Still the reconstruction of the nipple and the areola helps to put the finishing touches on the new breast after a long journey of reconstruction.
The nipple reconstruction takes place about three to six months after the final breast reconstruction. The time delay allows for the effects of gravity, and improved symmetry between the breasts. The type of reconstruction depend on the quality of the surrounding skin, the surgeon and patient preference.
Modern tattoo techniques are such that a very good 3 dimensional reconstruction of the nipple and areola may be achieved with a tattoo. A nipple tattoo avoids the need for a surgical procedure and is done by a trained tattoo artist.
The surgical creation of a nipple areola reconstruction comprises two parts. Firstly nipple reconstruction and secondly areola reconstruction, multiple options exist for both.
You may reconstruct the nipple either by nipple sharing or by skin from the breast. Nipple sharing requires the presence of a normal nipple of adequate size and volume so as to be shared between two breasts. The reconstruction provides excellent symmetrical colour and texture match but unfortunately requires scarring and sensory loss of the normal nipple.
The second reconstructive option utilizes various combinations of local breast flaps to create a protrusion similar to a nipple. The local flaps provides a very good reconstruction. Unfortunately the newly reconstructed nipple may suffer some volume loss over time thus the initial nipple will be reconstructed slightly larger.
The areolar reconstruction involves the removal of skin from the lower tummy. A skin graft is taken from the lower tummy by a process similar to a “mini-tummy-tuck”. Once the skin graft is healed the patient may elect to have a tattoo done by our units tattoo artist. The tattoo provides excellent symmetrical colour match. Unfortunately the tattoo may fade over time requiring a repeat tattoo. Another option in creation of the areolar or brown area around the nipple is to tattoo a circle around the nipple a good option in patients that do not have a tummy scar.
All nipple reconstructions loose projection or flatten over time as part of the normal wound healing process. The risk of wound complications in nipple reconstruction is very low in patients with no history of prior radiation but is common in the radiated breast. Sometimes the use of fat graft or fillers may be used to reverse the failures.
Nipple reconstruction is a day procedure. The rate of recovery depends on what other revisions are done simultaneously and the healing of the donor site.
You will receive a general anaesthetic.
First the nipple will be reconstructed either as nipple sharing procedure or local skin flaps from the breast will be used.
If the areola is reconstructed at the same time, a full thickness graft will be taken from your lower tummy more or less in the position of a Caesar scar. A drain will be left in the tummy to drain any excess blood.
The areola will be dressed with a special foam dressing which need to be in place for 10 days to ensure take of the full thickness skin graft.
Any additional surgery such as small adjustments, fat filling or any final oncological management will be done at this time.
You would have to stay in hospital for 1 day after the surgery, some patients may be able to go home the same day. The foam dressing around the areola needs to be in place for 10 days and the drain will be removed once it drains less than 30 ml in two days. Antibiotics and pain tables will be given to take home. You will have to apply an antibiotic ointment to the nipple on a daily basis.
Nipple reconstructions take longer than expected to heal especially in cases where patients have received radiation. It can take as long as 3 weeks due to the decreased blood supply from the previous surgery.
In addition the new nipple will never look or feel like your old ones and the two, left and right will never be the same. The aim is to give you something that resembles a nipple which will complete the reconstruction. There are tremendous psychological advantages of completing the reconstruction to both you and your partner. Having said that, many patients elect not to have nipple reconstruction which, of course is completely acceptable.
Below follows a list of some of the more frequent complications associated with nipple areola reconstruction.
Local compilations i.e. around the breast……
Loss of the skin graft
Delayed wound healing
Blackening of nipples
Systemic complication…. your body
Fluid and electrolyte abnormalities
Deep vein thrombosis
Post operative lung complications
Long term and cosmetic complications… the way it looks
Discrepancy in size and position of nipple
Asymmetries of the breast
Secondary procedures to improve the appearance e.g. Fat fills
Flatting of nipples
I hope I have explained the procedure in an understandable manner and have address some of your questions. Please feel free to ask any additional questions or concerns.