Continuing Education Activity

Breast cancer is the most common cancer diagnosis in women, with surgical treatment being one tenet of its care. Following breast cancer resection, breast reconstruction is commonly performed to restore the breast to its native appearance. In cases of non–nipple-sparing mastectomy, malignant involvement of the nipple-areolar complex (NAC), or NAC complications following prior reconstruction, the NAC is absent on the reconstructed breast. If the patient desires, NAC reconstruction may be undertaken using various techniques 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 interprofessional team in caring for patients who undergo NAC reconstruction.

Objectives:

• Identify the anatomical structures pertinent to nipple-areolar complex reconstruction.
• Select the appropriate timing of nipple-areolar complex reconstruction concerning adjuvant breast cancer therapies.
• Differentiate among techniques frequently utilized for nipple-areolar complex reconstruction.
• Develop and employ interprofessional team strategies to improve outcomes for patients undergoing nipple-areolar complex reconstruction.

Introduction

Breast cancer is the most common cancer diagnosis in women, with an annual incidence of approximately 1 in 10.[1] Breast cancer treatment frequently involves surgical oncologic resection and reconstruction if breast reconstruction is desired. Reconstructive breast surgery is frequently staged to recreate a naturally-appearing breast and correct asymmetries. Non–nipple-sparing mastectomy, malignant involvement of the nipple-areolar complex (NAC), and NAC complications following prior reconstruction may absent the NAC from the reconstructed breast. If NAC reconstruction is desired by the patient, this procedure is usually the final stage of breast reconstruction.[2][3] 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.

NAC reconstruction can be accomplished via various methods.[2][3] 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 accepting a reconstructed breast into a self-image. However, not all women desire NAC reconstruction.[3] The provider must discuss NAC reconstruction openly and not predicate the completion of breast reconstruction on the recreation of the NAC.  

This activity reviews the indications, contraindications, procedural techniques, and complications of NAC reconstruction following breast cancer surgery. Similar techniques may be utilized in the surgical treatment of athelia and burn-related disfiguration. The activity also outlines the role of the interprofessional team in caring for patients who elect to undergo NAC reconstruction following surgery for breast cancer.

Anatomy and Physiology

Several anatomic studies have demonstrated that the vascular supply of the NAC includes contributions from the subdermal plexus and deep breast parenchymal vessels, with large perforating vessels coursing along the horizontal septum of Würinger.[7][8] The NAC is consistently innervated by the anterior and lateral cutaneous branches of the third, fourth, and fifth intercostal nerves; the fourth lateral cutaneous nerve branch provides the most consistent innervation.[8]

The size, color, orientation, and shape of the native NAC varies between patients. While NAC reconstruction allows for the creation of a 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 sits at the point of maximum projection of the breast mound, vertically located in the middle of the breast mound but slightly lateral in the horizontal plane to create a 60:40 lateral-to-medial ratio.[9] The ideal natural proportion between the areola and the breast is 1:3.4, and the nipple to the areola is 1:3.[10] The reconstructed NAC should ideally lie in the same transverse plane as the contralateral nipple if one is present. 

Unfortunately, NAC reconstruction does not restore milk production, and the most commonly used reconstructive methods do not create a sensate NAC.

Indications

NAC reconstruction is driven by patient preference. Aside from the psychological benefits of NAC reconstruction, it is a purely aesthetic procedure.[4][5][6] NAC reconstruction should be offered to all breast reconstruction patients as the final step in breast reconstruction.

Correctly timing NAC reconstruction is imperative for optimizing outcomes. The type of reconstruction and the need for adjuvant treatment must be considered. NAC reconstruction should only be undertaken after achieving a stable breast mound, typically 3 months after autologous breast reconstruction or permanent implant placement in prosthetic-based reconstruction.[11] NAC reconstruction should be delayed until chemotherapy and radiation treatments are completed. Some surgeons advise against NAC reconstruction in the radiated breast and recommend NAC tattooing to improve cosmesis. Performing NAC reconstruction too early can lead to inappropriate NAC positioning, ruining an otherwise superb result.[12]

Contraindications

NAC reconstruction should only be performed secondary to patient desire and be delayed until breast reconstruction is complete and the breast has achieved a stable shape and volume.

Equipment

NAC reconstruction can be performed under intravenous sedation or local anesthesia. Autologous breast reconstruction skin flaps are often insensate, and breast envelopes following prosthetic reconstruction have varying degrees of sensation. A standard plastic surgery minor operations set is adequate unless cartilage composite grafts are taken. The sutures used to inset grafts or local flaps can be absorbable or nonabsorbable and should be of a small caliber, such as 4-0 or 5-0.

Personnel

The personnel required to perform NAC reconstruction include the following:

• Plastic surgeon
• Surgical first assistant
• Surgical technician or operating room nurse
• Circulating or operating room nurse

An anesthetist or anesthesiologist is required if general anesthesia is utilized during the procedure.

Preparation

Informed consent should be obtained before the procedure and include a thorough discussion of the complications of NAC reconstruction, including partial or total nipple necrosis and loss of nipple projection. 

The essential aspects of presurgical preparation are eliciting patient preferences for NAC reconstruction and assessing the contralateral native NAC if present. While aesthetic ideals for NAC position are outlined in the literature, it is helpful to allow patients to mark their preferred position of the new NAC using an electrocardiogram lead pad while standing in front of a mirror. In unilateral NAC reconstruction, the contralateral NAC must be studied to guide the positioning, orientation, size, and shape of the new NAC. 

Technique or Treatment

Numerous surgical techniques for NAC reconstruction have been described.[13][14] Surgical NAC reconstruction techniques generally utilize local skin flaps, composite grafts, nipple sharing, or tattooing.

Local Flap Transfer

This technique transfers adjacent skin and subcutaneous fat to create a projected nipple. At least 30 distinct techniques are described in the literature.[13] Local flap transfer techniques are based on random pattern skin and subcutaneous tissue flaps with blood supply from the subdermal plexus or a subcutaneous pedicle. Commonly used local skin flaps include the skate flap, modified skate flap, star flap, fishtail flap, C-V Flap, S flap, Bell flap, arrow flap, and Hammond flap.[13][15][16][17] Unfortunately, all local skin flaps demonstrate some degree of loss of projection over time. The degree of loss of projection is estimated to be between 45% and 75%, with most of the projection loss occurring within the first 2 postoperative months.[13][18] For this reason, the reconstructed NAC is intentionally over-corrected, placing the immediate postoperative nipple at approximately twice the desired final height.[19] Attempts at improving projection with autografts, allografts, and synthetic materials have been attempted with varying success.[20][21][22][23][24][25]

Nipple Sharing

Nipple sharing is a technique that can be 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 a nipple-sharing technique.[26][27] The contralateral nipple may be removed transversely or longitudinally and grafted on the reconstructed NAC. Nipple sharing results in excellent color and texture match but does insult the contralateral nipple. The donor nipple may have altered sensation or pain and cause difficulty with breastfeeding.

Skin Grafts

Skin grafting can be used to reconstruct the areola or the NAC. Full-thickness skin grafts are harvested from other pigmented areas, such as the axilla or upper inner thigh. Dermabrasion is an alternative for creating hyperpigmented skin for the reconstructed NAC.[28]

Intradermal Tattooing

Intradermal tattooing is a commonly used alternative to skin grafts to reconstruct the areola or color the NAC after nipple reconstruction with a local flap. Intradermal tattooing is typically performed 3 to 4 months after NAC reconstruction when most nipple shrinkage has occurred.[29] Immediately after tattooing, the color should be darker than desired to compensate for fading. New 3-dimensional tattooing techniques can avoid the necessity of surgery. Traditionally, intradermal tattooing is employed if skin tissue available for surgical reconstruction is lacking, in the presence of scars, following radiotherapy, for reconstruction and pigmentation of the areola complex, or by patient choice. 

Internal or External Nipple Prosthetics 

Prosthetics offer patients another minimally invasive NAC reconstruction option. Off-the-shelf and custom external prosthetics exist. An impression of the contralateral NAC is taken to create a custom prosthetic, from which a prosthetist can create a mold and silicone prosthetic.[30][31][32][33] The silicone NAC prosthetics are lifelike and attached to the breast mound with silicone tape or other adhesives. These prosthetics should be removed at regular intervals to perform hygiene of the underlying skin. Internal prosthetics include silicone and polyurethane, in which gumdrop-appearing implants are placed underneath well-vascularized nipples or local flaps.[34] Internal prosthetics benefit from persistent projection but risk infection, extrusion, and capsule formation.[30]

Postoperatively, nipple-specific dressings and shields are placed to protect the reconstructed NAC and avoid compression, trauma, or infection, leading to loss of NAC projection. Various dressings and shields have been described in the literature, including nipple-specific plastic guards, donut-shaped sponges, occlusive dressings with antibiotics, silicone-based products, and modified ocular shields and protectors.[35][36][37][38][39]

Tissue Engineering and Regenerative Medicine

Nipple-areolar reconstruction utilizing 3D-printed tissue scaffolds is being investigated as a NAC reconstruction method.[40] While thus far only trialed in animal models, tissue-engineered construct (TEC) NAC reconstruction would offer the benefit of minimal donor site morbidity, prolonged projection, and well-vascularized tissue.[41][42] Conceptually, the TEC consists of a 3D-printed nipple scaffold of natural biomaterials seeded with multipotent stem cells, which eventually differentiate into adipocytes. The TEC is implanted subdermally in the desired NAC location with a purse-string suture for contour improvement. Current challenges in the TEC NAC arena include generating sufficient vascular networks to support the nipple scaffolding and assessing the oncologic safety of coadministering growth factors to facilitate the ingrowth of the TEC.[40]

Complications

The most common complication of NAC reconstruction utilizing local flaps is the loss of nipple projection. The vascular supply to the reconstructed NAC cannot always be reliably located near or within prior scars, resulting in an unpredictable outcome and an inability to employ particular flap techniques. There is always a risk of complete flap or graft failure. Finally, asymmetry and unacceptable cosmesis are universal risks in NAC reconstruction.

Clinical Significance

NAC reconstruction provides aesthetic and psychological benefits to patients undergoing breast reconstruction following breast cancer treatment, increasing acceptance of the reconstructed breast into their 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.