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Nipple-Areolar Complex Reconstruction

Editor: Andrea Sisti Updated: 7/19/2023 1:35:21 AM

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

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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. 

References


[1]

Sisti A, Huayllani MT, Boczar D, Restrepo DJ, Spaulding AC, Emmanuel G, Bagaria SP, McLaughlin SA, Parker AS, Forte AJ. Breast cancer in women: a descriptive analysis of the national cancer database. Acta bio-medica : Atenei Parmensis. 2020 May 11:91(2):332-341. doi: 10.23750/abm.v91i2.8399. Epub 2020 May 11     [PubMed PMID: 32420970]


[2]

Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: a systematic review and meta-analysis. Gland surgery. 2017 Feb:6(1):4-13. doi: 10.21037/gs.2016.08.01. Epub     [PubMed PMID: 28210547]

Level 1 (high-level) evidence

[3]

Weissler EH, Schnur JB, Lamelas AM, Cornejo M, Horesh E, Taub PJ. The Necessity of the Nipple: Redefining Completeness in Breast Reconstruction. Annals of plastic surgery. 2017 Jun:78(6):646-650. doi: 10.1097/SAP.0000000000000943. Epub     [PubMed PMID: 27845965]


[4]

Wilkins EG, Cederna PS, Lowery JC, Davis JA, Kim HM, Roth RS, Goldfarb S, Izenberg PH, Houin HP, Shaheen KW. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plastic and reconstructive surgery. 2000 Oct:106(5):1014-25; discussion 1026-7     [PubMed PMID: 11039373]


[5]

Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Annals of surgery. 2008 Jun:247(6):1019-28. doi: 10.1097/SLA.0b013e3181728a5c. Epub     [PubMed PMID: 18520230]


[6]

Wellisch DK, Schain WS, Noone RB, Little JW 3rd. The psychological contribution of nipple addition in breast reconstruction. Plastic and reconstructive surgery. 1987 Nov:80(5):699-704     [PubMed PMID: 3671562]


[7]

Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plastic and reconstructive surgery. 1998 May:101(6):1486-93     [PubMed PMID: 9583477]


[8]

Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: an anatomic study. Plastic and reconstructive surgery. 2000 Mar:105(3):905-9     [PubMed PMID: 10724249]


[9]

Lewin R, Amoroso M, Plate N, Trogen C, Selvaggi G. The Aesthetically Ideal Position of the Nipple-Areola Complex on the Breast. Aesthetic plastic surgery. 2016 Oct:40(5):724-32. doi: 10.1007/s00266-016-0684-z. Epub 2016 Aug 5     [PubMed PMID: 27495261]


[10]

Hauben DJ, Adler N, Silfen R, Regev D. Breast-areola-nipple proportion. Annals of plastic surgery. 2003 May:50(5):510-3     [PubMed PMID: 12792541]


[11]

Gougoutas AJ, Said HK, Um G, Chapin A, Mathes DW. Nipple-Areola Complex Reconstruction. Plastic and reconstructive surgery. 2018 Mar:141(3):404e-416e. doi: 10.1097/PRS.0000000000004166. Epub     [PubMed PMID: 29481412]


[12]

Weber WP, Shaw J, Pusic A, Wyld L, Morrow M, King T, Mátrai Z, Heil J, Fitzal F, Potter S, Rubio IT, Cardoso MJ, Gentilini OD, Galimberti V, Sacchini V, Rutgers EJT, Benson J, Allweis TM, Haug M, Paulinelli RR, Kovacs T, Harder Y, Gulluoglu BM, Gonzalez E, Faridi A, Elder E, Dubsky P, Blohmer JU, Bjelic-Radisic V, Barry M, Hay SD, Bowles K, French J, Reitsamer R, Koller R, Schrenk P, Kauer-Dorner D, Biazus J, Brenelli F, Letzkus J, Saccilotto R, Joukainen S, Kauhanen S, Karhunen-Enckell U, Hoffmann J, Kneser U, Kühn T, Kontos M, Tampaki EC, Carmon M, Hadar T, Catanuto G, Garcia-Etienne CA, Koppert L, Gouveia PF, Lagergren J, Svensjö T, Maggi N, Kappos EA, Schwab FD, Castrezana L, Steffens D, Krol J, Tausch C, Günthert A, Knauer M, Katapodi MC, Bucher S, Hauser N, Kurzeder C, Mucklow R, Tsoutsou PG, Sezer A, Çakmak GK, Karanlik H, Fairbrother P, Romics L, Montagna G, Urban C, Walker M, Formenti SC, Gruber G, Zimmermann F, Zwahlen DR, Kuemmel S, El-Tamer M, Vrancken Peeters MJ, Kaidar-Person O, Gnant M, Poortmans P, de Boniface J. Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy. Breast (Edinburgh, Scotland). 2022 Jun:63():123-139. doi: 10.1016/j.breast.2022.03.008. Epub 2022 Mar 18     [PubMed PMID: 35366506]


[13]

Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D'Aniello C, Nisi G. Nipple-areola complex reconstruction techniques: A literature review. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2016 Apr:42(4):441-65. doi: 10.1016/j.ejso.2016.01.003. Epub 2016 Jan 30     [PubMed PMID: 26868167]


[14]

Nimboriboonporn A, Chuthapisith S. Nipple-areola complex reconstruction. Gland surgery. 2014 Feb:3(1):35-42. doi: 10.3978/j.issn.2227-684X.2014.02.06. Epub     [PubMed PMID: 25083492]


[15]

Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the 'arrow flap'. British journal of plastic surgery. 2003 Apr:56(3):247-51     [PubMed PMID: 12859920]


[16]

Cuomo R, Sisti A, Grimaldi L, D'Aniello C. Modified Arrow Flap Technique for Nipple Reconstruction. The breast journal. 2016 Nov:22(6):710-711. doi: 10.1111/tbj.12659. Epub 2016 Aug 4     [PubMed PMID: 27488589]


[17]

Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New technique for nipple areola reconstruction: arrow flap and rib cartilage graft for long-lasting nipple projection. Annals of plastic surgery. 2003 Jan:50(1):31-7     [PubMed PMID: 12545106]


[18]

Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: a comparison of three techniques. Plastic and reconstructive surgery. 2002 Sep 1:110(3):780-6     [PubMed PMID: 12172139]

Level 2 (mid-level) evidence

[19]

Few JW, Marcus JR, Casas LA, Aitken ME, Redding J. Long-term predictable nipple projection following reconstruction. Plastic and reconstructive surgery. 1999 Oct:104(5):1321-4     [PubMed PMID: 10513912]


[20]

Winocour S, Saksena A, Oh C, Wu PS, Laungani A, Baltzer H, Saint-Cyr M. A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction. Plastic and reconstructive surgery. 2016 Jan:137(1):14e-23e. doi: 10.1097/PRS.0000000000001861. Epub     [PubMed PMID: 26710046]

Level 1 (high-level) evidence

[21]

Garramone CE, Lam B. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. Plastic and reconstructive surgery. 2007 May:119(6):1663-1668. doi: 10.1097/01.prs.0000258831.38615.80. Epub     [PubMed PMID: 17440338]


[22]

Bernard RW, Beran SJ. Autologous fat graft in nipple reconstruction. Plastic and reconstructive surgery. 2003 Sep 15:112(4):964-8     [PubMed PMID: 12973210]

Level 2 (mid-level) evidence

[23]

Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: an original easy technique. Aesthetic plastic surgery. 2005 Jul-Aug:29(4):287-94     [PubMed PMID: 16044237]

Level 2 (mid-level) evidence

[24]

Evans KK, Rasko Y, Lenert J, Olding M. The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction: early results. Annals of plastic surgery. 2005 Jul:55(1):25-9; discussion 29     [PubMed PMID: 15985787]

Level 3 (low-level) evidence

[25]

Oliver JD, Beal C, Hu MS, Sinno S, Hammoudeh ZS. Allogeneic and Alloplastic Augmentation Grafts in Nipple-Areola Complex Reconstruction: A Systematic Review and Pooled Outcomes Analysis of Complications and Aesthetic Outcomes. Aesthetic plastic surgery. 2020 Apr:44(2):308-314. doi: 10.1007/s00266-019-01539-7. Epub 2019 Nov 13     [PubMed PMID: 31722063]

Level 1 (high-level) evidence

[26]

Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. British journal of plastic surgery. 1997 Jul:50(5):331-4     [PubMed PMID: 9245866]


[27]

Sakai S, Taneda H. New nipple-sharing technique that preserves the anatomic structure of the donor nipple for breastfeeding. Aesthetic plastic surgery. 2012 Apr:36(2):308-12. doi: 10.1007/s00266-011-9792-y. Epub 2011 Aug 19     [PubMed PMID: 21853407]


[28]

Cohen IK. Reconstruction of the nipple-areola by dermabrasion in a black patient. Plastic and reconstructive surgery. 1981 Feb:67(2):238-9     [PubMed PMID: 7465677]


[29]

Spear SL, Arias J. Long-term experience with nipple-areola tattooing. Annals of plastic surgery. 1995 Sep:35(3):232-6     [PubMed PMID: 7503514]

Level 2 (mid-level) evidence

[30]

Sainsbury R, Walker VA, Smith PM. An improved nipple prosthesis. Annals of the Royal College of Surgeons of England. 1991 Mar:73(2):67-9     [PubMed PMID: 2018322]


[31]

Roberts AC, Coleman DJ, Sharpe DT. Custom-made nipple-areola prostheses in breast reconstruction. British journal of plastic surgery. 1988 Nov:41(6):586-7     [PubMed PMID: 3207959]


[32]

Clarkson DJ, Smith PM, Thorpe RJ, Daly JC. The use of custom-made external nipple-areolar prostheses following breast cancer reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2011 Apr:64(4):e103-5. doi: 10.1016/j.bjps.2010.12.016. Epub 2011 Jan 28     [PubMed PMID: 21277268]

Level 3 (low-level) evidence

[33]

Ullmann Y, Peled IJ, Laufer D, Blumenfeld I. Nipple-areola reconstruction with a custom-made silicone ectoprosthesis. Annals of plastic surgery. 1992 May:28(5):485-7     [PubMed PMID: 1622025]


[34]

Hallock GG. Polyurethane nipple prosthesis. Annals of plastic surgery. 1990 Jan:24(1):80-5     [PubMed PMID: 2301890]

Level 3 (low-level) evidence

[35]

Staruch RMT, Din AH, See MS, Mohanna PN. The Ideal Nipple Reconstruction Shield. Plastic and reconstructive surgery. 2019 Mar:143(3):698-699. doi: 10.1097/PRS.0000000000005318. Epub     [PubMed PMID: 30817641]


[36]

Rosing JH, Momeni A, Kamperman K, Kahn D, Gurtner G, Lee GK. Effectiveness of the Asteame Nipple Guardâ„¢ in maintaining projection following nipple reconstruction: a prospective randomised controlled trial. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2010 Oct:63(10):1592-6. doi: 10.1016/j.bjps.2009.10.006. Epub 2009 Nov 7     [PubMed PMID: 19897430]

Level 1 (high-level) evidence

[37]

Yamamoto Y, Furukawa H, Oyama A, Horiuchi K, Funayama E, Tsutsumida A, Sugihara T, Nohira K. Two innovations of the star-flap technique for nipple reconstruction. British journal of plastic surgery. 2001 Dec:54(8):723-6     [PubMed PMID: 11728120]

Level 3 (low-level) evidence

[38]

Spear SL, Beckenstein MS. The nipple guard: an alternative covering for nipple-areola reconstructions with or without skin grafts. Plastic and reconstructive surgery. 1997 Nov:100(6):1509-12     [PubMed PMID: 9385965]

Level 2 (mid-level) evidence

[39]

Salgarello M, Cervelli D, Barone-Adesi L. The use of a silicone nipple shield as protective device in nipple reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2008 Nov:61(11):1396-8. doi: 10.1016/j.bjps.2008.02.033. Epub 2008 Jul 24     [PubMed PMID: 18656435]

Level 3 (low-level) evidence

[40]

Khoo D, Ung O, Blomberger D, Hutmacher DW. Nipple Reconstruction: A Regenerative Medicine Approach Using 3D-Printed Tissue Scaffolds. Tissue engineering. Part B, Reviews. 2019 Apr:25(2):126-134. doi: 10.1089/ten.TEB.2018.0253. Epub     [PubMed PMID: 30379123]


[41]

Cao YL, Lach E, Kim TH, Rodríguez A, Arévalo CA, Vacanti CA. Tissue-engineered nipple reconstruction. Plastic and reconstructive surgery. 1998 Dec:102(7):2293-8     [PubMed PMID: 9858161]

Level 3 (low-level) evidence

[42]

Pashos NC, Scarritt ME, Eagle ZR, Gimble JM, Chaffin AE, Bunnell BA. Characterization of an Acellular Scaffold for a Tissue Engineering Approach to the Nipple-Areolar Complex Reconstruction. Cells, tissues, organs. 2017:203(3):183-193. doi: 10.1159/000455070. Epub 2017 Jan 27     [PubMed PMID: 28125805]