Overview of Nipple-Areolar Complex Reconstruction
Breast cancer is the most common cancer found in women. It affects approximately one in every ten women every year. Treatments for breast cancer can often include a surgical procedure to remove the cancer, as well as reconstructive surgery if the woman wishes to restore the natural shape of her breast. Such a surgery is often done in stages to create a breast that looks natural and adjusts any imbalances.
Among the elements of the breast that may need to be reconstructed is the nipple-areolar complex (NAC). This is the nipple and the surrounding colored area, which could be absent after the cancer surgery, especially if there were complications or if the cancer had spread to that area. NAC reconstruction, if the patient wants it, is typically the final part of breast reconstruction. The desired result is a nipple and areola that look alike and match the one on the other breast in position, size, shape, texture, color, and projection.
There are several methods to perform the NAC reconstruction. Research has shown that having a nipple and areola can increase satisfaction with breast reconstruction and can help with the emotional toll of a breast cancer diagnosis. In other words, reconstructing the NAC could help women accept their reconstructed breast and feel positive about their appearance. However, not every woman may want to go through NAC reconstruction. The healthcare provider needs to have an open discussion with the patient and make sure she understands that her breast reconstruction can be complete even without recreating the NAC.
This information is provided to offer guidance about the reasons, potential negative effects, techniques, and complications associated with NAC reconstruction after breast cancer surgery. Similar surgical procedures might be used to treat athelia (absence of the nipple) and distortions caused by burns. It also highlights the importance of a team of health professionals in caring for patients who elect to undergo NAC reconstruction after having surgery for breast cancer.
Anatomy and Physiology of Nipple-Areolar Complex Reconstruction
The blood supply to the nipple and areola complex (NAC), which includes the nipple and the pigmented skin surrounding it, comes from a group of vessels beneath the skin and from deep within the breast tissue. There are also major blood vessels that run along a certain horizontal line within the breast. The feeling in the NAC comes from several sets of nerves connected to the third, fourth, and fifth ribs, with a particular branch of the fourth set providing the most consistent nerve supply.
The appearance of the NAC, including its size, color, and shape, can differ quite a bit from person to person. When reconstructing the NAC – for instance, after breast surgery – doctors aim to make it align with the patient’s aesthetic preferences. However, some guidelines suggest that the ideal position for the NAC is in the middle and slightly to the side on the breast mound. This creates a certain proportion between the left and right sides of the breast. The perfect size ratios between the nipple, the areola, and the overall breast have also been proposed. If only one nipple is being reconstructed, it should ideally be at the same level as the existing one.
However, it’s important to note that reconstructing the NAC doesn’t restore its ability to produce milk. Also, most commonly used reconstructive methods do not bring back sensitivity in the NAC.
Why do People Need Nipple-Areolar Complex Reconstruction
NAC, or nipple-areola complex, reconstruction is a surgical procedure that recreates the nipple and the surrounding darkened area on the breast, known as the areola. This procedure is typically the final part of breast reconstruction/ It isn’t medically necessary, but it can help people feel better about their appearance and assist them in their psychological recovery.
It’s important to time the NAC reconstruction right in order to get the best results. Other factors that are taken into account when scheduling the surgery include what other reconstruction has been done and any necessary additional treatments. The best time for this procedure is usually at least 3 months after the final stage of breast reconstruction. If someone is having chemotherapy or radiation treatments, the NAC reconstruction would usually be delayed until these treatments are finished.
Some surgeons might advise against having NAC reconstruction on a breast that has been treated with radiation, suggesting instead a non-surgical option – tattooing, which can improve the appearance. Rushing into the NAC reconstruction can lead to the nipple and areola not being in the best position, which could compromise the overall appearance.
When a Person Should Avoid Nipple-Areolar Complex Reconstruction
The decision to proceed with NAC (nipple-areola complex) reconstruction should primarily be based on the patient’s wish. However, it is recommended to hold off on this procedure until after the completion of breast reconstruction. The reason for this is that the structure and size of the breast needs to fully settle and become steady before the NAC reconstruction can take place.
Equipment used for Nipple-Areolar Complex Reconstruction
NAC (nipple-areola complex) reconstruction is a surgery that can be done while you’re awake or sedated, using numbing medicine. This is a method used in breast reconstruction. After certain types of breast surgeries, you might lose feeling in the skin of the new breast. The level of feeling you will have varies, especially after having a breast implant or similar procedure done. The tools your surgeon would use for this process are typical for minor surgeries in plastic surgery.
If the surgery involves taking cartilage (flexible tissue) grafts (transplanted tissue), additional tools might be needed. The surgeon uses stitches to hold the grafts or local flaps (sections of your own tissues moved to the breast area) together. These stitches can dissolve on their own over time (absorbable) or may need to be removed later (nonabsorbable). The stitches are usually fine or thin, labeled as 4-0 or 5-0 in the medical world.
Who is needed to perform Nipple-Areolar Complex Reconstruction?
To carry out a reconstruction of the nipple-areola complex (NAC), which is the colored circle around your nipple, several medical professionals are needed. This includes a plastic surgeon, who is a doctor trained to perform surgeries that repair or reshape body parts. Additionally, another medical expert called a surgical first assistant helps the plastic surgeon. There is also a surgical technician or an operating room nurse present who will assist through the procedure.
There is also an operating room nurse, who doesn’t directly help in the surgery but rather manages the procedures that happen around the surgery, ensuring everything runs smoothly. If you need to be put to sleep for the procedure, an anesthetist or anesthesiologist, a doctor specialized in safely putting patients to sleep during surgery, will be present. All these professionals work together to make sure everything goes well during your NAC reconstruction.
Preparing for Nipple-Areolar Complex Reconstruction
Before the surgery, it’s important for doctors to talk to their patients about the steps involved and possible complications of nipple-areola complex (NAC) reconstruction, such as issues with part of the nipple dying (necrosis) and loss of nipple projection or shape.
One of the key parts before the surgery is understanding what patients want and hope for in terms of their nipple and areola reconstruction. The patient’s own body and preferences guide the rebuilding of the nipple and areola area if they are present on the other side. Although there are guidelines for what the ideal location for the new nipple and areola area should be, doctors will often take into account where patients themselves would like this to be. This is done by allowing patients to mark their preferred location using a sticky pad, usually used in heart rate monitoring (EKG lead), while standing in front of a mirror.
In cases where just one nipple and areola area needs to be reconstructed, the natural one on the other side gives doctors the guide they need in deciding where to position the new one, as well as determining its size and shape.
How is Nipple-Areolar Complex Reconstruction performed
Nipple-areolar complex (NAC) reconstruction is a surgical procedure that can help restore the appearance of the breast after mastectomy (breast removal surgery) due to cancer or other conditions. There are several ways to rebuild the nipple and the surrounding darker area (the areola). Here are some of the most common methods:
Local Flap Transfer: This technique uses skin and a little bit of the fatty layer underneath, which are both nearby the surgical site, to create a nipple that sticks out. Many variations of this technique exist, but they all rely on moving skin and soft tissue that have a good supply of blood to function properly. The downside is that the newly created nipples may not stay as prominent as desired, often flattening out in the weeks after surgery. This is why doctors shape the new nipple to be taller than necessary, to account for the anticipated loss of height. Despite this, strategies to maintain the desired shape and height, using materials from your own body or synthetics, have mixed results.
Nipple Sharing: This option can work for people who have a healthy nipple that sticks out quite a bit on the opposite breast. About half of the healthy nipple is transferred onto the breast mound in need of a nipple. There is excellent similarity in the appearance (color and texture) of the new and old nipples, however the donor nipple can experience changes in feeling or pain, and may impact future breastfeeding.
Skin Grafts: Skin grafting involves taking a piece of skin from another part of the body to recreate the areola or the entire NAC. The skin is usually taken from areas where it is naturally pigmented (or colored) such as under the arm or the upper inner thigh. A technique known as dermabrasion can also be used to create darker skin for the areola.
Intradermal Tattooing: This method uses a tattoo gun to inject pigment into the skin to create the areola or recolor the NAC after it’s been reconstructed. The tattooing is done a few months after the NAC reconstruction and the skin is tattooed a bit darker than desired to allow for the eventual fading. Some modern tattoo techniques can even give the illusion of 3D, and can sometimes be an alternative to surgery.
Nipple Prosthetics: Another alternative to surgery is using a fake nipple that’s either attached to the breast mound with adhesive or implanted just under the skin. The external ones are usually made of silicone and can be customized to closely match the existing nipple, and they need to be cleaned regularly. The internal ones, also made of silicone or polyurethane, keep the permanent projected appearance of a nipple but run the risk of getting infected, being pushed out by the body, or forming a hard shell around them.
After the procedure, a protective dressing is applied over the reconstructed NAC to shield it from pressure or injury and to prevent infection. These dressings come in many forms and designs, including nipple-specific plastic guards and padded dressings.
Future Techniques – Tissue Engineering and Regenerative Medicine: Researchers are also exploring ways to use 3D-printing and other cutting-edge technologies to create new nipple scaffolds out of natural materials, that are seeded with special cells that can turn into fat cells. This technique is still in experimental stages and has so far only been tested in animals. Despite the promising prospects, challenges remain, such as ensuring the new tissue has a sufficient blood supply and understanding the long-term safety of using growth-promoting substances to encourage the new tissue to settle in its new location.
Possible Complications of Nipple-Areolar Complex Reconstruction
The main issue with using local flaps in NAC (Nipple-Areola Complex) reconstruction is that the reconstructed nipple may lose its projection, or stick-out shape. This is caused by inconsistencies in the blood supply to the reconstructed nipple, which can’t always be found near or within the existing scar tissue. Due to this, the surgery’s outcome can be unpredictable and certain surgical techniques may not work. There’s a possibility that the surgery might fail, resulting in loss of the flap or graft. Moreover, there may be unevenness in symmetry and unappealing cosmetic results from NAC reconstruction, which is a usual risk in these procedures.
What Else Should I Know About Nipple-Areolar Complex Reconstruction?
Reconstructing the nipple-areolar complex (NAC), which is a collective name for the nipple and surrounding tissue, is an important step after breast reconstruction surgery. This is typically done in people who have undergone treatment for breast cancer. This procedure not only helps improve the look of the reconstructed breast but also has psychological benefits. It can help people feel more accepting of their new breast as part of their body. This acceptance can substantially contribute to their overall self-image and wellbeing.