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sequence on man
J. Palacios
The goal of an areola reduction is to reduce the size of the
areola to make it more symmetrical and esthetically pleasing
to the patient.
Berger K, Bostwick J III.A woman’s decision: breast care, treatment
and reconstruction. 2nd ed. St. Louis, MI: Quality Med. Pub., Inc.;
1994.
Morehead JR. Anatomía y embriología de la mama. lnteramericana.
México Clin Obst y Gin. 1982;25:377–81.
Techniques toReconstruct theNAC
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MohanThomas andJamesD’silva
19
With increase in the number of breast cancer patients all over
the world, early diagnosis, and early surgery, more and more
ladies are opting for breast reconstruction which may be by
using autologous tissue or by using an Implant. Reconstruction
certainly, the native NAC size, colour, orientation, and shape
vary from patient to patient. The advent of skin sparing mastectomy has ushered a remarkable increase in immediate
reconstruction using breast implants (silicon or saline).
Unfortunately skin sparing mastectomy does not automatically mean nipple-areola sparing too which depends on the
type of breast cancer as well as the location of the tumour
(proximity to NAC). Absence of nipple-areola complex
(NAC) is akin to undergoing an abdominoplasty with no
umbilicus. Breast reconstruction can be considered incomplete without an NAC which is in harmony with the patient’s
aesthetic preferences.
Nipple reconstruction is a major challenge for creating a
three-dimensional protruding structure from a at twodimensional skin surface of the breast. There is no single
technique to create the NAC which is perfect. Multiple procedures have been advocated over the years to create the
nipple as well as the hyperpigmented areolar region. The
major issue with all published techniques of nipple reconstruction is the loss of projection due to effacement of the
tissues and the absence of sufcient brous support in the
nipple.
Supplementary Information The online version contains supplementary material available at
M. Thomas (*) · J. D’silva
Aesthetic Surgery, The Cosmetic Surgery Institute
and D. Y. Patil University, Mumbai, India
https://doi.org/10.1007/978- 981- 99- 3726- 4_19.
19.1 Ideal Position ofNAC
There is a signicant difference in opinion among breast surgeons regarding the ideal position as well as the ideal size of
the areola in both the operated breasts and natural breasts due
to its dynamic capability of contraction and relaxation because
of which accurate measurements may not be possible. The
aesthetic outcome of the reconstructed NAC depends on its
overall position and its diameter in relation to the size of the
breast, body, and the trunk height (Atiye and Chahine 2018).
1. The NAC is positioned in such a way that it falls on the
breast meridian drawn from the mid-clavicular point and
forms an angle of 38 degrees with the suprasternal notch
(Martinovic and Blanchet 2017).
2. Horizontally the nipple should ideally be placed lateral to
the mid-clavicular line by about 2.5 cm and vertically
should be lower than the mid-humeral line by about 4cm
corresponding to the lowest point of IMF (Brown etal.
1999).
3. A recent study demonstrated the aesthetically ideal NAC
position is located in the middle of the breast mound vertically and slightly laterally in the horizontal plane (60:40,
lateral: medial ratio) (Lewin etal. 2016).
4. The natural proportion between the areola diameter and
the breast should be 1 to 3.4, and nipple to areola is 1 to
3. Ideally the reconstructed NAC should lie in the same
transverse plane as the contralateral nipple (if present)
(Hauben etal. 2003). It must be noted though that age,
height, weight, and body mass index do not inuence
areola–nipple proportions, both breast size and areola–
breast proportion change with age, weight gain, pregnancy, and ptosis.
5. NAC should ideally be 18–21.5cm from the sternal notch
but anthropometric studies have shown that suprasternal
notch and NAC distance varies with the height of the
patient and the length of the torso. Also this distance is
not independent of the relative position of the nipple on
the breast mound (Swanson 2012).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_19
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M. Thomas and J. D’silva
6. Ideally the NAC looks best when it is sitting at the point
of maximum projection of the breast (Fig.19.1a). Centre
of the breast cannot be determined on the frontal view of
the chest rather the breast has to be examined front on and
then the NAC should be marked so that it is equidistant
from all the breast borders as seen in Fig.19.1b. Bilaterally
symmetrical NACs are not important rather a harmonious
ple, namely breastfeeding. It also does not have the same
natural sensations as the original nipple. Hence in essence
the creation of NAC is only for the purpose of beauty which
boils down to 4 key aesthetic norms that are essential for
rendering the reconstructed beast attractive and any change
from these guidelines yields an unattractive breast (Mallucci
and Branford 2012).
placement of the NAC within the borders of the breast at
the point of its maximum projection is required. The areola diameter is variable and it varies from race to race,
size of the breast and also if the patient has undertaken
breastfeeding. Smaller diameter areolas may be more
suitable in smaller breasts and the standard areola size
accepted worldwide is 38–45 mm (Martinovic and
Blanchet 2017).
1. The ratio between the upper pole and lower pole is 45:55
meaning most of the breast tissue will be in the lower
pole.
2. The nipple ideally should be located at this upper/lower
pole boundary (nipple meridian) and should be pointing
upward (mean angle of 20).
3. When seen on lateral prole the upper pole slope should
ideally be either a straight line or mildly concave.
It is very important to understand at this moment that the
reconstructed NAC does not restore the functions of the nip-
Fig. 19.1 (a) The red arrow
is pointed toward the most
projected area of the
reconstructed breast in the
mid-lateral position. (b) The
nipple position is marked as
equidistant from the breast
boundaries and at the same
time on the most projected
area. (c) The yellow line
shows the level of the
contralateral NAC which on
the reconstructed side is
signicantly lower. The blue
lines are the mid-clavicular
lines and red circle is the new
NAC which is marked lateral
to the mid-clavicular line
c
4. On lateral prole the lower pole should be a smooth convex curve.
19 Techniques toReconstruct theNAC
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19.2 Points toBeConsidered Before
Planning theNAC
1. Stability of the result on the operated side with respect to
the breast volume. Atleast 3months should have lapsed
after breast reconstruction with an implant or autologous
tissue. This will allow enough time for the tissue as well
as the implant to settle.
2. Assess the breast on the contralateral side. The recon-
structed breast will always be perkier as compared to the
un-operated side. Usually breast on the other side is
droopy and larger or smaller.
3. NAC on the contralateral side has to be assessed. If both
breasts (natural as well as reconstructed) look similar,
then the shape and position of the contralateral NAC
should be duplicated for reconstruction. If the contralateral side is signicantly dissimilar then there should be a
discussion with the patient about cosmetic surgery on
the normal side. If the patient is averse to surgery on the
normal contralateral breast, then planning of NAC on the
reconstructed side should not depend on the NAC position of the normal side.
4. First mark the most prominent point of the breast mound
in the lateral and mid-lateral positions as seen in gure.
5. Next mark the breast meridian which passes through the
mid-clavicular line.
6. Mark the centre of the breast tissue (not the centre of the
hemi chest) in the horizontal line of maximum
prominence.
7. Usually this point in an aesthetic breast will lie lateral to
the breast meridian.
8. Once the position of the nipple has been conrmed,
assess the scars on the breast.
9. If local tissues are being used for the nipple construc-
tion, then the scar should not be at the base of the ap as
it will reduce the aps vascularity.
10. Check for sufcient tissue laxity before making the cuts.
11. In case nipple reconstruction is undertaken using com-
posite nipple graft from the other side, then the rst
requirement is to assess the length of the opposite nipple. If it is not longer than 10mm, then graft cannot be
harvested from the opposite nipple.
12. Finally assess the colour of the areola on the opposite
side and plan either a split thickness skin graft or a permanent tattoo to create the areola which is the best possible choice today as contralateral colour can be very
well matched.
19.3 Techniques toCreate NAC
There are numerous techniques described for NAC reconstruction but most of the techniques utilize the local tissues
present at the site of the neo-NAC.Many times the mastec-
tomy includes excision of the NAC and there might be a scar
secondary to the excision which may compromise the blood
supply to the tissues which should be taken into consideration when planning a reconstruction of NAC. In general,
surgical techniques involve the use of local skin aps, composite grafts from the opposite nipple, tattooing, or a combination of these techniques.
19.3.1 Use ofLocal Tissue Flaps
Since there is no one technique which can be used in all
reconstructed breasts for nipple reconstruction, the surgeon
should know a few techniques which can be utilized in most
situations to create an aesthetic NAC. A brief discussion
about the different common techniques used to create the
NAC along with their indications and risks will help the
operating surgeon choose a technique that he/she feels comfortable with.
All local ap surgeries for NAC reconstruction have the
following common characteristics:
1. These aps are usually composed of epidermis, dermis,
and subcutaneous tissues.
2. These are random pattern aps based on the subdermal
plexus of vessels and also at times through the subcutaneous tissues.
3. They are planned in such a way that there is primary closure of the donor area.
When planning such local aps for surgery it is important
that such aps are planned with a wide pedicle, the design of
the ap should be simple and reproducible and it should be
oriented in such a way that there is no retraction in the ap
(Farhadi etal. 2006). The primary closure of ap donor area
does help in reducing scars but has a strong centrifugal force
acting on the reconstructed nipple and areola. Nipple constructed from the skin and subcutaneous tissue of the back
when done in association with a latissimus dorsi ap with a
skin island is more resistant to contraction than tissues of the
abdomen or the breast.
19.3.1.1 Double Opposing Peri-areolar Flaps
(SKATE FLAP) (Shestak andNguyen
2007)
This procedure is usually carried out in patients who have
undergone autologous breast reconstruction with a skin
island ap in the area of the areola. There is a circular scar
after this procedure hence the round or oval skin paddle associated with DIEP (deep inferior epigastric) or any other free
ap is the best choice. This includes creating a central CV/
CH ap to create the nipple. Once the central nipple has been
sutured, the peri-nipple aps are advanced and sutured to
each other (Fig. 19.2c), closing the C.V/C-H donor site
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de
M. Thomas and J. D’silva
Fig. 19.2 (a) Marking of a C-H ap for nipple reconstruction along
with a double opposing ap (b). The C-H aps being raised and sutured
to each other to create the nipple. (c) The double opposing aps are
mobilized to close the defect created by the C-H ap, (d) the defect
created by C-H ap is closed and a peri-areolar permanent apposing
suture (PTFE) is used to approximate the edges. (e) Final closure is
(Fig.19.2d). The two external circles were then sutured with
each other to close the circular defect. A modication of this
technique was advocated by Hammond etal. who used a permanent peri-areolar suture to prevent the centrifugal forces
from the outer scar to atten the neo-nipple (Hammond etal.
2007).
This technique can be used even in implant based recon-
structions but due to the multiple incisions which includes
the peri-areolar incision as well as the proximity of the breast
implant it is not commonly advocated. Figure19.3a–d shows
the clinical application of the use of this ap to create a NAC
complex.
19.3.1.2 C-V Flap Variation (Modied by
Thomas) (Thomas etal. 1996)
This is a local ap containing the central ‘C’ ap anked
traditionally by two ‘V’ aps. The drawback with this ap
was the absence of adequate tissue to add to the volume of
the nipple as a result Thomas etal. modied it into a wide
ap so that there was adequate tissue to build up the nipple.
The planning of the ap is mentioned in detail in Fig.19.4a–
undertaken using interrupted absorbable or subcuticular sutures.
(Pictures modied from Gougoutas, A.J., Said, H.K., Um, G., Chapin,
A., & Mathes, D.W. (2018). Nipple-Areola Complex Reconstruction.
Plastic and Reconstructive Surgery, 141(3), 404e–416e. doi: https://doi.
org/10.1097/prs.0000000000004166)
c. The execution of the ap is detailed in Fig.19.5a–d, while
a modication is discussed in Fig.19.6a, b.
19.3.1.3 The Star Flap (Anton etal. 1991)
This is a modication of the C-V aps discussed before,
Fig.19.7a–c. This technique is similar except that wings of
the ap are created in a tapering fashion and have a lot of
subcutaneous fat. The closure of the donor area is easier but
the limitation includes a smaller nipple size as well as greater
absorption of the central fat causing signicantly reduced
nipple projection.
All local aps lose projection to varied degrees over a
period of time. Figure19.8 mentions the various causes for
loss of nipple projection. The total loss of projection and volume is to the tune of 45–75% with the majority of losses
being in the rst 6months. This is the reason why an over
correction is recommended with the immediate postoperative nipple being approximately two times the desired
nal height. Projection can be improved by using autologous
dermis, allografts, and synthetic materials as a secondary
procedure.
ab
cd
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Fig. 19.3 (a) Marking of a skate ap with the base superiorly (green
arrow pointed towards the base). The ‘C’ part of the ap (marked as b)
forms the cap of the nipple. The two ‘a’ aps are wrapped around the
‘C’ ap to provide a three-dimensional nipple. (b) Showing the ‘a’ aps
being raised along with release of the double opposing aps. (c) The
double opposing aps have been sutured to create the neo-areola. To
adjust the outer and the inner incision a V shaped skin incision is
planned inferiorly (this is now replaced usually with a permanent PTFE
suture). (d) Incisions nally closed. (Modied from Thomas SV, Gellis
MB, Pool R.Nipple reconstruction with a new local tissue ap. Plast
Reconstr Surg 1996;97 (5): 1053–1056)
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b
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c
Fig. 19.4 Planning of a C-V ap with Thomas modication. (a) A
12mm diameter circle is marked at the location of the neo-nipple. (b)
A tangent is drawn on the circle towards the base of the ap. Two parallel lines are drawn along the tangent which should be 6mm from the
tangent. The line away from the circle should have a 12mm interrup-
19.3.2 Nipple Sharing
This technique is only used in people who have excessive
nipple size both in length and volume, are open to sacrice the projection on the normal side to create the nipple
on the reconstructed side as well as in most cases have
reduced sensitivity of the nipple on the donor side. Since
about 50% of contralateral nipple height is lost in nipple
sharing techniques this should be undertaken in women
having the normal nipple length of more than 10mm. The
contralateral nipple may be removed transversely
(Fig. 19.9a–d) or longitudinally and then grafted on the
reconstructed NAC as composite graft. Horizontal excision of the distal nipple reduces the chances of breastfeeding hence should not be considered if the person is
interested in having a child and breastfeeding. Nipple
sharing results in excellent colour and texture match if the
graft take is 100% else there may pigment changes which
may need to be tattooed later. The surgical insult on the
donor nipple may cause altered sensation, pain, and difculty with breastfeeding.
19.3.3 Areola Reconstruction
This is the last stage of the NAC reconstruction procedure.
Skin grafts can be used to reconstruct the areola or the
NAC. Full-thickness skin grafts are harvested from other
pigmented areas such as the labia minora, axillary area, or
upper inner thigh. Dermabrasion has been described as an
alternative to create hyperpigmented skin for the reconstructed NAC.
tion for the base of the ap which lies opposite to the circle. Please take
care that there should be no scars at the base of the ap. The length of
the limbs is marked at 13mm to cover the full circumference of the
nipple. (c) Finally the cap of the nipple is marked which should be
6–8mm as a semi-circle
Three-dimensional intradermal tattooing is now most
commonly used as an alternative to the skin graft for reconstruction of the areola or to colour the NAC after nipple
reconstruction with a local ap. It is typically performed
3–4months after nipple reconstruction allowing for most of
the nipple length shrinkage. The colour immediately after
the tattoo should be darker than desired as the colour fades
within the rst few weeks. Traditionally, this technique has
been used if there is a lack of skin tissue available for surgical reconstruction, in the presence of scars, following radiotherapy, for reconstruction and pigmentation of the areola
complex or patient choice but now once the nipple has been
reconstructed, almost all patients are undertaken for creation
of areola (Figs.19.10, 19.11, and 19.12).
Pearls
1. NAC reconstruction should be considered only after the
breast has been stable for 6months following reconstruction, chemotherapy, and/or radiotherapy. It is better to
wait longer if the patient has undergone radiation to the
local tissues.
2. Cessation of smoking is of utmost importance. The der-
mal blood supply on which the new nipple survives may
be badly hampered in smokers.
3. Keep adequate thickness in the aps so that the nipple has
sufcient volume.
4. Do not open up the implant capsule while creating the
ap, this may open an avenue for implant infection with
the patient ending up losing the implant.
5. Results with 3D tattoo of the areola are far superior to the
split thickness skin graft reconstruction which leaves
another scar on the body.
cd
ab
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a
b
Fig. 19.5 (a) Planning of the modied CV ap. (b) The ap is raised
at the subcutaneous tissue level with sufcient subcutaneous tissue in
the ap. (c) The lateral limbs of the ap are sutured to each other to
create a three-dimensional nipple. The donor area is closed primarily.
(d) Delayed post-healing and after a cutaneous areola tattoo. (Modied
from Boccola, M., Savage, J., Rozen, W., Ashton, M., Milner, C.,
Rahdon, R., & Whitaker, I. (2010). Surgical Correction and
Reconstruction of the Nipple-Areola Complex: Current Review of
Techniques. Journal of Reconstructive Microsurgery, 26(09), 589–600.
doi:
https://doi.org/10.1055/s- 0030- 1263290)
Fig. 19.6 (a) Modication of the ap inset as suggested by Mohammed
etal. (Mohamed SA, Parodi PC.A modied technique for nipple-areola
complex reconstruction. Indian J Plast Surg. 2011;44 (1):76–80. doi:
https://doi.org/10.4103/0970- 0358.81450). The skin opposite the base
of the ap is de-epithelized. (b) Nipple as seen after inset. The advantage of this procedure is that there is no constriction at the base of the
ap and the nipple stands erect rather than skewed towards the base
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Fig. 19.7 (a) Marking of a star ap within the tattoo of areola. (b) Flap
being raised along with subcutaneous tissue. (c) Nipple created with the
central ap covered with the lateral aps with primary closure.
Fig. 19.8 Loss of nipple support is caused by the above-mentioned
various factors
(Modied from Anton M, Eskenazi LB, Hartrampf CR.Nipple reconstruction with local aps: star and wrap aps. Perspect Plast Surg
1991;5:67)
ab
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c
Fig. 19.9 Various steps of harvesting the nipple from the contralateral donor breast. (a, b) Distal 5–7mm of the nipple is taken and the donor site
is closed (c) with a purse string suture (d)
d
Fig. 19.10 3D tattoo of the areola is being undertaken. Picture showing half areola tattoo being completed
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