Who needs a nipple replacement?

The nipple may be ‘lost’ in several situations. The commonest scenario is during a skin-sparing mastectomy.

A skin-sparing mastectomy is usually performed for breast cancer (or risk-reducing mastectomy) and involves removing the nipple areolar complex (NAC), as well as the breast tissue, but preserving the skin. The nipple is the part that projects or ‘sticks out’ while the areolar is the pigmented part of the skin that surrounds the nipple (Figure 1). Whilst it is usually round in shape, in some women, the areolar may be very large, irregular in shape and diffuse. The pigmentation also varies a lot; some patients have very dark areolas and others may be faint, and similar in color to the surrounding skin.

The nipple may need to be removed as part of the mastectomy because the cancer is close to the nipple. In some patients, the breasts may be elongated or droopy (also known as ‘ptotic’ or ‘ptosis of the breast’), leading to the nipple being very low down on the breast. In this latter situation, the blood supply to the nipple is unable to keep the nipple alive after a mastectomy. Occasionally, a patient may lose their nipple due to a breast reduction surgery or a different surgical procedure close to the nipple. In both these situations there is an irreversible disruption in the blood flow to the nipple, known as ‘nipple ischemia’. When this happens, the nipple tends to change to a dark bruised color and eventually turn black (necrotic) and need to be removed. Patients who smoke nicotine at the time of surgery do have an increased risk of this complication.

Many patients benefit from breast reconstruction, after mastectomy, to restore the breast mound. This is important for better fitter of clothing, improving patients’ self-esteem and helping patients recover emotionally. Replacing the nipple, on the other hand, is a very individual and personal choice. For many women replacing the lost nipple is the final, but mandatory, step to ‘completing their cancer journey’. Other woman may not feel the desire to go through more surgery or have another procedure. Dr Li believes that women in this situation should go through a detailed discussion about their options. She has seen her patients cry with joy after their nipple(s) have been restored. Conversely, some patients with one remaining healthy nipple have requested this get removed. Everyone is different and it’s important to know what you want to do. Here, she will discuss your options for nipple areolar complex restoration.

What are the options for nipple areolar complex replacement after mastectomy?

There are several options available and they can be divided into surgical (those involving surgery) and non-surgical (tattoo and prosthesis) and a combination of both.

Surgical Options for Nipple Areolar Restoration

1. Nipple areolar complex reconstruction using flaps
   This is a surgery that involves rearranging the skin and a little layer of tissue below the skin to develops ‘flaps.’ These flaps are stitched together to form a tiny cylinder that will become the projecting nipple, and usually a circle of tissue is stitched around this, to form the areolar (Figure 2). Dr Li prefers to perform these surgeries in the cleaner environment of the operating room, with the patient asleep, under general anesthesia. This is an outpatient surgery that usually takes 1 hour for each nipple. For patients who have had a double mastectomy and need right and left nipple areolar reconstruction, the procedure will take around 2 hours. Patients go home the same day and recovery is straightforward compared to breast reconstruction recovery. Most importantly, patients are often pleased to hear that no drains are needed! The newly reconstructed NAC is protected after surgery by a dressing that needs to be replaced daily. There is usually very little to no pain because the majority of patients have reduced or absence of sensation of the skin after mastectomy.

What are the risks of nipple areolar reconstruction?

The risks include the risk of general anesthesia, scarring, bleeding, delayed healing and loss of projection over time. For this reason, most plastic surgeons prefer to make the new nipple a bit taller (or more projecting) than normal, knowing it will flatten slightly with time.  Most healing problems can be managed with creams and dressing changes alone; very rarely is more surgery needed. There is a potential risk of harming your reconstructed breast if you have a breast implant in the same breast, especially in prepectoral implant reconstruction. In this form of reconstruction, the implant is located just beneath the skin. In research studies the risk has been listed as 2% of getting an implant infection.

How painful is a nipple reconstruction surgery?

In most cases, not painful at all because most patients have much reduced sensation after a mastectomy has been performed. During the surgery, Dr Li usually injects the surgery area with local anesthetic to numb the area and that may be enough. In some cases, patients might want to take a Tylenol pill for mild pain.

What to expect after nipple reconstruction surgery?

Day zero to one after nipple reconstruction surgery

The after care is straightforward when you wake up. You will be sent home with after care instructions (which can also be downloaded here) and some dressings.

You will have dressings applied from the operating room, covering the surgery site. You may carefully remove these the next day and take a shower and replace the dressing.

Usually, patients recover within a week and may be able to resume light work duties, provided there is no pressure applied to the newly recreated nipple. Patients must not wear a bra for 3 weeks, to avoid excess pressure on the new nipple. Too much pressure can cause tissue necrosis and delayed wound healing, or even death of the newly reconstructed nipple. You cannot wear any tight clothing.

Do you still need a nipple areolar complex tattoo if you get surgical reconstruction of the nipple?

Coloring the nipple using tattoo pigments is not mandatory. However, most patients like some pigmentation in their newly reconstructed nipple areolar complex, especially when there is a native nipple. Most patients in this case want to match the color. It also depends on how dark the patient’s native nipples were before the mastectomy. Dr Li and her team typically perform the NAC 2 D tattoo at 3 months after surgery, to allow healing (Figure 2 and Figure 3).

2. Nipple Areolar Complex Reconstruction Using Skin Grafts
   Some surgeons prefer to recreate the nipple areolar complex using a skin graft. This means a small piece of skin is removed from a different part of the patient’s body – commonly the inner thigh, (but some surgeons like the vulva), and sewn into recreate the nipple. This will result in a scar at the ‘donor’ site’, where skin originated from. Risks of this surgery include bleeding infection, scarring and poor healing of the skin graft.
   
   Earlier in her training, Dr Li was taught to perform nipple reconstruction using skin grafts from the inner thigh in England. However, she prefers the method using flaps due to the superior results in her hands.

3. Nipple Sharing Technique
   If a patient has lost a nipple and has a large nipple on the other side, nipple sharing can be considered. In this technique, half of the remaining nipple is excised and the wound is repaired. On the recipient breast (where there is no nipple), a wound is created and the piece of nipple is sewn on, like a small skin graft. Some patients like this technique as they are using their own nipple tissue. For best cosmetic results, patients should get areolar tattoo afterwards. This is a small surgical procedure and Dr Li has successfully performed these under local anesthesia in the office.

4. Free nipple areolar grafts
   As mentioned above, in some situations, the nipple areolar complex cannot stay alive attached to its original blood supply. This includes where the breasts are extremely large and ptotic during a breast reduction, or a patient wants to ‘go flat’ (esthetic flat closure) after mastectomy. In this situation, the patient may undergo a free nipple graft. This involves cutting out the nipple areolar complex and sewing this to the completed breast reconstruction. The nipple graft is treated like a skin graft. It must heal to its new wound bed and regrow a blood supply. The risks of this procedure include delayed healing – it may take some time to heal (managed by dressing), failure of graft take, meaning the new blood supply does not grow and the piece of tissue does not heal. This may need another procedure to remove the unhealthy tissue. The most common problem is patchy pigmentation, meaning the color is a bit uneven, with some parts being darker, while other parts are lighter. Free nipple grafting must take place at the time of the mastectomy or breast reduction to be successful. You will typically wake up with a tie-over bolster dressing – like a small padded dressing to improve the contact between the nipple and the wound bed. This dressing stays on for a week. After this, the newly grafted nipple(s) will need daily dressings and no extreme pressure for three weeks from the time of surgery. See Figure 4 for before and after pictures in a patient who underwent double mastectomy, immediate esthetic flat closure and double free nipple grafts.  

Non-Surgical Techniques

2-D nipple areolar tattoo

In this procedure, tattoo pigment is used to create a nipple and areola, usually to match the remaining nipple after single mastectomy, or to recreate both nipples. After a double mastectomy 2 D Nipple areolar tattoo is used to color both reconstructed nipples. This form of tattoo is to provide color, not projection. This is best suited for surgically reconstructed nipples (see Figure 2 and Figure 3). It is usually performed in the office, but some surgeon may prefer to do these in the operating room. If the patient still has sensation in that breast the tattoo artist or surgeon, will apply a numbing cream. Just like any other tattoo, the tattoo pigments are injected into the skin using a tattoo instrument, that consists of tiny needles. The tattoo is then covered by a dressing. Usually, the patient comes back for evaluation at one week and, if needed, a secondary supplementary tattoo (which is complimentary) at 6 weeks. The coloring tends to be uniform (one color). The risks of this procedure include poor take of ink pigment, 2% risk of implant infection (in patients with an implant in the same breast) and tattoo fading (this happens with most tattoos over several years). Whilst many tattoo artist may offer this service, given the potential risks, it is best performed by an experienced medical tattoo artist or medical team (nurse, nurse practitioner or plastic surgeon).

3-D nipple areolar tattoo

As in 2D nipple areolar tattoo, tattoo pigment is used to create a nipple and areola to match the remaining nipple after single mastectomy, or to recreate both nipples, after double mastectomy where both nipples have been removed. What is unique to 3D nipple areolar tattoo is the level of detail and shading that is included in the tattoo, compared to 2D tattoo. The goal of 3D nipple areola tattoo is to recreate the anatomical details on a normal nipple and areolar and shading to give the impression that the nipple is projecting. This is typically performed instead of surgical reconstruction of the nipple areolar complex, rather than in combination with surgery. 3D nipple areolar tattoo can sometimes be used to enhance a reconstructed nipple, but it typically is performed without a preceding surgical procedure. Dr Li has had many patients with excellent 3D nipple areolar complex tattoo performed by her experienced nurse practitioner and in some cases, this may be the ideal approach (see Figure 5 and Figure 6). The risks are identical to 2 D nipple and areolar tattoo. The recovery is straightforward. After the procedure, the area is covered with a waterproof dressing that is left in place for 7 days. Clear written instructions are provided after the tattoo.

Nipple areolar prosthesis

These are fake stick-on nipple areolas that are simply adhered to the skin as a temporary substitute. They can be useful for occasional use and is best for patients who do not wish to undergo surgery or tattooing. They are usually made from a soft plastic with adhesive on the back (see Figure 7)

Why Choose Dr. Wai-Yee Li at LA Breast and Body for Nipple Replacement Surgery?

Dr Wai-Yee Li has performed many nipple reconstructions using both dermal flaps and skin grafting. She has a wealth of experience in this surgery and her results are realistic and speak for themselves (see Figure 2 and Figure 3). She has also performed successful nipple sharing procedures in patients.

At LA Breast and Body, we offer in office 2-D and 3-D nipple areolar tattooing. Our nurse practitioner, Traci Young, has had extensive training and experience in both 2D and 3D nipple areolar tattoo. She has been performing 2D nipple areolar tattooing for over 10 years and 3D nipple areolar tattoo for several years. She was trained by a well-established nipple tattoo artist from England, Vicky Martin at the Beau Institute of permanent artistry, USA. She also uses Vicky Martin’s areolar ‘unstoppable’ inks that were designed for areolar tattoo. The alternative is to choose a tattoo artist who may not have the clinical experience in the medical field to understand the particular risks with cancer patients.

Is nipple areolar complex tattoo covered by insurance?

This varies from one insurance to another. Many insurance companies view this as a cosmetic procedure and will not cover the costs. At LA Breast & Body we are unable to accept insurance for nipple tattoo but can offer this as a competitive cash pay procedure.

What is the cost of nipple areolar tattoo?

Please call the office to discuss your individual needs and we will be happy to provide you with a financial estimate.