Nipple reconstruction surgery

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Breast reconstruction following a mastectomy. As a result of the mastectomy, patients lose one or both of their nipples. A NAC reconstruction can be performed to recreate a nipple and areola on the reconstructed breast. Image from the National Cancer Institute, photographed by Linda Bartlett. Breast reconstruction (2).jpg
Breast reconstruction following a mastectomy. As a result of the mastectomy, patients lose one or both of their nipples. A NAC reconstruction can be performed to recreate a nipple and areola on the reconstructed breast. Image from the National Cancer Institute, photographed by Linda Bartlett.

Nipple reconstruction, specifically nipple-areola complex (NAC) reconstruction, is a procedure commonly done for patients who had part or all of their nipple removed for medical reasons. [1] For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. [2] [3] NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development. [4] [5]

Contents

The visual appearance of the NAC, including its relative position, size, color, shape and texture, vary between individuals. [5] Hence, aesthetics is an important consideration when surgeons are reconstructing the NAC, so it can appear natural and pleasing to the patient. There are different methods to NAC reconstruction, however in general the procedure is safe and can be conducted under local anesthesia. [1] [5]

Development of NAC reconstruction techniques

Throughout history, different methods for NAC reconstruction have been proposed and implicated.

Composite graft reconstruction

In 1949, Adams used a composite graft from the labia minora, which is the skin surrounding the vagina, [6] to create the first reconstructed NAC. [4]

Nipple sharing

In 1972, Millard described a new method called "nipple sharing". [7] In this method, a split-skin graft from the patient's contralateral nipple is used to reconstruct a new nipple. This method was commonly used as it was often successful in achieving matching pigment and texture between the reconstructed nipple and the contralateral nipple. However, it still has risks of infection, pain, numbness, scarring, and depigmentation. Nipple sharing may still be conducted today for patients with nipples that are taller than 1 cm in height. [4]

Flap-based techniques

In the 1980s, flap-based techniques for reconstruction became increasingly popular. [4] Such techniques involve incising a small flap of skin on the patient's breast, and raising the flap so it forms a shape that resembles a nipple. In general, a reconstructed nipple tends to gradually shrink over time. However, an advantage of flap-based techniques is that surgeons can construct a nipple that is slightly taller than normal, to counteract the inevitable shrinking of the reconstructed nipple. [7] [4]

Tissue engineering and regenerative medicine

In the 21st century, advancements in tissue engineering and regenerative medicine hold the potential in developing techniques for nipple reconstruction. For instance, tissue engineering and regenerative medicine can help researchers develop suitable and safe nipple implants. [4]

Impact on patient well-being

Regardless of the technique used for NAC reconstruction, the main goal is to recreate a normal appearance of the breasts and therefore bring satisfaction to the patient. Therefore, the ultimate aim of NAC reconstruction is to benefit the well-being of the patient. [3]

NAC reconstruction has shown to have positive psychological effects on patients, especially to those who have undergone a mastectomy. These patients have to get their breast glandular tissue completely removed, resulting in the surgical removal of their breasts. [8] Post-procedure, patients might suffer from body image issues, sexual dysfunction, and low self-esteem. NAC reconstruction has been shown to reduce the psychological impacts that patients might face following a mastectomy. [4] This is especially the case for female patients, as the breasts play a key role in the female identity. [3] NAC reconstruction has reportedly empowered female patients by improving their body image and helping them overcome the psychological challenges from having breast cancer. [3]

Moreover, NAC reconstruction has been shown to positively influence a patient's body image. A study indicated that patients who had both NAC reconstruction and breast reconstruction saw improvements in the overall appearance and sensation of their breasts. [4] [5]

Anatomy of the nipple-areola complex

Diagram of the anatomy of the female breast. (1) Chest wall, (2) Pectoral muscles, (3) Lobules, (4) Nipple surface, (5) Areola, (6) Lactiferous duct, (7) Fatty tissue, (8) Skin. Image illustrated by Patrick J. Lynch, and reworked by Morgoth666 to add labels. Breast anatomy normal scheme.png
Diagram of the anatomy of the female breast. (1) Chest wall, (2) Pectoral muscles, (3) Lobules, (4) Nipple surface, (5) Areola, (6) Lactiferous duct, (7) Fatty tissue, (8) Skin. Image illustrated by Patrick J. Lynch, and reworked by Morgoth666 to add labels.

Similar to the breast, each NAC is unique. The anatomy of the NAC differs in size, texture, and color between different ethnicities and individuals. [5] Oftentimes, a patient may have two areolas of different morphology. [5] The nipple itself is defined as a protruded structure containing an abundance of sensory nerve endings and smooth muscle bundles facilitating erection for breastfeeding. [9] [5] It is located on the center of a pigmented patch on the breast, known as the areola. [5] Although there is no standard dimension for the NAC, the approximately 4-7mm nipple can protrude for over 1 cm from the typically 4.2-4.5cm diameter areola. [5]

Within the areola, gross anatomy includes the lactiferous ducts that drain the 15-20 mammary gland lobes extending into the depths of the breast. [10] The areolas cellular composition includes an assortment of cells and specific tissues that support the primary function of the mammary glands, secretion and drainage of breast milk during lactation. [10] The NAC is supported by stratified keratinized squamous epithelium that extend towards the surface of the nipple ducts. [10] This pathway facilitates metastasis of carcinomas such as, syringomatous adenomas, throughout the areola, it can allow cancer cells in the subareolar ducts to travel to the nipple skin. [11] On the surface of the areola, there are bumps denoted as Morgagni tubercles, which connect to the Montgomery glands. [10] The montgomery glands are modified sebaceous glands connected to premature mammary glands, this connection facilitates secretion of milk during lactation through areolar lubrication. [10]

To support the structures within the NAC, vascularization mainly depends on the dermal and subdermal plexuses. [12] These networks of blood vessels include the internal and external mammary arteries in the subcutaneous tissue which primarily provide blood to the NAC alongside the thoracoacromial arteries and intercostal perforator arteries. [12] Provision of blood to the base of the nipple is accomplished through branching vessels of the mammary arteries. [12] However, each breast would have different vasculature and can be affected by breast and NAC reconstruction procedures. [12]

Procedures

The purpose of NAC reconstruction, which is often performed a few months after other breast related operations are completed, [13] is to create a 3-dimensional structure from a 2-dimensional template such as breast skin. [14] Over time, more than 60 techniques have been introduced. [15] There are several procedures under the NAC reconstruction category, with mainstream options being flap based construction, augmentation grafting, nipple sharing, and 3d tattoos. [15]

Nipple sharing

Nipple sharing is one of the pioneers of NAC and was first introduced in 1972. [15] It is mainly applied for nipples that have a contralateral height of over 1 cm. Nipple sharing utilizes the most anterior part of the donor or native nipple or a wedge of the donor nipple is surgically removed to be used as a graft. [16] Within this branch there are two techniques, longitudinal splitting and decapitation. [15] For decapitation, at least 50% of a donor's nipple should be preserved to ensure nipple erection and sensation. [15] To transplant the donor nipple, it is sutured onto the patient when the area of treatment undergoes removal of epithelial cells. [15] As this procedure only forms the most anterior part of the NAC, the areola is typically 3D-tattooed. [16]

3D tattooing

3D tattooing is recommended for patients who cannot undergo surgery due to risk of complications. [15] Tattoo-artists imitate the morphological features of the nipple through detail and shading, creating the optical illusion and a 3-dimensional nipple despite the surface being flat. [15]

Flap-based construction

There are many types of flap based construction, with the most common one being local flaps, which has a few subcategories . [15] These subcategories include centrally based flaps, subdermal pedicled flaps, and purse-string flaps. [15] In terms of shape, there have been star flap, skate flap, S-flap, H-flap, C-V flap, arrow flap, cylindrical flap, and more. [17] A common weakness of local flap based construction techniques is the loss of projection and diameter. [17] The technique mainly involves suturing different skin flaps, known as dermal fat flaps, together to form the shape of the NAC. [15]

Diagram showing the four main steps in the C-H flap technique for nipple reconstruction C-H flap for nipple reconstruction.png
Diagram showing the four main steps in the C-H flap technique for nipple reconstruction

Augmented grafting

Augmented grafting is often an additional procedure to refine the structure of the reconstructed nipple that experienced flattening as an adverse effect [15] due to the loss of smooth connective tissue support and wound scarring. [19] The procedure aims to increase nipple projection through autologous or heterologous materials. [15] Autologous tissues include structural supporters such as dermis, cartilage from the ribs or rim of the ear, adipose or fat tissue, and mucosa from the oral cavity. [15] Some procedures can facilitate the attainment of costal cartilage such as internal mammary vessel dissection for flap based- breast reconstruction procedures. [15] Heterologous materials can be allogeneic natural materials or synthetic foreign bodies l. [15] Synthetic foreign bodies mainly act as scaffolding to allow the hosts' own cells to recellularize the affected NAC itself. [15] Due to foreign body response, alloplastic materials come with higher risk of complications compared to autologous grafts. Such complications include protruding implants, necrosis, dyschromia, loss of sensation, and wound dehiscence. [19]

Postoperative care

A silicon nipple shield, also known as a nipple guard. Image by Harmid. Siliconen tepelhoedje - vorm voor aanbrengen.jpg
A silicon nipple shield, also known as a nipple guard. Image by Harmid.

Postoperative care is relatively short as dressing is typically maintained for 2 weeks. [16] Some common dressings include covering the area of operation with antibiotic cream, petroleum jelly dressing, stacking gauze, and nipple guards. [16] In addition to protection of the reconstructed nipple, analgesic painkillers are prescribed other than some flap reconstruction cases where sensation has yet to be restored. [20] 2 weeks post-operation, sutures can be removed which may result in a longer a pointier nipple projection for 1 month when the elongated c-flap is used for reconstruction. [20] As recovery is quite quick, patients’ regular routines are not disrupted unless complications occur. [20]

Risks and complications

There are risks involved in nipple reconstruction. Upon completion of the procedure, patients are at risk of flap necrosis, local infections, separation of tissue due to improper wound healing, and accumulation of fluid in an orifice of the breast (seroma). [4] Flap necrosis is a common adverse effect that accompanies breast augmentation surgeries including mastectomies but systematic reviews have shown that this can be reduced through application of nitroglycerin ointment. [21]

A direct side effect of nipple reconstruction is the long-term loss of nipple projection; [4] this is a sign that the procedure has failed if over 80% of pre-procedure projection has been lost over time. The loss of projection is often a mental burden for patients that receive NAC reconstruction. [15] Currently, there are no techniques that prevent the loss of projection over time. The loss of projection has similar mechanisms to the inverted nipple, in which fibrous muscle bands at the base of the nipple are unable to retract normally. [22] The erection of a nipple is dependent on the sympathetic nervous system and the smooth muscles within the nipple, [23] thus if the nipple receives damage there would be loss of projection. Specifically, procedures can cause the loss of projection due to scar contracture, surrounding skin causing retraction, and the lack of blood perfusion within the area. [4] Although there are no existing procedures that prevent loss of nipple projection, augmentation grafting or repetition of local flaps can be done to recover some projection. [15] However, some procedures such as longitudinal splitting and decapitation only reduce projection by 50%. [15]

Related Research Articles

<span class="mw-page-title-main">Breast reconstruction</span> Surgical rebuilding of a breast

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Nipple</span> Part of the breast

The nipple is a raised region of tissue on the surface of the breast from which, in lactating females, milk from the mammary gland leaves the body through the lactiferous ducts to nurse an infant. The milk can flow through the nipple passively, or it can be ejected by smooth muscle contractions that occur along with the ductal system. The nipple is surrounded by the areola, which is often a darker colour than the surrounding skin.

<span class="mw-page-title-main">Areola</span> Pigmented area on the breast around the nipple

The human areola is the pigmented area on the breast around the nipple. More generally, an areola is a small circular area on the body with a different histology from the surrounding tissue, or other small circular areas such as an inflamed region of skin.

Tissue expansion is a technique used by plastic, maxillofacial and reconstructive surgeons to cause the body to grow additional skin, bone, or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion.

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

<span class="mw-page-title-main">Breast augmentation</span> Surgical procedure

Breast augmentation and augmentation mammoplasty is a cosmetic surgery procedure, which uses breast-implants and/ or fat-graft mammoplasty technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall in other cases it is performed purely for cosmetic reasons.

<span class="mw-page-title-main">Breast reduction</span> Plastic surgery procedure

Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.

<span class="mw-page-title-main">Paget's disease of the breast</span> Medical condition

Paget's disease of the breast is a rare skin change at the nipple nearly always associated with underlying breast cancer. Paget's disease of the breast was first described by Sir James Paget in 1874. The condition is an uncommon disease accounting for 1 to 4% of all breast cancers cases. 92% to 100% of patients with Paget's disease of the breast have an underlying breast cancer.

<span class="mw-page-title-main">Chest reconstruction</span> Surgical procedure

Chest reconstruction refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. People may pursue chest reconstruction, also known as top surgery, as part of transitioning.

<span class="mw-page-title-main">Breast hypertrophy</span> Rare human disease

Breast hypertrophy is a rare medical condition of the breast connective tissues in which the breasts become excessively large. The condition is often divided based on the severity into two types, macromastia and gigantomastia. Hypertrophy of the breast tissues may be caused by increased histologic sensitivity to certain hormones such as female sex hormones, prolactin, and growth factors. Breast hypertrophy is a benign progressive enlargement, which can occur in both breasts (bilateral) or only in one breast (unilateral). It was first scientifically described in 1648.

Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.

Amastia refers to a rare clinical anomaly in which both internal breast tissue and the visible nipple are absent on one or both sides. It affects both men and women. Amastia can be either isolated or comorbid with other syndromes, such as ectodermal dysplasia, Syndactyly and lipoatrophic diabetes. This abnormality can be classified into various types, and each could result from different pathologies. Amastia differs from amazia and athelia. Amazia is the absence of one or both mammary glands but the nipples remain present, and athelia is the absence of one or both nipples, but the mammary gland remains.

A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.

SPAIR is a short-scar breast surgery technique developed by Dennis C. Hammond, assistant professor of surgery at Michigan State University. The technique was designed to allow a better-shaped breast, a limited amount of scarring, and a more accelerated healing process, by eliminating the lateral scar beneath the breast found in conventional breast reduction surgery. The technique is considered to be a good alternative to vertical mammoplasty.

Trans-umbilical breast augmentation (TUBA) is a type of breast augmentation in which breast implants are placed through an incision at the navel rather than the chest.

Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.

<span class="mw-page-title-main">Nipple prosthesis</span>

Nipple/Areola prostheses are made of silicone by breast prosthesis manufacturers and anaplastologists for breast cancer survivors who were treated for breast cancer with a mastectomy. Prostheses can be worn weeks after a mastectomy, breast reconstruction, or even nipple reconstruction. As an inexpensive and convenient alternative to surgery, patients may choose to wear them anytime during treatment. Patients who ultimately find nipple prostheses thought that they should be informed of them during the consultation prior to mastectomy.

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.

<span class="mw-page-title-main">Nipple-sparing mastectomy</span> Breast cancer treating method

Nipple-sparing mastectomy (NSM), also known as nipple delay, is one of the surgical approaches for treating or preventing breast cancer. It involves the removal of all breast tissue, except the nipple-areolar complex (NAC), and the creation of new circulatory connections from the breast skin to NAC. By preserving the NAC, NSM has provided patients with higher cosmetic expectations and the opportunity to undergo a mastectomy while maintaining a more natural appearance.

References

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