Nipple reconstruction surgery

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. For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development. The visual appearance of the NAC, including its relative position, size, color, shape, and texture, varies between individuals. Therefore, aesthetics is an important consideration when surgeons reconstruct the NAC to ensure it appears natural and pleasing to the patient. There are different methods for NAC reconstruction; however, in general, the procedure is safe and can be performed under local anesthesia.

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, to create the first reconstructed NAC.

Nipple sharing In 1972, Millard described a new method called "nipple sharing". 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.

Flap-based techniques In the 1980s, flap-based techniques for reconstruction became increasingly popular. 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.

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.

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. 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. 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. This is especially the case for female patients, as the breasts play a key role in the female identity. NAC reconstruction has reportedly empowered female patients by improving their body image and helping them overcome the psychological challenges from having breast cancer. 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.

Anatomy of the nipple-areola complex Similar to the breast, each NAC is unique. The anatomy of the NAC differs in size, texture, and color between different ethnicities and individuals. Oftentimes, a patient may have two areolas of different morphology. The nipple itself is defined as a protruded structure containing an abundance of sensory nerve endings and smooth muscle bundles facilitating erection for breastfeeding. It is located on the center of a pigmented patch on the breast, known as the areola. 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. Within the areola, gross anatomy includes the lactiferous ducts that drain the 15-20 mammary gland lobes extending into the depths of the breast. 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. The NAC is supported by stratified keratinized squamous epithelium that extend towards the surface of the nipple ducts. 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. On the surface of the areola, there are bumps denoted as Morgagni tubercles, which connect to the Montgomery glands. The montgomery glands are modified sebaceous glands connected to premature mammary glands, this connection facilitates secretion of milk during lactation through areolar lubrication. To support the structures within the NAC, vascularization mainly depends on the dermal and subdermal plexuses. 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. Provision of blood to the base of the nipple is accomplished through branching vessels of the mammary arteries. However, each breast would have different vasculature and can be affected by breast and NAC reconstruction procedures.

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