This guide outlines the choices available when considering nipple and areola reconstruction, and what you can expect in this final phase of breast cancer recovery.
A breast cancer diagnosis represents a traumatic time for any woman and her family. The combination of fear, pain, and grief can deeply affect a person, and even after a positive outcome the body holds physical and emotional memories of the experience.
The reconstructive plastic surgery that can follow mastectomy is part of a healing process that is both physical and emotional. At the end of this process, a woman can look in the mirror and know she has survived, changed but not broken.
One particular challenge that breast cancer poses is the sudden need to make many unexpected decisions. The wide range of available options means that patients can receive a treatment that is personalized to their preferences and circumstances; however, the sheer number of choices can also be overwhelming.
This guide addresses the options currently available for those considering nipple and areola reconstruction, and what can be expected in this final phase of recovery.
Understanding the Anatomy of the Nipple
The nipple is an opening for small tubes (milk ducts) that lead from the milk glands (lobules). Most breast cancer begins in one of the ducts found in the breast. Treatment for cancer, therefore, puts an end to the nipple’s feeding function.
However, the breast and nipple also serve an additional function, as an erogenous zone. Although nipple reconstruction does not restore these functions, many breast cancer survivors find it restores their feeling of having a complete body.
Nipples vary considerably among women. Some protrude prominently above the breast, others are almost flat against the skin, and in some cases they are inverted and sink into the breast to a slight degree. While nipples generally match, sometimes they are quite different. Most breasts are, in fact, asymmetrical.
If one breast has been spared during the cancer surgery, surgeons generally like to ensure the reconstructed nipple and areola match the remaining breast, even if the two breasts did not match before the surgery.
The areola is the darker skin that encircles the nipple. It too, serves both a feeding and an arousal function. The areola renders the nipple easier for a nursing baby to see and recognize, and it helps with the nursing. Directly below the areola are a series of lubricating glands, also known as the Montgomery glands, that help keep the area moist during breastfeeding.
Nipple and Areola Reconstruction Options
The loss of one or both breasts through a mastectomy is often followed with breast and nipple reconstruction. First, the breast itself is reconstructed. During reconstruction, a plastic surgeon creates a breast shape either using a flap of tissue from another place on the body or an implant filled with saline or silicone.
After the breast has been rebuilt, a patient has a variety of options regarding reconstruction of the nipple.
Option One: No Reconstruction
Most women seek full breast reconstruction after a mastectomy, but not all choose to include the nipple and areola in the reconstruction. Some patients simply aren’t interested in undergoing yet more surgery.
Another reason for choosing this route comes from fear that the procedure will result in persistent pain. While a highly unlikely outcome, it’s not impossible either. Patients who underwent radiation therapy especially should consult their doctor about how much skin was damaged in the process, and the effects this damage might have on nipple reconstruction.
Nipple reconstruction can be performed years after the breasts themselves are reconstructed. There is no hurry to make a decision; however, patients should understand that nipple reconstruction can be considered an important element in recovering satisfaction with one’s body image after breast-cancer surgery.
Nipple reconstruction is also considered significant in drawing attention away from the scars that persist following a mastectomy by fully rebuilding the breast. A person who has undergone breast cancer treatment can then look at her reconstructed breasts and feel confident that the disease is definitely in the past.
Option Two: Nipple-Sparing Mastectomy
In earlier times, mastectomy removed the entire breast, skin, nipple, areola, and underlying tissue. Many patients these days are candidates for a less radical procedure; one that preserves skin, the nipple and the areola. In such cases, only the glandular tissue is removed.
This option depends on tumor size and location as well as breast size, and must be agreed upon before the surgery is performed.
Option Three: Nipple-Sharing Surgery
Another surgical solution is to move part of the remaining breast’s nipple to the reconstructed breast. Unless the unaffected nipple is larger than normal, the obvious downside to this method is that post-surgery neither nipple is normal sized. The method also risks a number of complications that leave a patient with two unsatisfactory nipples. Consequently, this solution is rarely advised.
Option Four: Reconstructive Surgery
The most popular choice is to undergo an outpatient nipple reconstruction procedure by a plastic surgeon who is skilled in the art. It is the usual finishing touch to breast reconstructive surgery, restoring a person’s appearance as much as possible to their pre-cancer days.
The nipple and areola are commonly reconstructed with a flap reconstruction, which utilizes skin cut from the peak of the breast. The skin is still attached to the breast, but like the flap on an airplane wing, it can move up and down. Depending on the shape of the flap, it can be folded and twisted in a variety of ways.
The flap contains all three layers of skin– the epidermis, dermis and hypodermis–and some deeper subcutaneous fatty tissue as well. The subcutaneous tissue is critical as it provides a blood source for the new nipple. There is no replacement of lost glands and ducts.
This procedure requires full healing and stabilization of the breast position before proceeding on to the creation of a new nipple. This initial delay usually lasts for three or four months, and then another three or four months must pass before the areola can be reconstructed around the nipple.
Older techniques took tissue from one part of the body (typically, from the groin, labia, or unremoved breast), but more contemporary techniques create a nipple mound by cutting and placing a flap from the reconstructed breast.
Option Five: Areola and 3D Nipple Tattoos
Individuals whose skin condition increases the risk of complications after nipple reconstruction sometimes have a three dimensional nipple tattooed on their breast. Like all tattoos, it may fade over time.
Tattoos are generally used as part of reconstructive surgery as well. The new areola is tattooed around the reconstructed nipple.
Option Six: Prostheses
It is also possible to obtain a silicone device that is worn only when desired. This silicone prosthetic looks and feels like the real thing. This option is favored by patients who are concerned about costs or do not want to undergo more surgery.
How Nipple Reconstruction Is Performed
If the patient decides on nipple reconstruction surgery, the patient and surgeon will meet and agree on where on the breast the nipple will be built prior to the operation. At this time, a diameter for the areola is determined as well.
A picture of the breast is usually taken to show exactly where the nipple will appear. If there is a surviving breast, it is measured and used to determine nipple and areola size.
The reconstruction itself is a straightforward operation that usually only takes about an hour. The chief idea is to cut flaps from the skin, fold them around one another and sew them together, creating a mound of skin that will look like a nipple.
Anesthesia and Outlining
The procedure begins with the administration of a local anesthetic that numbs the breast.
The preparatory photograph is consulted to identify the exact position of the nipple before a circle the size of the areola is drawn on the breast, marking exactly where the nipple is to appear.
The outline of the flap is then drawn and carefully measured in the circle. In most cases, the flap length is twice the size of the nipple’s height. The lines are positioned in order to minimize bleeding.
The design for these skin flaps can vary significantly. It depends on the plastic surgeon and how blood is supplied to the area around the breast. Flap designs include bell, bow tie, propeller, rolled dermal fat, skate, star, and top hat. Some surgeons prefer still other designs.
The flap chosen in any particular case depends on the surgeon’s training and experience – some prefer the skate flap because it leaves the fewest changes in the shape of the breast, but there are many other choices. The critical issues are minimizing the risk of bleeding, and ensuring a natural appearance.
Incisions and Reconstruction
Once the area is sufficiently numb, the surgeon makes incisions along the prepared marks. The cuts sever the skin and some subcutaneous tissue as well.
The flap is pulled up and tissue attached to the flaps is methodically snipped away, leaving the flaps free to be folded and sewn together. Once the flaps are ready, the surgeon cauterizes any small blood vessels, sealing them and stopping the bleeding. A properly designed flap should produce very little bleeding during the surgery.
The surgeon then closes the area where the flap was created by sewing the wound back together, leaving flaps of skin poking above the breast.
Finally, the reconstructed area is then bandaged with a thick pad with a hole in the middle to protect the new nipple. The sutures used to close up the wound and bind the flaps together should disappear of their own accord in approximately three to four weeks.
Some surgeons prefer to construct a small “platform” for the nipple to rest on. This step reduces the quantity of nipple that recedes into the breast. In this procedure, surgeons remove the very top layer of surface skin (the epidermis) that supports the nipple, creating a small depression, similar to a socket, to provide support for the nipple.
When the platform is readied, the future nipple is sewn onto it. The flaps are then sewn together. This sewing should not create any points of tension that could distort the breast shape.
The sealed flaps produce a smooth piece of cylindrical skin protruding above a sutured wound. This three-dimensional structure has been created on what was originally flat skin. It looks too large for a normal nipple, but once the area is fully healed roughly three or four months later, the protrusion will be half the size it is immediately after the surgery.
Your surgeon will give you full instructions on taking care of the nipple while it heals. Most patients use a surgical or recovery bra that is large enough to hold the dressing and gauze surrounding the new nipple. It should be soft and loose fitting, with no compression of the nipple.
- Some swelling and mild pain is normal the first two or three days following surgery. Tylenol or other non-inflammatory, over-the-counter pain medication can be taken to address it.
- Alert your doctor should you develop a fever or notice any signs of significant bleeding, or if the wound begins to open. These are rare events but you should be vigilant nonetheless. Be especially alert if your breast cancer was treated with radiation.
- Leave the post-surgical garment on until the first follow-up visit to your plastic surgeon (generally a week after surgery). That means no showers, although sponge baths for the rest of the body are fine.
- Do not go to the gym or engage in heavy exercise.
- During the follow-up visit, the doctor will remove the bandages and patients will be able to have their first look at their new nipple. At this stage, it is still healing and looks different to how it will appear once recovery is complete.
- Treat the nipple with care while it’s healing. When you resume showering, do not scrub your breast, and avoid wearing any clothing or undergarments that compress the nipple. Keep your breast and nipple area well moisturized.
- The healed nipple will be noticeably smaller than the one immediately after surgery and in some cases, may sink into the breast. If needed, the nipple can be retouched by using a dermal filler such as Radiesse. No further surgery is required. The filler is injected via a small needle, which then plumps up the nipple.
How Areola Reconstruction Surgery Is Performed
The areola can be reconstructed with or without a skin graft. The graft creates a distinct skin area around the nipple, giving the final result a more natural look. However, many people are quite content to skip the graft.
Even with a skin graft, when the reconstructed nipple is healed (in approximately three months), the surgeon will usually tattoo the areola, giving the area around the nipple a darker pigmentation.
If the areola is to include a skin graft, typically the procedure immediately precedes the nipple reconstruction, although in some cases it may be done later. A skin graft takes skin from one part of the body and places it elsewhere, in this case, at the site of the nipple.
Areola skin grafts are commonly taken from the scar left when the breast was reconstructed or from near the thigh or buttocks. The new skin thickens the areola and the grafted skin darkens, creating a sense of pigmentation. Some surgeons like to tattoo the grafted area as well.
A surgical areola tattoo can also create the appearance of pigmentation. Medical tattooing inks come in many shades and a color that matches the surviving breast’s shade is almost certain. It may take more than one session for the tattooing to be complete, however.
Over time, tattoos fade and a retouch may be required.
Nipple and Areola Reconstruction Costs
A federal law passed in 1998 – the Women’s Health and Cancer Rights Act – requires insurance policies that cover mastectomies to also cover reconstructive surgery, including nipple reconstruction.
However, insurance policies are not required to cover mastectomies. The rule is that if your mastectomy was covered by insurance, breast and nipple reconstruction will also be covered, although there may still be expenses in the form of co-pays and deductibles. For instance, the law does not require coverage for a three-dimensional tattoo, even though it costs less than reconstructive surgery. If nipple reconstruction is covered, the areola tattoo should also be insured.
Medical fees vary enormously, but there is time to shop around before undergoing surgery. In cases when a patient is required to cover the entire expense, they can expect to pay roughly $2,000 for reconstructive surgery.
Three-dimensional nipple tattooing typically costs about $500, whereas prosthetic nipples are $20 on average for a pair.
Frequently Asked Questions
Do I really need nipple reconstruction?
It is your personal choice. Nipple reconstruction represents a cosmetic procedure in the sense that it does not restore a physical function like breast feeding, but many women consider it important to their sense of self that the surgery serves a fundamental need. At the same time, it’s not hard to find women who have had mastectomies and have no regrets about not seeking nipple reconstruction. Some even choose to forego breast reconstruction entirely and go flat.
Despite being elective, the choice seems routine for many women. To many it feels perfectly natural and normal to want to recover as much as possible the look and body they once had.
Is a three-dimensional tattoo sufficient?
It can look surprisingly realistic when viewed from the front, as in a mirror. The main appeal of the tattoo is that it’s less expensive than surgical reconstruction and is suitable for people who recoil from the idea of undergoing yet another surgical procedure.
Why doesn’t everyone get a nipple-sparing mastectomy?
Nipple-sparing mastectomy is still a relatively newer procedure and many breast surgeons do not perform it. Some patients are also not ideal candidates for the procedure.
Patients who have nipple areolas that are positioned very low on the breast due to breast sagging are at a significant risk of wound complications with nipple-sparing mastectomy. Similarly, patients who have previously undergone radiation therapy are at a higher risk of complications, as are diabetics and smokers. Lastly, nipple-sparing mastectomies can’t be considered if the cancer has spread to the nipple itself.
Can I have nipple reconstruction but then skip the areola tattoo?
Yes, but it may compromise the nipple reconstruction results. A nipple without an areola will look unusual, and the point of the reconstruction is to look natural. Commercial tattoos are often painful experiences, but surgical tattoos are given with local anesthesia and should be relatively painless.
If a patient objects to a tattoo, a skin graft areola can serve instead.
How much time does this procedure add to the recovery time?
The nipple and areola reconstruction can add six or eight months to the treatment period; however, this question may reveal the wrong way of looking at the process. A better question is when do you consider the treatment complete? Is it when the mastectomy is finished? Is it after a new breast has been constructed? Or is it when the lost breast has been replaced by a full, natural-looking one?
If a patient wants a full breast, stopping sooner does not shorten the recovery period. It ends the treatment prematurely.
Will my reconstructed nipple look like a real one?
It will not be as sensitive as a real nipple and on close examination, you may find minor incongruent features, but the final result should strike an observer as being perfectly real. Since we are talking about human biology, there are always variations and surprises in what nature provides. Expect a reconstructed nipple made by a skilled plastic surgeon to look natural.
What about banking the areola and nipple?
Banking is a procedure whereby the areola and nipple are surgically removed as part of a skin-sparing mastectomy, and then stored until they can be re-grafted onto the reconstructed breast. American surgeons often mistrust the storage technique and do not recommend it. Studies suggest, however, that when it works, women tend to be satisfied with the results.
Will my reconstructed nipple be sensitive to touch?
The nipple is likely to be highly sensitive (and not in a good way) for about a month after surgery. Once the nipple area is healed it probably won’t be as sensitive as it was before.
The nipple/areola complex is an especially sensitive area and a source of sexual pleasure. It can still be a source of pleasure after surgery, but it will feel different.
Does the reconstruction last a lifetime?
Nipples can flatten and tattoos can fade. If a person so desires, the work can be revised at a later point.
What risks should I be aware of?
Most outcomes of nipple and areola reconstruction are satisfactory, but there are risks. A history of radiation therapy increases risks for reconstruction. The surgery can fail completely and the new nipple may detach itself. The nipple can be poorly positioned, or shrink too much and become excessively flat. (A too-flat nipple can, however, often be touched up with a dermal filler.)
There are also the risks, inherent in any surgery, of infection, nerve damage, and permanent scarring.
Updated, November 2017