Nipple and Areola Reconstruction

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Introduction to Nipple and Areola Reconstruction

Although not every patient opts for this procedure, nipple and areola reconstruction is often the final step involved in reconstructing the appearance and feel of the post-mastectomy breast. The advantages are obvious: A breast which more closely matches the remaining natural breast (in the case of a uni-lateral mastectomy), and the ability to maintain a more natural appearance, even when going braless.

However, some patients do choose to forego this procedure because of its disadvantages, not the least of which is the simple fact that it is one more surgical procedure that some patients view as prolonging the process of “getting on with their lives.” With this additional procedure come a few unfavorable realities:

  • Depending on the methods used, the patient may need to once again undergo general anesthesia.
  • There is additional recovery time following the new procedure.
  • It results in additional scars (at the site of the new areola/nipple, and/or at the donor site if grafting is used.

Typically, nipple and areola reconstruction is performed at about 3 to 6 months after the primary reconstruction. This allows for optimal healing and the dissipation of post-op swelling. However, the timing can vary considerably based on surgeon and patient preference, as well as the specific techniques used in both procedures.

Graft and Flap Reconstruction Techniques

The graft technique involves harvesting skin from a donor site separate from the reconstructed breast. The skin graft is then attached to the site of the newly constructed nipple and/or areola. Common donor sites for areola grafts include the abdominal scar from a flap reconstruction, the inner thigh, or the buttock crease.

For nipple grafts, the three most common donor sites are the patient’s remaining nipple, the earlobe, and the labia. In general, the patient's remaining nipple is the preferred donor site, since it provides the best match in terms of skin texture and color. However, in the case of a bilateral mastectomy (or particularly small nipples), the other donor sites can be quite useful.

In the flap approach to nipple reconstruction, the nipple mound is created from a “flap” of skin taken directly from the skin adjacent to the site of the newly reconstructed nipple. This technique has the advantage of keeping the blood supply intact, and of confining any scarring to the area of the new nipple and areola (as opposed to creating a new scar at the donor site, as with a graft procedure).

Reconstruction Via Micropigmentation (Tattooing)

The tattooing procedure, called micropigmentation, is usually performed as the final stage of a complete breast reconstruction, only after the nipple itself has been reconstructed.

This procedure is performed with equipment that is very similar to what one might find in use at a tattoo shop. Its main advantage is that it is a relatively quick and simple outpatient procedure which requires no more than local anesthesia, and does not create an additional scar. In fact, micropigmentation can be used to camouflage the color and even soften the texture of existing scars left behind after the initial breast reconstruction procedure.

Primarily, this technique is used to simulate the color, shape and texture of the area surrounding the nipple (called the areola). However, for those patients who do not wish to undergo further surgery after their primary breast reconstruction, the appearance of the nipple itself may be re-created using only tattooing. The obvious disadvantage of this method is that it can only create the optical illusion of texture and dimension, offering no nipple projection. In some cases, your surgeon may recommend the use of such fillers as Radiesse or Alloderm in order to enhance nipple projection. In this case, it may also be helpful to look specifically for a surgeon or micropigmentation technician who specializes in creating the most realistic-looking and three dimensional appearance.

Your surgeon or technician will mix various pigments to come up with just the right color to complement your skin tones and/or to match your remaining nipple. Achieving the perfect shades may require more than one visit, and as with any tattoo, the pigment will fade in time, necessitating a return visit for a color touch-up.

Risks & Complications

First, there is the possibility that the graft or flap may not survive in its new location. If this happens, further surgery will be necessary. In addition, if general anesthesia is required, there are the usual risks that go along with it, together with the risks and possible complications inherent to most surgical procedures, which include: unfavorable scarring, excessive bleeding or hematoma, skin loss (tissue death), blood clots, fat clots, skin discoloration or irregular pigmentation, anesthesia risks, persistent edema (swelling), asymmetry, changes in skin sensation, persistent pain, damage to deeper structures such as nerves, blood vessels, muscles, lungs, and abdominal organs, deep vein thrombosis, cardiac and pulmonary complications, unsatisfactory aesthetic results, and the need for additional surgery.

After surgery, call your surgeon immediately if any of the following occur: chest pain, shortness of breath, unusual heartbeats, excessive bleeding.


In most cases, reconstruction of the nipple and areola are considered to be the final step in post-mastectomy breast reconstruction. Therefore, by law, the costs would be covered by the patient’s insurance. However, you should always check with your insurance provider regarding the particulars of your coverage before scheduling any surgery.

Post-Op Care

Following the procedure, a non-adherent gauze dressing and a generous amount of ointment will be placed onto your breast and held in place by surgical tape. The dressing will need to be changed every few hours for the first few days. If you have been tattooed as part of your reconstruction, your tattoo will probably ooze a mixture of ink and blood. It is important not to let the tattoo get dry, or to allow excessive friction between clothing and the tattoo during this time.

Because of the blood, the tattoo’s color will appear much darker than it will be once it has healed. During the healing period, scabs will form and fall off, revealing the true color of the tattoo. Do not pick at the scab or try to remove it. If removed too early, the scab will take much of the tattooed pigment with it.

Recovery & Downtime

Reconstruction of the nipple and areola is usually an outpatient procedure requiring less than an hour to complete. Most patients will have some mild pain or discomfort which may be treated with mild pain-killers, and will be able to return to their normal activities within a few days.

As with all surgical procedures, it is important to understand that these guidelines can vary widely based on the patient’s personal health, the techniques used, and other variable factors surrounding the surgery. Regardless, it is important to take care not to subject the procedure sites to excessive force, abrasion, or motion during the healing period.

Any severe pain should be reported to your doctor.

Scarring and Sensation

If the reconstruction is accomplished by tattooing alone, there is no new scarring created. In the case of a flap reconstruction, the small scars are usually within the region of the nipple and are mostly hidden by the areola reconstruction.

If a graft technique is used, a new scar will show up around the perimeter of the new areola. An additional scar is also created in the donor site.

Regardless of the method used for reconstruction, it is important to be prepared for the fact that the new nipple area will not have the same sensation as the nipple of the remaining breast (or the previous natural breasts).


C-V Flap Nipple Reconstruction Combined With Areola Grafting, Yuksel F, Celikoz B. Indian Journal of Plastic Surgery 2003;36:71-5

Micropigmentation: Tattooing for Medical Purposes, Garg Geeta MD, Thami Gurvinder P. MD, Dermatologic Surgery, Volume 31 Issue 8 Page 928-931, August 2005

Skin-Sparing Mastectomy with Immediate Breast Reconstruction, S. E. Singletary, Annals of Surgical Oncology, Vol 3, Issue 4 411-416

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