Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm

Abstract

Background: Nipple-areola complex reconstruction (NAR) most commonly represents the finishing touch to breast reconstruction (BR). Nipple presence is particularly relevant to the patient's psyche, beyond any shadow of doubt. Many reconstructive options have been described in time. Surgery is easy, but final result is often disappointing on the long run.

Methods: The goal of this manuscript is to analyze and classify knowledge concerning NAR techniques and the factors that influence success, and then to elaborate a practical evidence-based algorithm. Out of the 3136 available articles as of August 8th, 2020, we selected 172 manuscripts that met inclusion criteria, which we subdivided into 5 main topics of discussion, being the various NAR techniques; patient factors (including patient selection, timing and ideal position); dressings; potential complications and finally, outcomes/patient satisfaction.

Results: We found 92 articles describing NAR techniques, 41 addressing patient factors (out of which 17 discussed patient selection, 14 described ideal NAC location, 10 described appropriate timing), 10 comparing dressings, 7 studying NAR complications, and 22 addressing outcomes and patient satisfaction. We elaborated a comprehensive decision-making algorithm to help narrow down the choice among NAR techniques, and choose the correct strategy according to the various scenarios, and particularly the BR technique and skin envelope.

Conclusions: No single NAR technique provides definitive results, which is why we believe there is no "end-all be-all solution". NAR must be approached as a case-by-case situation. Furthermore, despite NAR being such a widely discussed topic in scientific literature, we still found a lack of clinical trials to allow for more thorough recommendations to be elaborated.

Level of evidence iii: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Keywords: Breast cancer; Breast reconstruction; Nipple-areola complex; Nipple-areola reconstruction; Nipple-areola surgery.

Fig. 1

Flow diagram representation of the search strategy with included and excluded articles

Fig. 2

Patient at 3 weeks follow-up after bilateral skin-sparing mastectomy and immediate breast reconstruction with fat-augmented latissimus dorsi (FALD) flap for bilateral infiltrating ductal carcinoma (Left). Areolas were initially replaced with LD skin and NAC were banked in the inguinal crease. Right NAC was later discarded for oncologic reasons, and the new NAC was reconstructed with C-V flap 3 months later. Left NAC was transplanted 3 months later from the inguinal region to the breast mound, showing mild discoloration and loss of nipple projection. Patient refused any additional procedures to reconstruct the right areola and improve the left and returned to follow-up 2 years later (Right)

Fig. 3

Patient at 12-month follow-up for left nipple-sparing mastectomy and right skin-sparing mastectomy, with immediate breast reconstruction using a bilateral DIEP flap (a). She underwent right nipple reconstruction using Lossing’s S-flap and a fat grafting session of the left breast during the same setting under general anesthesia 6 months later (b). Patient returned 4 months later for a single dermopigmentation session for areolar reconstruction (c) and 5 more months later for follow-up (d)

Fig. 4

The Sant’Andrea University Hospital (SAUH) decision-making algorithm for nipple-areola reconstruction, with (a) general recommendations and specific recommendations for implant-based BR, and (b) specific recommendations for autologous-based BR

Fig. 5

Patient at 6-month follow-up after secondary breast reconstruction with implant-enhanced latissimus dorsi flap (Left) after failed implant reconstruction of bilateral skin-sparing mastectomy. Patient underwent a fat grafting session and bilateral C-V flap for nipple reconstruction during the same operative setting (Center). Preoperative markings were oriented in accordance with the NAR algorithm to reduce breast mound asymmetries. Patient at 6-month follow-up following NAR (Right)