Overview

For the first 3-6 months following any type of reconstruction surgery, the new breast will change. Tissue flap based reconstructions generally shrink slightly and even purely prosthetic reconstructions will change shape as scars form and slowly soften. When all of these changes are complete, the breast is ready for the creation of a new nipple.

Many women are content to leave their reconstructed breast without a nipple. You may feel that you do not wish to face another procedure or that having a nipple on the reconstructed breast is not important.

Before deciding to undergo nipple reconstruction, there are several factors to consider about the new nipple. As they do not react to sensation, reconstructed nipples do not grow and flatten as natural nipples will, which can lead to asymmetry between the two nipples at different times, and there will be no feeling in the reconstructed nipple.

All of the techniques to reconstruct a nipple can be performed without the need for a general anaesthetic, and can be a good time to adjust the breast reconstruction, if necessary, now that it has settled into its final position.

Nipple prosthesis

Even without an operation, a silicone prosthesis can provide a realistic, natural looking nipple and areola (surrounding darker skin). This can be used immediately after reconstruction, either as a short term measure while waiting for the breast to settle, or in the long term as a substitute for nipple reconstruction.

Areolar tattooing

Tattooing the reconstructed breast can create an areola to match the natural breast, and can even create the illusion of a nipple. Although there will be no texture or projection from the breast surface, the results can be very realistic. Tattooing can be performed by the reconstructive surgeon, a specialist nurse or by a tattooing artist. There is a large variety of different colours to choose from, and there are swatches to help choose a colour or to match the colour to the natural areola. Areolar tattooing can fade by as much as 40-50%, so you may be recommended to use a darker colour than would appear natural, or to have the tattoo applied in 2-3 layers to provide a more even and colourfast tattoo. Areolar tattooing is a painless procedure because, although some women regain some feeling in their reconstructed breast, at a few months after reconstruction the nipple area of the reconstruction is numb.

Nipple grafting

A nipple graft involves taking skin from elsewhere in the body and moving it to the site of the nipple. The top layer of skin is removed from the reconstructed breast at the site of the nipple, and the graft attached in its place. Skin to create the nipple graft can be taken from the inner thigh, opposite nipple, labia, toe pulp, earlobe or part of the reconstruction scar. Nipple grafting may be supplemented with areolar tattooing to provide a natural looking colour to the nipple and surrounding darker skin. Disadvantages to nipple grafting are that the new graft is not transferred to the nipple site with a blood supply. Instead, it needs to establish a new blood supply from the reconstructed breast, which occasionally does not happen, resulting in graft failure. Also, grafts tend to flatten over time and, if hair-bearing skin is used to create the graft, hair will continue to grow from the new nipple. This can be treated with electrolysis or laser therapy.

Nipple flap

There are many types of nipple reconstruction using flap techniques, but they all involve freeing a small area of skin and fat from the surface of the reconstruction and twisting or folding it in a way to create a nodule on the surface of the breast, which is sutured in place. Flap based nipple reconstruction may be supplemented with areolar tattooing to provide a natural looking colour to the nipple and surrounding darker skin. As with nipple grafting, the new nipple shrinks over the first year, so is made 'too big', but the extent of the shrinkage is more constant than with nipple grafting and flap based nipples are less likely to flatten or lose their shape. The disadvantage is that new scars are created in the skin around the nipple, but these can be well hidden with tattooing.

Complications you should be aware of