Nipple Reconstruction Surgery
If one or both of your nipples were removed when you had a mastectomy, you may have a few options if you want to recreate them. Nipples can be reconstructed using surgery, tattooing, or both.
The main benefit of nipple reconstruction surgery is that it creates a nipple that will project out from the breast. Some people feel this gives a more natural look. The biggest drawback is that it involves another surgery. There’s also a risk that the reconstructed nipple may flatten over time. Unlike your original nipple, a reconstructed nipple doesn’t change in projection with touch or temperature.
If you’d rather avoid surgery, you could opt for 3D nipple tattoos, which don’t project out from the breast but can look very realistic. There are also lower-commitment alternatives like stick-on prosthetic nipples and temporary nipple tattoos.
Nipple reconstruction is usually an outpatient procedure. It’s performed using skin from the breast area — or from another part of the body — to form a new nipple. The areola (the circle of darker skin around the nipple) may also be reconstructed with skin. Tattooing may later be used to add color and dimension, help cover up scars, and create the look of the areola.
It’s important to know that, while nipple reconstruction surgery can give you a good cosmetic outcome, the reconstructed nipple won’t look and feel just like your original nipple. And since most people lose some sensation in their breast area after mastectomy, you likely won’t have much sensation in your reconstructed nipple either.
Nipple reconstruction surgery is typically done as a separate, final step after you’ve had either breast reconstruction or aesthetic flat closure. You can take your time to decide about it, if you’d like, because it can potentially be done months or years after you’ve healed from those surgeries.
Who can get nipple reconstruction surgery?
Most people whose nipples were removed during a mastectomy are candidates for nipple reconstruction surgery. However, nipple reconstruction may not be right for you if:
your breast skin became very thin or very tight after the mastectomy
you have lymphedema that involves the chest
you have a history of infections in the breast area
your breast skin has been damaged by radiation treatments
Nipple reconstruction surgery techniques
Plastic surgeons can take skin from a number of different places to reconstruct a nipple. No matter which approach is used, the surgeon will usually try to create a reconstructed nipple that is larger than the final desired size. That’s because the reconstructed nipple will flatten over time.
Talk with your plastic surgeon about the nipple size you want and which reconstruction approach might work best for you.
Your breast skin
This is the most common approach. To create the nipple, the plastic surgeon uses skin from the area where the new nipple will be located. This involves making small incisions, forming the tissue into a nipple shape, and securing it with stitches. The areola may be created later with tattooing.
Your breast skin and a skin graft
In this approach, the plastic surgeon creates the nipple using skin from the area on the breast where the new nipple will be located. To create the areola, the surgeon uses skin from another part of the body, such as from a mastectomy or C-section scar, or from some loose skin on the lower belly or inner thigh. An advantage of this approach is that the reconstructed nipple is less likely to flatten over time.
Your other nipple (called nipple sharing)
If you have a mastectomy on only one breast and the nipple on the other breast is large enough, the plastic surgeon can use a portion of that nipple to build one on the reconstructed breast. This approach can make it easier for the surgeon to match the nipples in size, color, and position. The downside is that it involves an incision on the other nipple. The areola may be created later by tattooing.
When nipple reconstruction is done
Plastic surgeons usually recommend waiting at least four months after breast reconstruction or mastectomy with aesthetic flat closure, to have nipple reconstruction. This will give your breasts or chest time to heal and settle into a final position. It’s also best to wait until you’re satisfied with the results of your other surgeries.
Sometimes nipple reconstruction is performed at the same time as other follow-up procedures to make adjustments to a reconstructed breast, such as fat grafting. However, it’s generally not recommended to get nipple reconstruction during the same surgery as the initial breast reconstruction, because it can lead to poor positioning of the new nipples.
How long does nipple reconstruction take?
Nipple reconstruction is usually an outpatient surgery that takes less than one hour. However, some people have an overnight stay at the hospital if they have nipple reconstruction at the same time as another procedure.
What to expect with nipple reconstruction surgery
Your surgeon will give you a list of instructions on how to prepare for the surgery and talk with you about what to expect.
Before surgery begins
Your surgeon will draw markings on your breast (and on another area of your body if a skin graft is being used) to show where the incisions will be made. You’ll probably be standing while this happens.
Anesthesia
Nipple reconstruction is often done under local anesthesia, sometimes with IV medications that relax you (called twilight sedation). The doctor uses a needle to inject numbing medicine into the breast area where the reconstructed nipple will be. If your doctor is taking skin from another place on your body to reconstruct the nipple, that area will be numbed, too. If you and your doctor decide that nipple reconstruction surgery should be done under general anesthesia, you'll receive an IV that will put you fully to sleep for the procedure.
Recovery
After the surgery, a nipple shield (a protective covering shaped like a tiny hat with a wide flat brim) or other protective dressing is taped over the reconstructed nipple. It may be filled with antibacterial ointment.
Your doctor will give you specific instructions to follow for your recovery, including how to care for the protective dressing and stitches. The protective dressing is usually left on for about three days to a week. After it's removed, you can shower. It’s important to avoid putting any pressure on the reconstructed nipple until it’s healed.
Because of the lack of sensation in the breasts after mastectomy, you probably won’t feel much pain or tenderness in the nipple area after surgery. If skin was grafted from another part of your body, that area is likely to feel tender or painful for a week or two. Ask your doctor what medicines you can take to ease the pain.
Your new nipple(s) may look large, pointed, red, and swollen, with visible stitches. As the nipple(s) heal, they will start to shrink and look more like you expected.
Healing after nipple reconstruction surgery can take about four to six weeks.
Follow-up
If you want tattoos applied to the reconstructed nipple(s) and areola(s), your surgeon will probably recommend that you wait for at least four months.
Nipple reconstruction surgery risks
Like all surgeries, nipple reconstruction carries some risks.
Tissue breakdown
When the tissue used to reconstruct the nipple doesn’t get enough blood, some of the tissue can die. This tissue breakdown is called “necrosis.” If necrosis occurs, your plastic surgeon will have to trim away the dead tissue. If you have just a small amount of tissue necrosis — for example, if only the tip of the nipple is affected — then you might only need basic wound care after the dead tissue has been removed. But if the tissue breakdown is more extensive, you may need to have the nipple removed. In most cases, you can have the nipple reconstructed again.
Nipple flattening
It’s common for a reconstructed nipple to flatten over time. If you’re bothered by its appearance your surgeon may be able to redo the reconstruction.
The surgeon may add a piece of tissue-like material called acellular dermal matrix (ADM), or a skin, cartilage, or fat graft from another part of your body to reduce the risk that the nipple will flatten again.
Poor positioning
There is a risk that you may not be happy with the position of the new nipple(s) once they heal. You may be able to have another surgery to reposition the nipple(s). The plastic surgeon will make a number of incisions and move the breast skin to reposition the nipple(s). The nipple(s) will remain attached to the underlying skin.
Your plastic surgeon may not be able to move a reconstructed nipple that has already been tattooed. If you had one nipple reconstructed and kept one natural nipple, and they’re not symmetrical, it may be easier for your plastic surgeon to move the natural nipple.
Finding a plastic surgeon for nipple reconstruction surgery
Most plastic surgeons who do a lot of breast reconstruction surgery have experience with nipple reconstruction. However, they vary in their level of skill and expertise with the procedure. It makes sense to choose a plastic surgeon who has done a lot of nipple reconstruction surgeries and has a track record of getting good results. Ask the plastic surgeons you are considering:
How many nipple reconstruction surgeries have you performed?
Which technique do you use?
Can I see before-and-after photos of your nipple reconstruction surgeries?
Paying for nipple reconstruction surgery
In the U.S, your health insurance plan should cover nipple reconstruction (and follow-up or corrective procedures) if it also covers breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 requires all group health plans and health insurance companies (including HMOs) that pay for mastectomy to also cover reconstructive procedures. Medicare generally covers breast reconstruction procedures including nipple reconstruction, while Medicaid coverage can vary from state to state. It’s not unusual to have some challenges with getting your health insurance to cover nipple reconstruction.
Nipple reconstruction is usually performed and billed separately from your other reconstructive procedures and requires a separate insurance authorization. Before you get nipple reconstruction, you and your plastic surgeon may need to make the case to the insurance company that it’s medically necessary and not just cosmetic. You’ll also want to find out in advance exactly what will be covered and what you’ll need to pay out of pocket.
Nipple reconstruction images
Before and after right breast reconstruction with APEX flap. Left breast lift for symmetry and right nipple reconstruction with areolar tattooing for pigment restoration.
Before and after bilateral skin-sparing mastectomy and Body-Lift Perforator Flap breast reconstruction with subsequent nipple reconstruction.
This information made possible in part through the generous support of www.BreastCenter.com.