In the U.S., nipple reconstruction is usually performed with a small flap of breast skin that is twisted into a nipple. Bowtie flap, skate flap and C-V flaps are common, but many other shapes can also be used, depending on the surgeon’s preference. Tattooing the nipple and areola is the final reconstructive step. (Nipples can also be tattooed directly onto the new breast. 3-D nipples look particularly realistic; although completely flat, they give the illusion of protrusion.)
Although most surgeons now use the mini-breast flap procedure to rebuild nipples, some still prefer to create nipples with skin grafts taken from the labia, ear, or inner thigh, which tend to be darker than breast skin and don’t require tattooing. The grafting process is more complex, creates an additional scar, and the donor site remains sore for a week or two.
Less frequently, surgeons use nipple banking, a procedure that is more common in Europe than in the U.S. Women with early-stage cancer that is at least 2 cm away from the nipple are candidates. The nipple-areolar complex (NAC) is removed during mastectomy and checked for cancer cells; if none are present, the NAC is transplanted intact to the groin for several months until it can be transferred to the reconstructed breast at a later time. Aside from the awkwardness of having nipples on the abdomen for 9 months or longer, nipple banking leaves a scar. Storing the nipple in this way can damage it, and if it doesn’t get adequate blood supply it will die.
Because the nipples are grafts—they’re stripped of the underlying tissue—they lack the fine nerves and muscles that facilitate feeling and function. Future reliability of the NAC is difficult to predict, especially if infection occurs. One Dutch study published in 2012 showed that 40% of women who had nipple banking had complications.
Nipple banking isn’t common in the United States, but it is sometimes used for women who want to save their NAC, but their overly large, sagging breasts make them poor candidates for nipple-sparing mastectomy. Because mastectomy for these women usually involves removal of more breast skin than someone who doesn’t have droopy breasts, the natural nipples aren’t likely to end up in in the center of their smaller and higher reconstructed breasts. So the nipples are stored in the groin, and subsequently surgically attached to the new breast.
A more common nipple-sparing alternative for women with large, sagging breasts is to perform a breast reduction before nipple-sparing mastectomy, or perform a breast lift after reconstruction. (Both alternatives require reconstruction with a tissue flap.) Although this requires another visit to the OR, both methods properly center the saved NAC on the new breast, without removing them and storing them in the groin.
If you’re having immediate reconstruction and saving your nipples is important to you, talk to your oncologist to determine if you’re a candidate for nipple-sparing mastectomy. It’s not available everywhere, and not all surgeons perform this type of mastectomy, which requires additional skill and experience to preserve the blood supply to the nipple while removing the breast tissue. You’re more likely to find a surgeon who is experienced with this procedure in a large cancer center, teaching university or someone who is affiliated with a surgical practice that is devoted primarily to breast reconstruction.