Reconstruction of the Nipple-Areola Complex: How to Choose a Few, Among So Many Techniques
The nipple-areola complex (NAC) in breast reconstruction should be considered a unique aesthetic unit, and its reconstruction represents the final stage in breast reconstructions. The literature shows that this stage is essential throughout the process, and it should not be underestimated. Studies show that patients and partners assess the result of reconstruction better whenever there is the reconstruction completion of this anatomical unit compared to patients who did not undergo NAC reconstruction. In addition, the satisfaction relates to the sustained projection of the neo-nipple (especially in long term) and with the occurrence of complications. There is a great a variety of techniques published about this topic. Some authors utilized dermocutaneous grafts for NAC reconstruction. Others have opted by local flaps. The technical challenges of making a neo-nipple include proper position and projection, imperceptible scar within the areolar limits, and that whenever tattooed with a color similar to the contralateral, it matches the dimensions of the opposite breast nipple. The literature shows several difficulties faced by the surgeon until obtaining a satisfactory NAC. The projection can be of difficult maintenance (especially in patients with flabby, thin, or irradiated skin). Some patients do not feel permanently comfortable with the nipple projection. Others refuse surgical approaches, for they do not wish undergoing another procedure. Furthermore, in irradiated patients, the tattoo may be the safest option, considering the increase in the rate of complications by other techniques in this type of patient. The loss of projection and the final result of the papilla confection are related to a number of reasons: reduced subcutaneous tissue, poor flap planning, natural process of wound contraction, tissue memory, increase of the internal (strained sutures) or external pressure (e.g., the pressure made by the use of the bra), prior infection, and radiation. Therefore, the main challenge lies in rebuilding a papilla able to overcome these local obstacles and natural tendencies.
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