Reconstruction of the areola can be achieved very successfully by tattoo alone or by skin grafting. ‘Nipple and areola sharing’ methods are rarely used today. In this method, the normal unaffected areola is reduced in order to create a new areola on the reconstructed breast. Donor site scarring and potential damage to milk ducts and breast-feeding, as well as to the erogenous structure, have made this technique unpopular. Skin grafting is a commonly used technique for areola reconstruction. The upper inner thigh is a popular site for taking a full thickness skin graft, as skin from this area is more pigmented than breast skin. Other sites include skin from the labia and from behind the ear. These are not so popular as patients find them less acceptable.
NAC reconstruction using full thickness skin graft from the upper thigh
Ready for graft Full thickness grafts in place
Tattooing
The quality of pigments available for medical tattooing has improved greatly over the last fifteen years, giving a more natural and less ‘painted on’ appearance. Tattooing can be used independently for
areola reconstruction (the reconstructed nipple is also tattooed a darker shade than the areola) or as a final ‘touch-up’ technique to achieve the best colour match and symmetry. Tattooing is generally done six to twelve weeks after nipple reconstruction to allow your wounds to heal and your nipple to contract down. Some surgeons prefer to have the tattoos done before nipple reconstruction. The advantages of tattooing are the lack of need for a donor site and extremely realistic results. It can be done on an outpatient basis, is quick to perform, and risks such as allergies are very low. The dis - advantages of tattooing are that the pigments fade with time and therefore secondary touch-ups are not uncommon. The technique of tattooing requires training and experience to achieve good results. Rarely, overcorrection with the tattoo may persist.
Stages of tattooing: the patient had a delayed DIEP breast
reconstruction followed by nipple reconstruction alone (the normal nipple is small)
Marking the areola Applying the pigment
Results
The following pictures show a selection of postoperative results. These are average results and not necessarily a selection of the best. Nipple reconstruction is often carried out three to six months after breast reconstruction, using a technique such as the CV flap (described above) followed by areola tattooing some six to twelve weeks later.
Latissimus dorsi (LD) with implant reconstruction and nipple reconstruction with full thickness grafts
Left delayed DIEP breast reconstruction with faded NAC reconstruction requiring top-up tattoo (the areola was a tattoo only)
Left delayed DIEP flap breast reconstruction and NAC reconstruction with right-sided reduction (the areola is a tattoo only)
I was not so happy with the match of the new nipple but after having the colour tattooed on, I felt much happier.
The reconstructed nipple did have some colour but as it settled down over a period of time, it became patchy. I had it tattooed to
make it a better colour match. I think that it was worth it. You can live without it but it is important for the sake of your
appearance.
Although I was very pleased with the nipple reconstruction as it was, I decided to have the nipple colour tattooed on as well. I had
been completely undressed once or twice in the female showers at the swimming pool and just felt slightly conscious that one side
was coloured and the other was not. The colour was not uniform all over. I have been told that it will fade. I shall leave it and see
how it goes but know that I can have it coloured again in the future.
I did have a nipple reconstruction, which initially was thoroughly disappointing because it was not a good shape and it turned white when it healed. However, it was still better than having no
nipple. I took the breast care nurse’s advice and had the nipple tattooed and it looks much better now. The size and colour of the
area matches the other breast and I am glad that it has been done.
Complications
Complications of NAC reconstruction are rare, but they need to be discussed. They include wound infection and wound breakdown, and there may be partial or complete nipple loss if the blood supply to your nipple is poor. This may be due to the design of the flaps, or sometimes where radiotherapy or smoking has affected the blood supply of the skin. A common complication is loss in the projection of your nipple. This is usually acceptable, but correction can be achieved using local tissue, cartilage or commercial fillers if required. Complications of
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areola reconstruction include fading of the tattoo and, rarely, a tattoo that is too dark. Top-up tattooing to correct fading is a simple procedure. Complications of areola reconstruction when your surgeon has used a skin graft include wound infection and poor graft ‘take’. This happens when the skin doesn’t pick up a good blood supply from its new position on the breast and some of the skin dies away. This can lead to loss of part of the graft, or occasionally the whole graft.