Along with accepting the need for mammary reconstruction as a conduit for breast post ablation, the interest in the reconstruction of the nipple and mammary areola increased. Physicians have begun to realize, from a psychological point of view, the importance for the patient that a reconstructed breast must also be aesthetic. Reconstructive mammary surgery has begun to be performed approximately 30 years ago, and nowadays new techniques and approaches are being developed for the benefit of patients.
Even so, in the minds of patients who undergo this type of intervention, a beautiful-shaped breast, placed in a correct position, is not finished as long as the nipple and the mammary areola are not reconstructed as finely as possible. Reconstructive methods of the nipple and areola are multiple, each having its advocates from among plastic surgeons, with their advantages and disadvantages. As a reconstructive tissue graft, labial tissue or skin of the scrotum are successfully used. A major challenge is how to obtain symmetry and appearance closer to that of normal nipple and areola.
MEDICAL TATTOO
The multiple needle tattoo method is used to obtain a mixture of light brown and natural color of the areolar tissue. The technique is simple: a drawing of the areola to be tattooed is possible, useful; it is preferable that the needles penetrate the skin diagonally and not vertically. The areola edges normally do not have to be well defined.
NIPPLE AND AREOLA GRAFT
The use of dermatomy to obtain a medium thickness graft for areola and nipple gives a satisfactory result. Normally, the healing of the donor nipple and areola is good when the graft does not exceed the average thickness. Of course, the graft should be placed on a rich vascular bed and should not be placed subcutaneously. Taking more grafting is better, the graft area tends to be higher than the surrounding skin, which gives it a look closer to the normal one.
METHOD OF AREOLA DIVISION
“Full – thickness graft” at the areola level is obtained from the skin of the opposite breast areola reduced in size. The reduction in diameter of the areola can be achieved without reducing the size of the breast.
LABIAL TISSUE GRAFT
Grafting from small or large labia tissues turns out to be one of the most compatible methods of nipple and areola reconstruction, provided they are darker in color. Usually half a circle of a small lace is excised and stretched to form a complete circle.
The graft must be perfectly relaxed because when contracting it must stay light in the new place. The donor area will be sutured by keeping 1-2 spaces between the suture threads using the 4/0 type chrome thread followed by 5/0. The graft is sutured at the level of the recipient skin area with wires to be removed, the “tie-over” dressing technique is usually the best.
In some cases, the middle part of the slightly thicker or slightly cut graft may be left to simulate the nipple’s normal appearance in the middle of the areola. The grafts taken from the labial tissue are darker in color, usually darker than the opposite nipple or the areola, but offer a satisfactory result.
SKIN GRAFTS OBTAINED FROM GROIN
The graft taken from the inguinal area as close as possible to the genitals is probably the most used method of reconstruction of the areola. If the areola on the opposite side is lighter, this type of graft offers a good fit. The central part can serve as nipple construction material later or in the same surgical session.
GRAFTS OBTAINED FROM POSTAURICULARLY TISSUE, EYELIDS, NECK OR AXILLA
The skin from virtually any area of the body can be used to reconstruct the areola but it is preferable to harvest the graft from areas where scars can be hidden, areas that provide better graft quality. The skin of the eyelids can provide good satisfaction compared to the skin of the neck; the one in the axilla gives more chances of matching as color but it is inconvenient to have the hair follicles that exist, leading to a hairy areola, requiring IPL or laser hair removal.
“DONUT” SKIN GRAFT
This is a simple method of reconstruction of the nipple and areola in a single session. It consists of sampling a circular portion of tissue with a diameter close to the diameter of the opposite areola, which is applied to the area to be grafted. The graft can be taken from the thigh tissue. Once placed carefully, a star-shaped incision is made in the middle of the graft, allowing the graft to adhere to the new site. A small auricular cartilage graft is placed under the skin followed by a single suture resulting in the filling of the central area of the graft in order to reconstruct the nipple. The light skin color can then be tattooed and brought to the normal color of the opposite areola.
DIVIDING THE NIPPLE
When the opposite nipple is prominent, a graft of this tissue is borrowed for reconstruction.
The most satisfying method of reconstruction in men is the graft tissue from the scrotum. This type of graft provides a real and natural look. The central part can then be transformed into a nipple.
SILICON IMPLANT
A large number of plastic materials – silicone – the most used, of different shapes were used to lift the central part of the graft to reconstruct the nipple.
DESIGNING THE GRAFT AREOLA
Different methods of designing the center of the graft have been used to reconstruct the nipple. A common method is the trigeminal or trapezoidal resection of the skin, followed by suturing around the central area to reveal the nipple. This method can be combined with the “advancement flap” implant. This method is useful for the reconstruction of a stretched and flattened nipple.
OVERLAPPED GRAFT
Grafts obtained from labial tissue, external haemorrhoidal tissue, auricular lobe, axillary tissue, and even large nerves, can be used to provide color, consistency and prominence to the nipple graft.
COMPOSITE GRAFT
This type of graft consists in using the skin and the cartilage taken from behind the ear. It can be effective as long as it is not very thick, it is strongly vascularized, and the suture is not very tight. The graft should be arranged carefully, edge-to-edge on the new site.
FILLER INJECTIONS
They have been used to design the central area of an areola graft to form the nipple, the inconvenience being that the substance is absorbed over time. There is hope that the autologous fat graft obtained by aspiration will have more success.
ALL THE TECHNIQUES CURRENTLY USED HELP PATIENTS TO FEEL WHOLE AGAIN!
