Introduction:
With surgery in an overall cancer incidence globally, breast cancer in women still remains to be on the top. Cancer surgery of the breast often involves partial or total removal of the breast, commonly followed by reconstruction of the breast to restore its original appearance. Sometimes in certain cases of breast cancer treatment, where removal of the Nipple-areolar complex (NAC) (the area that includes both the nipple and surrounding areola) is mandatory and cannot be overlooked or avoided. In such cases, the reconstruction of the NAC requires multiple and highly skilled techniques and is often done as the last reconstruction step. This is because restoration of the NAC is done with careful evaluation and methods of treatment with multiple objectives like restoring its anatomical structure, time difference involved in restoration, and ensuring minimal complications.
What Is the Anatomy of the Nipple Areolar Complex?
The nipple-areolar complex is a pigmented surface surrounding the prominent nipple part of the breast. These nipples are a part of the breast that comprises structures consisting of around fifteen to twenty lobes and lactating ducts converging together as mammary glands. The blood supply of the NAC is supplied by the subdermal plexus along with the breast parenchyma. The perforating vessels run across the breast along the surface called the wuringer’s septum. This structure is also highly vascularized, with the third and the fourth cutaneous nerve running along the fifth. However, the color, size, orientation of the structure, and shape vary from one patient to another.
Hence, it is necessary to keep this in mind before the reconstruction and curate it according to their preferences. According to the clinical considerations, it is considered ideal to position the nipple in the most prominent part of the breast mound, positioning it in the middle, slightly lateral to the horizontal plane, with a ratio of sixty - forty. Naturally, the proportion between the areola and the breast is between one and 3.4 and the ratio of the nipple and areola is one to three. It is also important to make sure that the NAC should be present in a line in a transverse plane beside the contralateral nipple. Although reconstruction is possible, the ability of the NAC complex to produce milk is still not compensated.
Who Is Indicated to Undergo Nipple Areolar Complex?
Although nipple reconstruction surgery is widely performed in today's scenario, there are certain criteria for patient selection. Nipple complex reconstruction surgery, that is, nipple reconstruction is ideal when done a minimum of three months after the permanent placement of prosthetic nipple rehabilitation. This surgery is delayed in patients undergoing chemotherapy or radiotherapy and should be done after the treatment. Because choosing for immediate rehabilitation of the NAC complex can lead to improper positioning of the NAC complex and can compromise the outcome.
What Are the Surgical Methods Used for the Reconstruction of the NAC Complex?
The preparation phase of the reconstruction surgery is very crucial as it requires a lot of assessments of the size, shape, structure, positioning, etc, and also to meet the requirement of the patient. However, following all these come the main pages of nipple reconstruction, and multiple techniques are used to do the reconstruction. They are:
-
Using Local Flaps: Tissues, predominantly fat tissue around the surrounding areas, are used for reconstructing the breast and nipple. This is because these tissues, which are common around the area, comprise similar patterns of skin subcutaneous tissues and skin along with a similar blood supply. The most commonly chosen flap for this surgery is the skate, modified skate flap, Hammond flap, star flap, fishtail flap, C-V flap, arrow, or bell flap. However, most of these flaps show loss of nipple projection irrespective of the improvising attempts to gain success.
-
Nipple Sharing: This is the method of transferring a part of the nipple from the adjacent breast to the breast to be reconstructed. The method is done by harvesting the contralateral nipple longitudinally or transversely and grafted on the other side. The best advantage of nipple sharing is that it shows an exact replica along with the color and the texture that must match with the adjacent one.
-
Using Skin Grafts: Grafts of the skin are also used in the reconstruction of the areola or the entire NAC complex. Grafts that are full in thickness are taken from sites that are pigmented, like the axilla or the inner thighs are usually preferred. The other option for inducing hyperpigmentation from the flaps is through skin dermabrasion.
-
Using Nipple Prosthetics: Nipple prosthetics are nipple-like silicone models made from molds that recreate the appearance of the nipple. These external nipple reconstruction processes are very comfortable for the patients as they require a very minimally invasive procedure. The NAC prosthesis has a life-like appearance that is then attached to the mound of the breast along with the silicone tape. However, it is important to remove these silicone tapes and cleans the prosthesis to maintain hygiene. The internal prosthesis is the one that is directly attached to the breasts and shows the advantage of a constant projected surface, although it also has a high chance of infection risk, extrusion, and formation of a capsule.
-
Through Intradermal Tattooing: Intradermal tattooing is a concept that is used to color the areola after reconstructing the nipple with a local flap. The color used for tattooing is darker than the normal color as it fades over a period of time. The tattooing of the skin is advised three to four months after the surgery, as most of the flaps tend to shrink post-surgery. Here both normal and three-dimensional tattooing techniques are also performed during reconstruction.
-
Using Regenerative Medicine After Tissue Engineering: Here, the nipple replacement is done using advanced technologies like three dimensional printing. This 3D reconstruction uses 3D printed tissue nipples that have shown great improving performances. However, these advanced techniques are still used only in animal models and will take time to be implied in human treatment modalities.
What Are the Complications of NAC Reconstruction?
Although NAC reconstruction is a successful surgery, there are quite a few complications to the same, where the commonly anticipated symptom is the loss of projection of the reconstructed nipple of about forty-five to seventy percent. The other complications also include graft failure, which can be a complete or partial failure. And one of the least common complications includes the unevenness or asymmetry of the reconstructed nipples, which can also occur due to reasons like tissue shrinkage or surgery earlier than the healing time.
Conclusion:
The main purpose of performing this nipple alveolar complex reconstruction surgery is that it affects the patient in physiological, psychological, and esthetic appearance, and there is an important need to restore the three. NAC reconstruction can be a tedious task and requires a well-skilled team of multidisciplinary doctors like the oncologist (cancer specialist), the surgeons, the radiologist (radiological imaging specialist), and surgical assistants and nurses. With this successful interpretation of the surgical team, patients have better chances of gaining a positive outcome from the surgery.
