Open Medicine Journal




ISSN: 1874-2203 ― Volume 5, 2018
REVIEW ARTICLE

Nipple Reconstruction Techniques: Which is the Best Choice?



Nicolò Bertozzi1, *, Francesco Simonacci1, Marianna Pesce2, PierLuigi Santi2, Edoardo Raposio1
1 Department of Medicine and Surgery, Plastic Surgery Division, University of Parma; Cutaneous, Mini- invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
2 Department of Surgery and Related Methodologies, Plastic Surgery Section, San Martino-IST University of Genova, Genova, Italy

Abstract

Nipple-Areolar Complex (NAC) reconstruction represents the final, concluding journey of breast reconstruction by being able to give to reconstructed breasts the shape of a natural breast mound. Nevertheless an enormous amount of nipple reconstruction techniques are described in literature, given the fact that most reconstructive options fail to give satisfactory outcomes in relation to the long-term nipple projection. In this review, the authors will browse most common nipple reconstruction techniques, taking into account: Indication, outcome, and side effect. Composite nipple grafts, traditional flaps, flaps with autologous graft augmentation, flaps with allograft augmentation, and flaps with alloplastic augmentation are the main strategies employed nowadays. Composite nipple grafts give the best guarantee of color-texture match with the contralateral side and show satisfactory nipple projection even at long-term follow-up. Skate, star, C-V, and arrow flap are by far the most commonly employed and the most reliable local flaps, however loss of projection of up to 70 percent are reported in literature. Alloplastic grafts were associated with the lowest rates of projection loss followed by autologous and allogenic ones. Nevertheless allogenic grafts are also associated with the highest complication rate, while autologous and allogenic ones have similar rates. Infection, seroma, and fat necrosis are the more commonly reported complications of autologous grafting along with donor site morbidity, while allogenic and alloplastic augmentation grafts may also experience the risk of overcorrection and graft exposure. Given the numerous techniques described in literature it is clear that the ideal nipple reconstruction hasn’t been found yet. Whereas it should be chosen on case to case basis depending on type of mastectomy, radiotherapy, type of reconstruction, skin thickness, tissue condition, and patients’ expectations to ensure the best cosmetic outcome.

Keywords: Nipple-areola complex reconstruction, Breast cancer, Breast reconstruction, Plastic Surgery, Surgical techniques, Alloplastic grafts, Allogenic grafts.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 5
First Page: 62
Last Page: 75
Publisher Id: MEDJ-5-62
DOI: 10.2174/1874220301805010062

Article History:

Received Date: 7/5/2018
Revision Received Date: 6/9/2018
Acceptance Date: 19/9/2018
Electronic publication date: 18/10/2018
Collection year: 2018

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© 2018 Bertozzi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medicine and Surgery, Plastic Surgery Division, University of Parma; Cutaneous, Mini- invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy, Tel: +393342439587; E-mail: nicolo.bertozzi@yahoo.com




1. INTRODUCTION

Nipple-Areolar Complex (NAC) reconstruction represents the final, concluding journey of breast reconstruction [1Nimboriboonporn A, Chuthapisith S. Nipple-areola complex reconstruction. Gland Surg 2014; 3(1): 35-42.[PMID: 25083492] ]. Despite being the less technically challenging step of breast reconstruction, it is of great concern for patients from an aesthetic and psychological point of view [2Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: A systematic review and meta-analysis. Gland Surg 2017; 6(1): 4-13.[http://dx.doi.org/10.21037/gs.2016.08.01] [PMID: 28210547] ]. Indeed recreated NAC can finally give to reconstructed breasts the shape of a natural breast mound. Furthermore NAC reconstruction can be done anytime and following any type of breast reconstruction strategy.

Nevertheless an enormous amount of nipple reconstruction techniques and approach can be found in literature, given the fact that most reconstructive options fail to give satisfactory outcomes in relation to the long-term nipple projection [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.].

2. MATERIALS AND METHODS

In this review, the authors will browse most common nipple reconstruction techniques, taking into account: indication, outcome, and side effect. Notes of surgical technique won’t be taken into consideration since it goes beyond the aim of this paper and are described in deep in numerous papers and books chapters.

A literature search was conducted across PubMed database from inception to March 2018 in order to identify a list of article of potential interest. Among those identified, manual review of titles, abstract and main text was conducted sequentially to capture relevant articles to be added to our paper. The keywords used for the search in the database were: “nipple,” AND “reconstruction,” OR “augmentation,” OR “areola,” OR “breast reconstruction,” OR “graft,” OR “allogeneic,” OR “autologous,” OR “synthetic”.

Prospective, retrospective studies, and systematic reviews were included only if reporting outcomes of either nipple or NAC reconstruction following mastectomies. Each articles had to report nipple reconstruction outcomes and follow-up periods in order to be included. Whereas studies only describing surgical techniques or reviews with patient cohorts of articles already included in this review were excluded Chart. (1).

Chart. (1)
Study’s flowchart schematically reporting articles inclusion and exclusion criteria.


3. RESULTS

3.1. Anatomical Landmark

When recreating a normal breast mound, correct anatomical landmarks should be clearly kept in mind. Ideally, the nipple should be located at the point of maximum projection on the breast mound as it can be seen in a youthful breast, having a sternal notch-nipple distance ranging from 19 to 21 cm and a nipple to inframmammary fold distance ranging from 7 to 8 cm [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.].

Furthermore nipples can differ even greatly from one person to another for what concerns: Size, shape, color, and position. Nevertheless nipples have an average 1.3 cm diameter, 0.9 cm high, and nipple-areola ratio of approximately 1:3 [4Sanuki J, Fukuma E, Uchida Y. Morphologic study of nipple-areola complex in 600 breasts. Aesthetic Plast Surg 2009; 33(3): 295-7.[http://dx.doi.org/10.1007/s00266-008-9194-y] [PMID: 18626683] ].

These measures can be particularly helpful in patients that underwent bilateral breast reconstructions, while the contralateral side guides the reconstructive strategy in monolateral ones.

3.2. Timing

Adjuvant therapies and revisional reconstructive procedures (including contralateral matching surgeries) guide timing of NAC reconstruction, which should be ideally done after a 3-5 months period following the last reconstructive procedure in order to let inflammation and edema fade [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. Furthermore the breast mound would appear in his final shape having reached the desired grade of ptosis after this time break [5Nahabedian MY. Nipple reconstruction. Clin Plast Surg 2007; 34(1): 131-7. [abstract vii.].[http://dx.doi.org/10.1016/j.cps.2006.11.009] [PMID: 17307077] ].

3.3. Patient Selection

Based on the reconstructive strategy, proper nipple reconstruction technique should be employed. Indeed prosthetic-based reconstructions tend to have thin skin as a consequence of skin expansion, while autologous reconstructions have skin paddle of various shape and varying skin thickness depending on the flap used [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. Furthermore when present, contralateral NAC characteristics have to be taken into consideration when planning adequate matching reconstruction approach.

3.4. Nipple Reconstruction Techniques

Among the many ways to recreate a nipple, reconstructive strategies can be dived into the following categories: composite nipple grafts, traditional flaps, flaps with autologous graft augmentation, flaps with allograft augmentation, and flaps with alloplastic augmentation.

4. COMPOSITE NIPPLE GRAFTS

Special consideration should be given to composite nipple grafts. Distant site composite grafts were employed successfully. Toe pulp, and labial tissue grafts gave satisfactory results; however donor site morbidity made these techniques fall in disuse [6Amarante JT, Santa-Comba A, Reis J, Malheiro E. Halux pulp composite graft in nipple reconstruction. Aesthetic Plast Surg 1994; 18(3): 299-300.[http://dx.doi.org/10.1007/BF00449798] [PMID: 7976765] , 7Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: An original easy technique. Aesthetic Plast Surg 2005; 29(4): 287-94.[http://dx.doi.org/10.1007/s00266-004-0145-y] [PMID: 16044237] ]. Only contralateral nipple grafts still be even nowadays a widespread technique when patients have a contralateral over projected nipple [8Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg 1997; 50(5): 331-4.[http://dx.doi.org/10.1016/S0007-1226(97)90541-5] [PMID: 9245866] ]. Indeed nipples exceeding 1 cm in high can be safely removed of their distal portion to be used as free composite graft for contralateral nipple reconstruction with aesthetically pleasant outcomes. Nevertheless contralateral surgery, additional morbidity, reduced contralateral nipple sensation, and related addition emotional/psychological distress make patients incline to different reconstructive options [8Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg 1997; 50(5): 331-4.[http://dx.doi.org/10.1016/S0007-1226(97)90541-5] [PMID: 9245866] ]. Contralateral composite nipple graft is a feasible option even in irradiated breasts, and graft survival is likely to occur if proper medications are performed in the postoperative days [9Zenn MR, Garofalo JA. Unilateral nipple reconstruction with nipple sharing: Time for a second look. Plast Reconstr Surg 2009; 123(6): 1648-53.[http://dx.doi.org/10.1097/PRS.0b013e3181a3f2f9] [PMID: 19483562] ]. Nipple grafts usually have an early postoperative discoloration; however altered pigmentation and hypertrophic scarring are usually not observed. Indeed composite nipple grafts give the best guarantee of color-texture match with the contralateral side and show satisfactory nipple projection even at long-term follow-up [10Spear SL, Schaffner AD, Jespersen MR, Goldstein JA. Donor-site morbidity and patient satisfaction using a composite nipple graft for unilateral nipple reconstruction in the radiated and non-radiated breast. Plast Reconstr Surg 2011; 127: 1-10.[http://dx.doi.org/10.1097/PRS.0b013e318208d107] [PMID: 20871489] -12Winocour S, Saksena A, Oh C, et al. A Systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg 2016; 137(1): 14e-23e.[http://dx.doi.org/10.1097/PRS.0000000000001861] [PMID: 26710046] ] (Table 1).

Table 1
Study’s flowchart schematically reporting articles inclusion and exclusion criteria.


5. TRADITIONAL FLAPS

Over the last 30 years numerous local flaps along with their modifications were designed for nipple reconstruction; all of them owe their design to the Little’s skate flap and Anton’s arrow flap [13Little JW III. Nipple-areola reconstruction. Clin Plast Surg 1984; 11(2): 351-64.[PMID: 6373095] -35Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: An update. J Plast Reconstr Aesthet Surg 2006; 59(1): 40-53.[http://dx.doi.org/10.1016/j.bjps.2005.08.006] [PMID: 16482789] ]. The development of a high amount of flaps described in literature can be explained the lack of the currently available techniques to provide reliably and predictably projection to the reconstructed nipples over time. Indeed 25 to 50% projection are lost on average due to scar contraction, thus reconstructed nipples should be initially overprojected in order to obtain satisfying cosmetic outcomes [35Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: An update. J Plast Reconstr Aesthet Surg 2006; 59(1): 40-53.[http://dx.doi.org/10.1016/j.bjps.2005.08.006] [PMID: 16482789] ].

Two are the main causes of loss of projection: retraction forces and tissue contraction. Retraction forces exerted by surrounding and underlying tissues in order to return to their original position have to ability to reduce projection [35Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: An update. J Plast Reconstr Aesthet Surg 2006; 59(1): 40-53.[http://dx.doi.org/10.1016/j.bjps.2005.08.006] [PMID: 16482789] ]. Furthermore centrally-based flaps are more subjection to retraction forces than subdermal-based ones. Contraction or shrinkage of reconstructed nipples occurs as a consequence of scar contraction and compromised blood supply at various and unpredictable degree.

Among the various flaps designed, C-V, S, star, skate, and arrow flaps are by far the most commonly employed [2Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: A systematic review and meta-analysis. Gland Surg 2017; 6(1): 4-13.[http://dx.doi.org/10.21037/gs.2016.08.01] [PMID: 28210547] ].

Skate flap is one of the most appreciated flaps since it can reliably recreate a projected nipple over time [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. It’s a centrally-based flap that includes subdermal fat to guarantee long-term nipple projection. In its original design it leaves a doughnut-shaped area that needs to be grafted recreating the areola at the same time of nipple reconstruction. Modifications allowed for direct closure, nevertheless tapered flap design increases tension and retraction forces and tend to flatten reconstructed breasts.

Shestak [15Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: A comparison of three techniques. Plast Reconstr Surg 2002; 110(3): 780-6.[http://dx.doi.org/10.1097/00006534-200209010-00010] [PMID: 12172139] ] compared long-term results of reconstructed nipples with bell, skate, and star flaps and have found out that: (1) major loss of projection occurs during the first 3 post-operative months, while results tend to stabilize after the first six; (2) bell flap gives the worse results over time, while skate and arrow flaps can achieve the best outcomes; (3) skate flap is the most appropriate choice when projection goal is >5 mm. Richer et al. [16Richter DF, Reichenberger MA, Faymonville C. Comparison of the nipple projection after reconstruction with three different methods. Handchir Mikrochir Plast Chir 2004; 36(6): 374-8.[http://dx.doi.org/10.1055/s-2004-821031] [PMID: 15633081] ] also describes skate flap as the best reconstructive choice. Zhong et al. [17Zhong T, Antony A, Cordeiro P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg 2009; 62(5): 591-5.[http://dx.doi.org/10.1097/SAP.0b013e31819fb1c9] [PMID: 19387168] ] described the high series of reconstruction (422 patients) with the skate flap, and reported a mean projection of 2.5 mm at 44 months of follow-up. Furthermore they reported that minor complication occurred in 7.22% of reconstructions: skin graft donor site dehiscence was the most common (3.1%) followed by partial graft non-take (2.1%).

Star flap has similar design to skate flap, nevertheless it allows for direct closure not requiring skin graft, thus reducing donor-site morbidity [18Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg 1997; 99(6): 1602-5.[http://dx.doi.org/10.1097/00006534-199705010-00020] [PMID: 9145129] ]. Opposing to skate flap, direct closure do not flatten reconstructed breast, furthermore the result scar is linear and can lie on the one resulting from skin sparing mastectomy. However it is reported to have lower nipple projection retention at long-term follow-up [19Alfano C, Tenna S, Caggiati A, Campanella A. Nipple reconstruction by local flaps: A long-term comparative study between star and skate techniques. Acta Chir Plast 2004; 46(4): 127-31.[PMID: 15715145] ]. Banducci et al. [20Banducci DR, Le TK, Hughes KC. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg 1999; 43(5): 467-9.[http://dx.doi.org/10.1097/00000637-199911000-00001] [PMID: 10560860] ] reported that star flap retain higher long-term projection when performed on autologous reconstructions, while Few et al. [21Few JW, Marcus JR, Casas LA, Aitken ME, Redding J. Long-term predictable nipple projection following reconstruction. Plast Reconstr Surg 1999; 104(5): 1321-4.[http://dx.doi.org/10.1097/00006534-199910000-00012] [PMID: 10513912] ] reported no differences between autologous and implant-based ones. Furthermore they reported that wings lengths predictably correlate with initial and long-term projection.

C-V flap fuses skate and star flap designed into a pedicle-based flap that is easy to elevate and ensure direct closure of donor site [15Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: A comparison of three techniques. Plast Reconstr Surg 2002; 110(3): 780-6.[http://dx.doi.org/10.1097/00006534-200209010-00010] [PMID: 12172139] , 22Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: A long-term evaluation. Plast Reconstr Surg 2001; 108(2): 361-9.[http://dx.doi.org/10.1097/00006534-200108000-00013] [PMID: 11496176] -24El-Ali K, Dalal M, Kat CC. Modified C-V flap for nipple reconstruction: Our results in 50 patients. J Plast Reconstr Aesthet Surg 2009; 62(8): 991-6.[http://dx.doi.org/10.1016/j.bjps.2007.12.059] [PMID: 18595790] ]. When employed for nipple reconstruction in implant-based breast reconstructions, higher amount of vascularized tissue should be included in the core of the flap to compensate for the dermal thinning caused by tissue-expansion stage (Fig. 1).

Fig. (1)
A 43-year-old female patient who had undergone skin sparing mastectomy and expander-implant based right breast reconstruction. (a,b) Follow-up two months after contralateral symmetrization surgery of the left breast. (c) Frontal and lateral view of reconstructed nipple by means of at the 1st post-operative months (d,e).


Arrow flap is a versatile flap characterized by geometric design, ease of dissection, and fast learning curve [25Li W, Mu LH, Luan J, et al. Nipple-areolar reconstruction with the modified arrow flap. Zhonghua Zheng Xing Wai Ke Za Zhi 2008; 24(1): 23-5.[PMID: 18437977] , 26Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: The ‘arrow flap’. Br J Plast Surg 2003; 56(3): 247-51.[http://dx.doi.org/10.1016/S0007-1226(03)00094-8] [PMID: 12859920] ]. It allows for direct closure but it adds a further vertical scar that can be covered by tattooing of the areola. Rubino et al. [26Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: The ‘arrow flap’. Br J Plast Surg 2003; 56(3): 247-51.[http://dx.doi.org/10.1016/S0007-1226(03)00094-8] [PMID: 12859920] ] reported a better projection retention of their modification of the arrow flap when compared to the modified star flap. Furthermore no outcome difference was reported between autologous and implant-based breast reconstructions, with good patients satisfaction and compliance.

Bell, double opposing peri-areolar/purse-string, and top-hat flaps have different design than the previous ones since they are defined as pull-out/purse-string flaps [15Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: A comparison of three techniques. Plast Reconstr Surg 2002; 110(3): 780-6.[http://dx.doi.org/10.1097/00006534-200209010-00010] [PMID: 12172139] , 26Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: The ‘arrow flap’. Br J Plast Surg 2003; 56(3): 247-51.[http://dx.doi.org/10.1016/S0007-1226(03)00094-8] [PMID: 12859920] -29Gamboa-Bobadilla GM. Nipple reconstruction: The top hat technique. Ann Plast Surg 2005; 54(3): 243-6.[PMID: 15725823] ]. These flaps mobilize surrounding tissue through purse-string techniques in order to recreate a projected nipple; however a supple breast mound is required to perform these flaps.

As previously reported, Shestak [15Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J. Assessment of long-term nipple projection: A comparison of three techniques. Plast Reconstr Surg 2002; 110(3): 780-6.[http://dx.doi.org/10.1097/00006534-200209010-00010] [PMID: 12172139] ] found that bell flap is not able to provide over time highly projected nipples, hence it should be performed only in case of contralateral nipple that has a projection of 2-3 mm.

Double opposing peri-areolar/purse-string flap is a good option in case of autologous-based reconstructed breasts that have large skin paddles and thick dermal/subcutaneous layers [27Dolmans GH, van de Kar AL, van Rappard JH, Hoogbergen MM. Nipple reconstruction: The “Hammond” flap. Plast Reconstr Surg 2008; 121(1): 353-4.[http://dx.doi.org/10.1097/01.prs.0000300297.72188.e4] [PMID: 18176266] , 28Shestak KC, Nguyen TD. The double opposing periareola flap: A novel concept for nipple-areola reconstruction. Plast Reconstr Surg 2007; 119(2): 473-80.[http://dx.doi.org/10.1097/01.prs.0000246382.40806.26] [PMID: 17230078] ].

Top-hat flap has peculiar design given the fact that no true flap is lifted, and purse-string sutures are used to give projection to the reconstructed nipple [29Gamboa-Bobadilla GM. Nipple reconstruction: The top hat technique. Ann Plast Surg 2005; 54(3): 243-6.[PMID: 15725823] ]. It is a centrally-based flap with broad base, thus high retraction forces are exerted preventing it from being able to achieve projected nipples over time.

Finally, S, double-opposing tab, and spiral flaps are the best choice when blood supply is an issue [18Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg 1997; 99(6): 1602-5.[http://dx.doi.org/10.1097/00006534-199705010-00020] [PMID: 9145129] , 30Cheng MS, Ho CM, Cheung WY, Or A, Wong WM. Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients’ perspective. Ann Plast Surg 2004; 53(4): 328-33.[http://dx.doi.org/10.1097/01.sap.0000137247.53249.a1] [PMID: 15385765] -33Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: The S flap. Plast Reconstr Surg 1988; 81(5): 783-7.[http://dx.doi.org/10.1097/00006534-198805000-00026] [PMID: 3362992] ]. Indeed, low blood supply is not only responsible for promoting scar tissue formation hence reconstructed nipple retraction, but also can led to partial or total flap loss.

S flap is a double-opposing flap oriented in a S-configuration, ideated by Cronin [33Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: The S flap. Plast Reconstr Surg 1988; 81(5): 783-7.[http://dx.doi.org/10.1097/00006534-198805000-00026] [PMID: 3362992] ] in case of transversely located mastectomy scars. In the modification of Lossing et al. [30Cheng MS, Ho CM, Cheung WY, Or A, Wong WM. Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients’ perspective. Ann Plast Surg 2004; 53(4): 328-33.[http://dx.doi.org/10.1097/01.sap.0000137247.53249.a1] [PMID: 15385765] ] no skin grafts were required for donor-site closure and 1 cm back-cuts were added to ease flap rotation, however the risk for tip necrosis increased greatly. Furthermore 80% projection was lost at 36 month of follow-up.

Double-opposing tab flap is also designed as double-opposing flaps placed on either side of mastectomy scars that transverse ideal nipple position. In the works of Kroll [18Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg 1997; 99(6): 1602-5.[http://dx.doi.org/10.1097/00006534-199705010-00020] [PMID: 9145129] , 32Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing-tab flap. Plast Reconstr Surg 1989; 84(3): 520-5.[http://dx.doi.org/10.1097/00006534-198909000-00026] [PMID: 2762412] ] double-opposing tab flap proved itself to be a better choice than S flap by being able to provide satisfying projection over long-term follow-up.

Spiral flap is characterized by simple design and ease of elevation. It employs only little amount of breast skin since it is designed over the mastectomy scar. However including scar tissue within the flap can result in reduced blood supply and limited projection over long-term follow-up [34Di Benedetto G, Sperti V, Pierangeli M, Bertani A. A simple and reliable method of nipple reconstruction using a spiral flap made of residual scar tissue. Plast Reconstr Surg 2004; 114(1): 158-61.[http://dx.doi.org/10.1097/01.PRS.0000128378.13290.36] [PMID: 15220585] ] (Table 2).

Table 2
Studies reporting outcomes following composite nipple grafts.


6. AUTOLOGOUS GRAFT WITH TRADITIONAL FLAPS

In the attempt to provide long-term maintenance of projection to reconstructed nipples, autologous, allogenic, and alloplastic grafts were incorporated in the architecture of traditional flaps [7Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: An original easy technique. Aesthetic Plast Surg 2005; 29(4): 287-94.[http://dx.doi.org/10.1007/s00266-004-0145-y] [PMID: 16044237] , 36Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New technique for nipple areola reconstruction: Arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg 2003; 50(1): 31-7.[http://dx.doi.org/10.1097/00000637-200301000-00006] [PMID: 12545106] -58Tierney BP, Hodde JP, Changkuon DI. Biologic collagen cylinder with skate flap technique for nipple reconstruction. Plast Surg Int 2014; 2014: 194087.[http://dx.doi.org/10.1155/2014/194087] [PMID: 25114802] ].

Among the various autologous grafts available, costal cartilage is one of the most valuable, particularly when performing free flap breast reconstructions where a little portion of costal cartilage is removed during dissection of the internal mammary vessels and can be banked for the time of nipple reconstruction [36Guerra AB, Khoobehi K, Metzinger SE, Allen RJ. New technique for nipple areola reconstruction: Arrow flap and rib cartilage graft for long-lasting nipple projection. Ann Plast Surg 2003; 50(1): 31-7.[http://dx.doi.org/10.1097/00000637-200301000-00006] [PMID: 12545106] -40Mori H, Uemura N, Okazaki M. Nipple reconstruction with banked costal cartilage after vertical-type skin-sparing mastectomy and deep inferior epigastric artery perforator ap. Breast Cancer 2015; 22: 85-97.[http://dx.doi.org/10.1007/s12282-011-0329-7] ]. Thus costal cartilage harvest has minimal donor site morbidity and authors reported sustained nipple projection. However costal cartilage graft are discouraged in case of breasts reconstructed by means of thick and stiff skin flap as the SGAP flap because of the unsatisfying results [39Cheng MH, Rodriguez ED, Smartt JM, Cardenas-Mejia A. Nipple reconstruction using the modified top hat flap with banked costal cartilage graft: Long-term follow-up in 58 patients. Ann Plast Surg 2007; 59(6): 621-8.[http://dx.doi.org/10.1097/SAP.0b013e318048573c] [PMID: 18046141] ]. Furthermore costal cartilage guarantees superior nipple projection maintenance over time when compared to the other autologous grafts employed, however the excessive rigidity of reconstructed nipples can be an issue for patients. Finally complications as partial flap loss, nipple malposition, and cartilage exposure may occur in as high as 12% of reconstructions [39Cheng MH, Rodriguez ED, Smartt JM, Cardenas-Mejia A. Nipple reconstruction using the modified top hat flap with banked costal cartilage graft: Long-term follow-up in 58 patients. Ann Plast Surg 2007; 59(6): 621-8.[http://dx.doi.org/10.1097/SAP.0b013e318048573c] [PMID: 18046141] ].

Auricular cartilage was also advocated as augmentation graft for nipple reconstruction [41Jones AP, Erdmann M. Projection and patient satisfaction using the “Hamburger” nipple reconstruction technique. J Plast Reconstr Aesthet Surg 2012; 65(2): 207-12.[http://dx.doi.org/10.1016/j.bjps.2011.09.014] [PMID: 21958990] , 42Tanabe HY, Tai Y, Kiyokawa K, Yamauchi T. Nipple-areola reconstruction with a dermal-fat flap and rolled auricular cartilage. Plast Reconstr Surg 1997; 100(2): 431-8.[http://dx.doi.org/10.1097/00006534-199708000-00025] [PMID: 9252612] ]. Results showed higher loss in projection when compared to costal cartilage grafts, with minimal but still higher donor site morbidity, and low complication rate.

Fat graft has been also proposed for reconstructed nipple augmentation. Bernard [43Bernard RW, Beran SJ. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg 2003; 112(4): 964-8.[http://dx.doi.org/10.1097/01.PRS.0000076245.12249.BE] [PMID: 12973210] ] advocates for fat grafting the site where nipple is going to be recreated prior to C-V flap elevation, especially in breast that underwent tissue expansion. While Eo et al. [44Eo S, Kim SS, Da Lio AL. Nipple reconstruction with C-v flap using dermofat graft. Ann Plast Surg 2007; 58(2): 137-40.[http://dx.doi.org/10.1097/01.sap.0000235445.86570.80] [PMID: 17245138] ] grafted dermal fat harvested from discarded breast tissue at the center of a C-V flap. Fat graft is easy, fast, with minimal donor site morbidity, and they found satisfactory long-term nipple projection. However high reabsorption rate and projection loss are reported in radiated breasts.

Finally, Chia et al. [45Chia HL, Wong M, Tan BK. Nipple reconstruction with rolled dermal graft support. Arch Plast Surg 2014; 41(2): 158-62.[http://dx.doi.org/10.5999/aps.2014.41.2.158] [PMID: 24665425] ] advocated for the use of stacked dermal grafts harvest from the dog-ear deformities of previous scars in conjunction with C-V flap. Reabsorption rate ranged from 25% to 30% and initial overcorrection should be performed. They found out that nipples reconstructed with thicker dermis of Latissimus Dorsi skin island were less prone to contracture. Furthermore patietns that underwent adjuvant radiotherapy had poorer results and higher complications (Table 3).

Table 3
Studies reporting outcomes of nipple reconstructions by means of traditional flaps.


7. ALLOPLASTIC GRAFT AUGMENTATION

Alloplastic grafts were investigated in place of autologous one for nipple reconstruction in order to reduce morbidity related to donor sites. Alloplastic augmentation grafts proved to be able to retain long-term nipple projection in various studies [7Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: An original easy technique. Aesthetic Plast Surg 2005; 29(4): 287-94.[http://dx.doi.org/10.1007/s00266-004-0145-y] [PMID: 16044237] , 46Hallock GG. Polyurethane nipple prosthesis. Ann Plast Surg 1990; 24(1): 80-5.[http://dx.doi.org/10.1097/00000637-199001000-00015] [PMID: 2301890] -50Jankau J, Jaśkiewicz J, Ankiewicz A. A new method for using a silicone rod for permanent nipple projection after breast reconstruction procedures. Breast 2011; 20(2): 124-8.[http://dx.doi.org/10.1016/j.breast.2010.10.001] [PMID: 21115347] ]. Hallock [46Hallock GG. Polyurethane nipple prosthesis. Ann Plast Surg 1990; 24(1): 80-5.[http://dx.doi.org/10.1097/00000637-199001000-00015] [PMID: 2301890] ] in 1990 was the first to describe alloplastic grafts augmentation for nipple projection. He inserted polyurethane-coated silicon gel implants in subdermal pockets in two patients that underwent autologous-based breast reconstruction. No loss of projection was observed at long-term follow-up.

Evans et al. [47Evans KK, Rasko Y, Lenert J, Olding M. The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction: early results. Ann Plast Surg 2005; 55(1): 25-9.[http://dx.doi.org/10.1097/01.sap.0000168370.81333.97] [PMID: 15985787] ] described the use of calcium hydroxylapatite gel (Radiesse; BioForm, Inc., Franksville, WI, USA) for secondary nipple reconstructions. Patient satisfaction at 10 months follow-up was the only parameter assessed, and no postoperative complications were reported.

Panettiere et al. [7Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: An original easy technique. Aesthetic Plast Surg 2005; 29(4): 287-94.[http://dx.doi.org/10.1007/s00266-004-0145-y] [PMID: 16044237] ] described the use of labia minora wedge and composite nipple graft in conjunction to hydroxyethyl methacrylate and ethyl methacrylate hyaluronic acid suspension (DermaLive marketed through Dermatech, Paris, France) injections performed at the 2nd postoperative months. Good long-term nipple projection, high patient satisfaction rate and no complications were reported. However outcomes were significantly better when patients underwent nipple reconstruction with labia minora wedge and hydroxyethyl methacrylate and ethyl methacrylate hyaluronic acid suspension injections. Furthermore one patient had false-positive result on PET scan.

Yanaga [48Yanaga H. Nipple-areola reconstruction with a dermal-fat flap: Technical improvement from rolled auricular cartilage to artificial bone. Plast Reconstr Surg 2003; 112(7): 1863-9.[http://dx.doi.org/10.1097/01.PRS.0000091243.42112.32] [PMID: 14663232] ] employed artificial bone (Ceratite; Chugai Medical Device, Tokyo, Japan) as augmentation graft in nipple reconstruction positioned in the core of elevated traditional flaps. No loss of nipple projection was reported at long-term follow-up in all patients treated.

Wong et al. [49Wong RK, Wichterman L, Parson SD. Skin sparing nipple reconstruction with polytetrafluoroethylene implant. Ann Plast Surg 2008; 61(3): 256-8.[http://dx.doi.org/10.1097/SAP.0b013e31815d5bfa] [PMID: 18724123] ] reported the use of polytetrafluoroethylene in nipple reconstruction. Overall patient satisfaction rate was high and good nipple projection was retained. Implant extrusion was reported in one case only that required removal and replacement.

Jankau et al. [50Jankau J, Jaśkiewicz J, Ankiewicz A. A new method for using a silicone rod for permanent nipple projection after breast reconstruction procedures. Breast 2011; 20(2): 124-8.[http://dx.doi.org/10.1016/j.breast.2010.10.001] [PMID: 21115347] ] perfromed 30 nipple reconstruction by means of C-V flap along with a silicone rod (NA 515-7, Nagosil; Nagor Ltd., Isle of Man, United Kingdom) for augmentation. All patients that underwent breast reconstruction by means of latissimus dorsi flap developed nipple necrosis, implant exposure and healed by secondary intention. While the remaining patients that had undergone breast reconstruction by means of TRAM flap had no complications and experienced a 33.9% decrease in nipple projection at 10-month follow-up (Table 4).

Table 4
Studies reporting outcomes of nipple reconstructions by means of autologous grafts and traditional flaps.


8. ALLOGENIC GRAFT AUGMENTATION

Acellular Dermal Matrix (ADM) not only revolutionized the field of implant-based breast reconstruction but also that of nipple reconstruction [51Nahabedian MY. Secondary nipple reconstruction using local flaps and AlloDerm. Plast Reconstr Surg 2005; 115(7): 2056-61.[http://dx.doi.org/10.1097/01.PRS.0000164490.99581.F9] [PMID: 15923855] -55Bramhall RJ, Thiruchelvam PTR, Concepcion M, Gui GP. Use of Acellular Dermal Matrix (ADM) in nipple reconstruction: The ‘central-pillar technique’. Gland Surg 2017; 6(4): 394-8.[http://dx.doi.org/10.21037/gs.2017.03.13] [PMID: 28861381] ]. Indeed ADMs were shaped differently by various authors and employed as augmentation graft in combination with traditional flap to create sustained projected nipple. ADMs were attractive given their low reabsorption rate with high incorporation rate that helped reduce the risk of infections. ADMs were particularly suited for revisional nipple reconstruction as they can ensure low to mild projection loss at long-term follow-up [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. Furthermore, given the high cost of ADMs, they can be banked at the time of breast reconstruction in order to cut down related costs [52Chen WF, Barounis D, Kalimuthu R. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in postmastectomy breast and nipple reconstructions. Plast Reconstr Surg 2010; 125(2): 479-81.[http://dx.doi.org/10.1097/PRS.0b013e3181c82da6] [PMID: 20124833] ]. AlloDerm (LifeCell Corporation, Branchburg, NJ, USA) and SurgiMend (TEI Biosciences, Boston, MA, USA) were the ADMs employed by Nahabedian [51Nahabedian MY. Secondary nipple reconstruction using local flaps and AlloDerm. Plast Reconstr Surg 2005; 115(7): 2056-61.[http://dx.doi.org/10.1097/01.PRS.0000164490.99581.F9] [PMID: 15923855] ], Chen et al. [52Chen WF, Barounis D, Kalimuthu R. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in postmastectomy breast and nipple reconstructions. Plast Reconstr Surg 2010; 125(2): 479-81.[http://dx.doi.org/10.1097/PRS.0b013e3181c82da6] [PMID: 20124833] ], Garramone and Lam [53Garramone CE, Lam B. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. Plast Reconstr Surg 2007; 119(6): 1663-8.[http://dx.doi.org/10.1097/01.prs.0000258831.38615.80] [PMID: 17440338] ], Seaman et al. [54Seaman BJ, Akbari SR, Davison SP. A novel technique for nipple-areola complex reconstruction: The acellular dermal matrix onlay graft. Plast Reconstr Surg 2012; 129(3): 580e-1e.[http://dx.doi.org/10.1097/PRS.0b013e3182419c68] [PMID: 22374028] ], Bramhall et al. [55Bramhall RJ, Thiruchelvam PTR, Concepcion M, Gui GP. Use of Acellular Dermal Matrix (ADM) in nipple reconstruction: The ‘central-pillar technique’. Gland Surg 2017; 6(4): 394-8.[http://dx.doi.org/10.21037/gs.2017.03.13] [PMID: 28861381] ], and Craft and May [56Craft RO, May JW Jr. Staged nipple reconstruction with vascularized SurgiMend acellular dermal matrix. Plast Reconstr Surg 2011; 127(6): 148e-9e.[http://dx.doi.org/10.1097/PRS.0b013e3182131e74] [PMID: 21617431] ].

Across all studies, nipple projection loss rate was similar, ranging from 48.8% to 53%; only Craft and May [56Craft RO, May JW Jr. Staged nipple reconstruction with vascularized SurgiMend acellular dermal matrix. Plast Reconstr Surg 2011; 127(6): 148e-9e.[http://dx.doi.org/10.1097/PRS.0b013e3182131e74] [PMID: 21617431] ] reported loss of nipple projection as low as 25%. Nevertheless, overall complication rate was lower than alloplastic and autologous graft too.

Other allogenic material employed as augmentation grafts for nipple reconstruction were: lyophilized Costal Cartilage and extracellular matrix collagen [57Kim EK, Lee TJ. Use of lyophilized allogeneic costal cartilage: Is it effective to maintain the projection of the reconstructed nipple? Ann Plast Surg 2011; 66(2): 128-30.[http://dx.doi.org/10.1097/SAP.0b013e3181ee73e8] [PMID: 21178755] , 58Tierney BP, Hodde JP, Changkuon DI. Biologic collagen cylinder with skate flap technique for nipple reconstruction. Plast Surg Int 2014; 2014: 194087.[http://dx.doi.org/10.1155/2014/194087] [PMID: 25114802] ].

Kim and Lee [57Kim EK, Lee TJ. Use of lyophilized allogeneic costal cartilage: Is it effective to maintain the projection of the reconstructed nipple? Ann Plast Surg 2011; 66(2): 128-30.[http://dx.doi.org/10.1097/SAP.0b013e3181ee73e8] [PMID: 21178755] ] described the use of cadaveric lyophilized costal cartilage along with modified top hat technique. However they observed 57.7% loss of projection at 12 months follow-up, concluding that no added benefit could be achieved when compared with traditional flap only.

Tierney et al. [58Tierney BP, Hodde JP, Changkuon DI. Biologic collagen cylinder with skate flap technique for nipple reconstruction. Plast Surg Int 2014; 2014: 194087.[http://dx.doi.org/10.1155/2014/194087] [PMID: 25114802] ] used extracellular matrix collagen of porcine small intestinal submucosa origin (Biodesign Nipple Reconstruction Cylinder; Cook, Inc., Bloomington, IN, USA) shaped into rolled cylinder as augmentation graft along with skate flap for nipple reconstruction. At 6 months, loss of projection ranged from 30 to 50%, and reconstructed nipples were 3 to 5 mm high. Furthermore the only reported complication was cylinder extrusion that occurred in 3.5% of reconstructed nipples requiring revision surgery (Table 5).

Table 5
Studies reporting outcomes of nipple reconstructions by means of alloplastic implants and traditional flaps.


9. DISCUSSION

Most NAC reconstruction follow its loss as consequence of breast cancer, but it can be also caused by trauma, congenital absence, burn deformities, and complications from breast surgeries [1Nimboriboonporn A, Chuthapisith S. Nipple-areola complex reconstruction. Gland Surg 2014; 3(1): 35-42.[PMID: 25083492] ]. In case of breast cancer, many surgical techniques and devices have been developed for breast reconstruction to restore an aesthetically pleasing breast shape, however patients may still experience psychological distress until NAC recreation [59Raposio E, Santi PL. Topical application of DMSO as an adjunct to tissue expansion for breast reconstruction. Br J Plast Surg 1999; 52(3): 194-7.[http://dx.doi.org/10.1054/bjps.1998.3096] [PMID: 10474470] -91Grieco M, Grignaffini E, Simonacci F, Di Mascio D, Raposio E. Post-bariatric body contouring: Oue experience. Acta Biomed 2016; 87(1): 70-5.[PMID: 27163898] ]. Thus, NAC reconstruction is often the final and completing stage of breast reconstruction for postmastectomy patients [2Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: A systematic review and meta-analysis. Gland Surg 2017; 6(1): 4-13.[http://dx.doi.org/10.21037/gs.2016.08.01] [PMID: 28210547] ]. During the last 30 years an enormous amount of techniques has been described given the unsatisfactory results obtained [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. Indeed, the ideal reconstructed nipple should symmetrically resemble the contralateral one in high and diameter and should match in color and texture. Contralateral color/texture match can be achieved by tattooing, but nipple reconstruction options fail to ensure adequate nipple projection at long-term follow-up [3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520.]. Composite nipple grafts give the best guarantee of color-texture match with the contralateral side and show satisfactory nipple projection even at long-term follow-up [11Lee TJ, Noh HJ, Kim EK, Eom JS. Reducing donor site morbidity when reconstructing the nipple using a composite nipple graft. Arch Plast Surg 2012; 39(4): 384-9.[http://dx.doi.org/10.5999/aps.2012.39.4.384] [PMID: 22872843] , 12Winocour S, Saksena A, Oh C, et al. A Systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg 2016; 137(1): 14e-23e.[http://dx.doi.org/10.1097/PRS.0000000000001861] [PMID: 26710046] ]. Moreover composite nipple graft is the better choice in case of breast that has undergone implanted-based reconstruction where reconstructed breast skin envelope is usually tight and thin. Indeed, local flaps would be more prone to shrinkage because of tension [11Lee TJ, Noh HJ, Kim EK, Eom JS. Reducing donor site morbidity when reconstructing the nipple using a composite nipple graft. Arch Plast Surg 2012; 39(4): 384-9.[http://dx.doi.org/10.5999/aps.2012.39.4.384] [PMID: 22872843] , 12Winocour S, Saksena A, Oh C, et al. A Systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg 2016; 137(1): 14e-23e.[http://dx.doi.org/10.1097/PRS.0000000000001861] [PMID: 26710046] ].

Local flaps most commonly used have a loss of projection of up to 70 percent. This is particularly true when reconstruction is under-taken in the thinned dermis seen after tissue expansion or following adjuvant radiotherapy. Nevertheless they give the best outcomes in case of reconstructed breast by means of Latissimus Dorsi flap, followed by gluteal one. Indeed these are the flap that display the thickest dermis layer. Whereas autologous reconstruction with flap raised from the abdominal wall or gracilis flap are more prone to nipple projection loss because of the thinner dermis [2Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: A systematic review and meta-analysis. Gland Surg 2017; 6(1): 4-13.[http://dx.doi.org/10.21037/gs.2016.08.01] [PMID: 28210547] , 3Patel KM, Nahabedian MY. Reconstruction of the nipple-areola complex.Plastic Surgery 3rd ed. 3rd ed.2013; 498-520., 30Cheng MS, Ho CM, Cheung WY, Or A, Wong WM. Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients’ perspective. Ann Plast Surg 2004; 53(4): 328-33.[http://dx.doi.org/10.1097/01.sap.0000137247.53249.a1] [PMID: 15385765] ].

Skate, star, C-V, and arrow flap are by far the most commonly employed and the most reliable ones; hence surgeons should be familiar with them and be able to employ the most adequate one on case-to-case basis [10Spear SL, Schaffner AD, Jespersen MR, Goldstein JA. Donor-site morbidity and patient satisfaction using a composite nipple graft for unilateral nipple reconstruction in the radiated and non-radiated breast. Plast Reconstr Surg 2011; 127: 1-10.[http://dx.doi.org/10.1097/PRS.0b013e318208d107] [PMID: 20871489] ]. Minor morbidity is usually associated, while the main complication is tip necrosis of elevated flaps.

Autologous, allogenic, and alloplastic materials proved to be able to provide sustained projection to reconstructed nipples [12Winocour S, Saksena A, Oh C, et al. A Systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg 2016; 137(1): 14e-23e.[http://dx.doi.org/10.1097/PRS.0000000000001861] [PMID: 26710046] ]. Alloplastic grafts were associated with the lowest rates of projection loss followed by autologous and allogenic ones. Nevertheless allogenic grafts are also associated with the highest complication rate, while autologous and allogenic ones have similar rates. Infection, seroma, and fat necrosis are the more commonly reported complications of autologous grafting along with donor site morbidity, while allogenic and alloplastic augmentation grafts may also experience the risk of overcorrection and graft exposure [12Winocour S, Saksena A, Oh C, et al. A Systematic review of comparison of autologous, allogeneic, and synthetic augmentation grafts in nipple reconstruction. Plast Reconstr Surg 2016; 137(1): 14e-23e.[http://dx.doi.org/10.1097/PRS.0000000000001861] [PMID: 26710046] ].

CONCLUSION

NAC reconstruction is the final and concluding stage of breast reconstruction. Given the numerous techniques described in literature it is clear that the ideal nipple reconstruction hasn’t been found yet. Indeed current techniques are unable to ensure symmetry with the contralateral nipple in high and diameter and color/texture match. However, surgeons should be familiar with most nipple reconstruction techniques since one can be the best choice over another depending on type of mastectomy, radiotherapy, type of reconstruction, skin thickness, tissue condition, and patients’ expectations. Skate, star, arrow, and C-V flap are usually surgeons’ first choice given long-term outcomes. Common traditional flaps can be employed along or in combination of augmentation grafts. Autologous grafts ensure sustained nipple projection but donor site morbidity remains an issue as well as implant extrusion in case of alloplastic grafts. In addition, careful patient evaluation and trustful doctor-patient relationship are essential to achieve satisfying results.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

There is no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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