Nipple reconstruction – the cherry on top

The presence of a nipple on a breast contributes greatly to the realism and femininity of the final result; it’s ‘the icing on the cake’ or ‘the cherry on top’. This is why nipple reconstruction is an essential component of breast reconstruction.

Creation of a nipple is typically performed in the latter stages of a breast reconstruction, when symmetry between the reconstructed breast and the contralateral natural breast is being pursued. The goals of nipple-areola reconstruction are:

• Proper location on the breast mound, prior to commencement.

• Symmetry of nipple position.

• Symmetry of size, colour, texture and projection.

Numerous techniques have been described. The shared problem with all of them is loss of projection, over time, as a consequence of scar contraction (scar tightening). It has been shown that certain techniques, such as the Maltese cross and the double opposing tabs, will ‘flatten’ by 50% – 70% over two years. Thus the search for the perfect technique continues.

How a nipple gets reconstructed

There are two basic methods – the first is to use local tissue from the breast, with or without skin grafts, and the second is to harvest  a ‘composite free nipple graft’ from the opposite breast; this can only be done if there is sufficient tissue to allow this.

Well-known techniques include

Those requiring a skin graft for closure: skate flap, bell flap and S flap. And, for those where the skin can be closed: star flap, cv flap and double opposing flap.

What to consider when choosing a procedure

Timing of nipple reconstruction is important; it is usually performed at least three months after breast mound reconstruction and also after completion of adjuvant treatments, such as chemotherapy and radiation. The outcomes after radiation therapy are always less predictable, with a higher risk of delayed healing and soft tissue complications.

The aim of all techniques is to create about 1cm of nipple projection, on the day of surgery, since most flatten over time and lose up to 50% of their initial height over the first two months.

Post-operatively, most women will be back to work and normal activities within a few days. It takes up to 10-14 days to recover, but it is generally an easier road than other forms of breast surgery.

Antibiotics and pain medication are usually prescribed. If skin grafts are used, special dressings are needed for the first two weeks. Stitches are removed by postop day 14 in the majority of cases.

cherry on top

Are there other options?

Areola tattooing can be performed about three months after the nipple reconstruction. It is best done by experienced professionals. Various colours are available and the final choice is dictated by the appearance  of the opposite nipple-areola complex. It takes approximately 20-30 minutes per nipple, and can be done in an outpatient setting, under local anaesthesia. The tattoos often fade over time and secondary procedures may be desired in order to give a more pleasing result.

What can go wrong?

Fortunately, complications following nipple reconstruction are rare. The most severe complication is partial or total loss of the nipple which, thank goodness, occurs in less than 2% of cases. This type of complication is more commonly seen when the nipple reconstruction was performed after radiation therapy.

Another problem that is quite common and many women complain about is nipple malposition. In order to prevent instances where nipples need to be removed and recreated, women and their partners are encouraged to participate in the decisions to determine where a nipple should be located on their reconstructed breasts.

The creation of a nipple-areola complex on a reconstructed breast provides the final ‘finishing touch’. Its presence is intended to fulfil the aesthetic desires and psychological needs of the woman. Not all women choose to pursue nipple reconstruction, but those that do are, generally, very satisfied with the results.


Dr Anton Potgieter trained at Wits University and worked at Baragwanath Hospital before starting private practice at Sandton Mediclinic. He has special interests in breast surgery and paediatric plastic surgery.