Nipple reconstruction and tattoos

Reconstruction of a nipple is an essential component of breast reconstruction. The presence of a nipple on a breast contributes greatly to the realism and femininity of the final result.

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 of the breast mound prior to commencement

• Symmetry of nipple position

• Symmetry of size, colour, texture and projection

Numerous techniques have been described. The commonest problem with all of them is loss of projection over time as a consequence of scar contracture. It has been shown that certain techniques will ‘flatten’ by 50%-70% over 2 years. Thus the search for the perfect technique continues.

There are 2 basic methods to reconstruct a nipple: The first is to use local tissue from the breast with or without skin grafts, and the other is to harvest a “composite free nipple graft” from the opposite breast (as long as there is sufficient tissue to allow this.)

Well known techniques include:

Those requiring a skin graft for closure: Skate flap; Bell flap; S flap.

And, those where the skin can be closed: Star flap; CV flap; Double opposing flap.

Many factors need to be considered when deciding which procedure will be best suited to a given patient.

Timing of nipple reconstruction is important and it is usually performed at least 3 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 1-2 months.

Postoperatively, 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 used for the first 2 weeks. Stitches are removed by post op day 14 in the majority of cases.

Areolar tattooing is carried out about 3 months after the nipple reconstruction. It is best performed by trained 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.

Fortunately, complications following nipple reconstruction are rare. The most severe 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 is complaints about “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 “icing on the cake”. Its presence is intended to fulfill the aesthetic desires and psychologic needs of the woman. Not all women choose to pursue nipple reconstruction, but those that do are generally very satisfied with the results.

How to make a nipple

Breast reconstruction is aimed at obtaining a reasonable “mock-up” of a breast.

We cannot make breasts themselves. Often, our efforts fall way short of achieving the aesthetics of the normal breast.

The elements of a good reconstruction include symmetry, proportionality and stability. Most of our patients are well aware of the restrictions of our abilities. And yet breast reconstruction is successful in at least partially restoring the damaged body image suffered by patients who have undergone cancer surgery.

Why reconstruct the nipple? Again, we are able to make only a crude approximation of the female nipple. Yet nipple reconstruction adds a new, fuller dimension to a reconstruction. It is almost as if the presence of a nipple-like structure, situated accurately on a breast reconstruction, fools the eye into accepting more readily that the breast is real. It adds a personality to the breast.

There are many options in nipple reconstruction, reflecting the fact that no single method is perfect. These may range from “stick on” adherent prostheses, to tattooing, to more complex surgical approaches. In all cases, the aim is to restore the semblance of an areola and a projecting nipple.

The most frequently used method in our unit consists of using the skin on the breast to make the nipple itself, using a variety of local skin flaps, and then making the areola from a skin graft, usually obtained from the lower abdomen.

Nipple reconstruction is not a mandatory part of breast reconstruction. But the impact on the overall quality of the reconstruction is undeniable. Patient satisfaction is generally very high, especially because the skin harvest site on the lower abdomen has the effect of tightening up the abdominal wall, much like a mini-abdominoplasty.

With time, the nipple flattens out, giving a remarkable realistic look to the reconstruction. This may be augmented by later tattooing. Indeed, the whole is greater than the sum of its parts!


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.