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The final step in breast reconstruction is creation of the nipple areola complex. This can be done with a variety of techniques. The technique recommended will depend to some degree on whether an already existing nipple is being matched or two matching nipples need to be reconstructed. In order to obtain nipple projection some of the tissue on the newly reconstructed breast mound must be utilized. The techniques vary in how much of the skin and soft tissue is used on the breast mound.
The technique that involves the least alteration of the overall shape of the breast mound is the skate flap. The skate flap involves cutting some of the skin and soft tissue on the newly reconstructed breast and folding the tissue like a Japanese origami puzzle to create the nipple. A skin graft from a remote location such as the upper medial thigh or abdominal scar is then used to reconstruct the areola. We prefer the upper medial thigh as the donor site because it has the closest color and crepe-like texture of the native areola.
Other techniques such as a C-V flap, Arrow flap, or Bell flap involve some distortion of the breast mound as they require primary closure of the local site from where the tissue was taken. These procedures are performed on an outpatient basis and take about an hour to reconstruct each nipple areola complex.
The final step in nipple reconstruction when it has been created from the local skin on the breast is to tattoo the nipple. This is done because the nipple is made from the skin of the breast and it is the wrong color to match the areola. If no further surgery is desired by the patient, or if I am trying to match a relatively large light areola with an almost flat nipple, a circle can be tattooed on the breast to simulate the areola and a smaller darker circle tattooed within to represent the nipple. Nipple areola reconstruction involves minimal patient discomfort and provides maximum patient satisfaction.