Nipple reconstruction is usually performed as the final surgical stage of a patient’s breast reconstructive journey prior to nipple-areolar tattooing. It can be performed surgically by using local flap or nipple sharing techniques. It has been shown that patients are more satisfied with their breast reconstruction if it includes a nipple reconstruction (1,2).
Nipple sharing is not a new procedure and was first described by Wexler and Oneal in 1972. The authors reconstructed a previously ablated areola and nipple using half of the nipple-areola from the contralateral breast during a bilateral reduction mammoplasty (3). Studies have shown that there is minimal morbidity to the donor nipple, with minimal loss of sensation (4,5). The literature also demonstrates high patient satisfaction scores after nipple sharing (4,6) and a recent systematic review showed satisfaction data is higher in nipple share groups compared to local flap nipple reconstruction groups (7).
In the senior author’s experience, nipple sharing can result in superior aesthetic outcomes (Figure 1) and high patient satisfaction, especially in women with larger nipples who benefit from a contralateral nipple reduction. This owes to the fact that the nipple is a structure of unique tissue composition, containing smooth muscle and lactiferous ducts. To achieve a “like for like” reconstruction, no other tissue but that of a nipple contains the same structural elements to mimic nipple texture, colour match and give long-term projection. This is demonstrated when using local flap techniques whereby the new “nipple” is softer and will flatten over time with loss of projection (8).
Our preferred technique is to harvest the inferior half of the donor nipple via transverse incision and close the defect directly. The graft is sutured to a de-epithelialised recipient wound bed and secured with a tie-over dressing (Figure 2). We have seen consistently good results with minimal donor site morbidity.
However, in our unit, where over 300 free flap breast reconstructions are performed yearly, nipple sharing is not offered to the majority of patients. We suspect this surgical preference may be due to lack of experience with the procedure and concerns regarding donor site.
To test this hypothesis, we conducted clinician surveys to find out what nipple reconstruction technique plastic surgeons in our unit prefer and the reasons for these preferences. We also conducted a retrospective study of patients in our unit who had undergone nipple reconstruction after breast reconstruction under the care of a single surgeon who performs both the nipple share and local flap techniques. We used patient surveys to ascertain patient satisfaction with their nipple reconstruction and that of the donor nipple if they had a nipple share procedure.
For the first part of the study, we conducted a clinician survey to assess current nipple reconstruction preferences and practice of plastic surgical consultants in our unit. All eight breast reconstructive surgeons, who regularly perform nipple reconstruction, were approached. We asked what their preferred nipple reconstructive method was and their reasoning for this preference. We also asked how many cases of nipple sharing they had seen and/or performed in their career.
After gaining ethical approval from our local hospital Governance Department, surveys were sent to 60 patients who had undergone nipple reconstruction in our unit under the care of a single surgeon between 2012 and 2017. Along with their survey, patients were provided with an information leaflet providing information about the study, a consent form for enrolment and were advised that if they did not respond to the study letter they would not be re-contacted. All participating patients gave informed consent by returning a signed consent form.
The surveys asked them to evaluate aspects of their nipple reconstruction (including size, shape, projection, sensation, texture and colour), as well as the donor nipple result in nipple sharing cases. Patients were also asked if they would have the same type of nipple reconstruction procedure again. Patients were given three months to return their questionnaires.
Out of eight consultants only one preferred nipple sharing over the local flap technique. The reasons given for his preference include an associated superior cosmetic result and higher patient satisfaction. It also has the ability to reduce a large donor nipple and is suitable when carrying out nipple reconstruction over a thinly covered implant
The remaining seven consultants all noted their preferred nipple reconstruction to be the (modified) C-V local flap. Their reasons for this choice varied but included not liking nipple sharing due to oncological reasons, risk of chronic pain to the donor nipple, risk of graft failure and preference not to touch the “healthy breast”.
Of the seven consultants who did not prefer the nipple share method, only one had seen/performed more than 10 nipple share procedures over their career.
Out of the 60 patient questionnaires sent (38 local flaps and 22 nipple shares), there was a response rate of 53% (total responses =32, with 21 local flaps and 11 nipple shares).
When comparing satisfaction scores with the features of the reconstructed local flap versus the nipple share result, the nipple share group scored higher in all areas (see Table 1). Patients had no concerns regarding their donor nipple after the nipple share procedure, with no reports of scar issues or chronic pain. Of the nipple share group 100% of patients would undergo the same procedure again, compared to a lower 80% in the local flap group.
The opinion of the majority of our consultant body was a preference for local flap nipple reconstruction over the nipple share technique. This does not seem to correlate with our patient satisfaction data and conclusions made within the literature, which favour nipple sharing. Reasons for the consultants’ choice were very varied, highlighting that like in many plastic surgery procedures, preferences are usually supported by personal views rather than scientific evidence. However, we appreciate that only a small number of consultants were surveyed in our study. A national practice clinician survey would yield a more representative sample of current surgical opinion.
As detailed in the results section, there are higher satisfaction scores when patients rated aspects of a nipple share reconstructed nipple compared to a local flap reconstructed nipple. None of the patients surveyed who underwent nipple sharing reported any donor site morbidity. Only 1 out of 22 nipple grafts failed in a patient who had previously undergone radiotherapy. Donor site morbidity and graft failure were concerns surgeons had regarding the nipple sharing, but these opinions are unsupported by our study.
It is also important to note that there has been a single case of Paget disease in a nipple graft following nipple-sharing reported in the literature (9). The oncological risk is extremely low and not something we have seen in our practice but highlights the importance of careful patient selection and oncological follow-up.
In the senior author’s opinion, patient selection is also important as an adequately sized contralateral donor nipple is vital when employing the nipple share technique. The recipient bed must be correctly de-epithelialized and no electro-coagulation should be used as this can compromise graft take. It is also essential that specialist plastic surgery nurses manage these patients post-operatively, as they are experienced in the evolving appearances of the new nipple. This is of particular importance because the nipple graft often looks necrotic with a superficial scab lasting up to 8 weeks post-operatively. Only the surgeon should be permitted to remove this scab to avoid inadvertent removal of the graft.
Two of the eleven patients in the nipple share group felt that their new nipple had grown in size during the post-operative period. This may support the senior author’s hypothesis that nipple tissue has growth potential. A prospective study measuring the dimensions of the new nipple at intervals post-operatively would provide more information on this topic.
Our survey does show a trend towards higher patient satisfaction in the nipple share group, which is supported by current literature on the subject. However, it appears that many surgeons performing nipple reconstruction prefer the local flap reconstructive technique. Despite little experience with nipple sharing, they incorrectly associate it with higher complication rates and lower patient satisfaction. We hope this article provides education to surgeons performing breast reconstruction of the advantages of the nipple share approach in the appropriate selected patient.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: This study was approved by the local hospital Governance Department. Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
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Cite this article as: Friebel TR, Gardiner S, Naji S, Mathur BS. Nipple sharing: an undervalued technique in nipple reconstruction. Ann Breast Surg 2018;2:16.