How do you reconstruct a nipple and areola after breast cancer?

        I am scheduled to have nipple reconstruction in May, and know there are various options available. Can you comment on the differences in cosmetic outcome when utilizing tissue from another part of the body, skin from the flap itself or tattooing alone?

The nipple and areolar complex (NAC) reconstruction involves two components, the nipple prominence and the areolar circle.  Sometimes the nipple reconstruction is performed first, with the areola done at a later date; at other times, they are performed together.  NAC reconstruction is the finishing touch of a breast reconstruction, and is the "icing on the cake" to complete the breast! 

Nipple reconstruction usually involves a local flap procedure where wings of tissue (skin and fat) from the breast reconstruction itself are rotated in place to create a nipple prominence.  Some surgeons also add some additional tissue inside the local flaps (soft or firm) to try to improve projection of the nipple reconstruction.  After surgery, the nipple reconstruction is expected to shrink between 30% and 50%.  The ideal nipple prominence matches a natural nipple at rest.  It will not have the capacity to become erect with stimulation or cold temperature.

The areolar circle can be made using either a medical tattoo or a skin graft.  Natural flesh-colored medical tattoo pigments (ranging from tan, to pink or brownish or black) are available and can be mixed together to very closely match a natural nipple and areola.  The nipple prominence is also tattooed to match the other side.  Tattooing can be done either in the operating room or in the office of your Surgeon under local anesthesia, and is usually done by the Plastic Surgeon or occasionally a specially-trained surgical Nurse. 

Skin grafting for areolar reconstruction involves taking a full-thickness graft (all the layers of the skin, requiring closure of the "donor site" with stitches) from another area of the body.  Common sites for harvest of a skin graft for areolar reconstruction include the groin, the other breast's areola (if a balancing breast reduction or a lift is also being done), or rarely, the labia (external genitalia).  Skin grafts may heal with either lighter or darker pigmentation than expected, and by definition, require creation of a scar at their donor location.  For this reason, I usually use a tattoo for the areolas I create.