Nipple Reconstruction

Nipple reconstruction is not the “small final step” of breast reconstruction—it is the focal point. A great breast mound can be undermined by poor nipple position, poor projection, or a mismatch in size and symmetry. In this episode, we break down the high-yield principles that actually matter when planning and performing nipple-areola complex reconstruction. We cover how to mark the nipple thoughtfully rather than relying on rigid measurements alone, why patient input matters more than many residents realize, and how technique selection changes depending on whether the breast mound is autologous or implant-based. We also review local flap options, contralateral composite grafting, cartilage and acellular dermal matrix strategies, and the role of tattooing as both an adjunct and a stand-alone option. Most importantly, we discuss the unavoidable issue of projection loss and why initial overcorrection is often the smarter move. Built from the uploaded chapter and study guide on nipple reconstruction. Key Takeaways Nipple position is the most unforgiving variable in NAC reconstruction and often matters more than the flap design itself. Local flaps remain the workhorse, especially in autologous reconstruction with adequate soft tissue. Expect projection loss over time; deliberate overcorrection is usually necessary. Prosthetic reconstruction often requires alternative strategies such as grafts, cartilage, ADM, or tattoo-only reconstruction. Tattooing is not just cosmetic finishing—it significantly affects final patient satisfaction. References Fuentes PM, Langstein HN. A review of nipple-areola complex reconstruction and tattooing in postmastectomy breast reconstruction. Gland Surg. 2026;15(1):29-43. PMID: 41668920. Paolini G, Amoroso M, Pugliese P, et al. Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm. Aesthetic Plast Surg. 2021;45(3):933-945. doi:10.1007/s00266-020-02047-9. PMID: 33216178. Sisti A, Grimaldi L, Tassinari J, et al. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol. 2016;42(4):441-465. doi:10.1016/j.ejso.2016.01.003. PMID: 26868167. Smallman A, Smith M, Ramakrishnan V. Does nipple-areolar tattooing matter in breast reconstruction? A cohort study using the BREAST-Q. J Plast Reconstr Aesthet Surg. 2018. PMC7061635. Levy J, Bell DE, Winocour S, et al. Long-term nipple projection retention following local flap nipple reconstruction using 3D imaging. Plast Reconstr Surg Glob Open. 2025. PMID: 40677291. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #PlasticSurgery #BreastReconstruction #NippleReconstruction #NACReconstruction #PRS #PlasticSurgeryResident #BreastSurgery #ReconstructiveSurgery #SurgicalEducation #PlasticsInPractice