NAC reconstruction is the culmination of an interprofessional team approach to patient care and often the final step in breast reconstruction. Procedurally, a plastic surgeon and surgical scrub team are all that is needed. 

The most important aspects of preparation are elicitation of patient preferences in NAC reconstruction and assessment of the contralateral native NAC (if present). While there are aesthetic ideals for the NAC position in the literature, it is useful to allow the patient to mark the position of the new NAC using an electrocardiogram lead pad in front of a mirror. In unilateral reconstruction, it is important to study the NAC on the unoperated breast to guide the positioning, orientation, size, and shape of the new nipple. 

Informed consent should discuss complications of NAC reconstruction, which include partial or total nipple necrosis, and loss of nipple projection. 

There have been numerous surgical techniques for NAC reconstruction that have been described over time.[12][13] In general, surgical techniques involve the use of local skin flaps, composite grafts, nipple sharing, tattooing, or a combination of these techniques. 

Local flaps transfer adjacent skin and subcutaneous fat to create a projected nipple. Multiple techniques exist, with at least 30 unique techniques in the literature.[12] These techniques share the common characteristics of being based on random pattern skin and subcutaneous tissue flaps with blood supply from the subdermal plexus and/or subcutaneous pedicle. Commonly used local flaps include the skate flap, modified skate flap, star flap, fishtail flap, C-V Flap, S flap, Bell flap, Arrow flap, and Hammond flap.[12][14][15][16] The following review article has direct links to the index papers.[12] Unfortunately, all local flaps demonstrate some degree of loss of projection over time. The degree of loss of projection is estimated to be between 45-75%, with a majority of projection loss occurring within the first 2 months postoperatively.[12][17] For this reason, there is an over-correction of the reconstructed NAC with the immediate postoperative nipple approximately twice the desired final height.[18] Attempts at improving projection with autografts, allografts, and synthetic materials have been attempted with varying success.[19][20][21][22][23][24]

Nipple sharing is a technique considered for patients with excessive contralateral nipple projection who are willing to sacrifice contralateral projection for ipsilateral reconstruction. About 50% of contralateral nipple height is lost in nipple sharing techniques.[25][26] The contralateral nipple may be removed transversely or longitudinally and then grafted on the reconstructed NAC. Nipple sharing results in excellent color and texture match but does create an insult to the contralateral nipple. The donor nipple may have altered sensation, pain, and difficulty with breastfeeding.

Skin grafts can be used to reconstruct the areola or the NAC. Full-thickness skin grafts are harvested from other pigmented areas such as the axillary area or upper inner thigh. Dermabrasion has been described as an alternative to create hyperpigmented skin for the reconstructed NAC.[27]

Intradermal tattooing is commonly used as an alternative to the skin graft for reconstruction of the areola or to color the NAC after nipple reconstruction with a local flap. It is typically performed 3-4 months after nipple reconstruction after most nipple shrinkage has occurred.[28] The color immediately after the tattoo should be darker than desired as the color fades within the first few weeks. Furthermore, new 3D tattooing techniques can avoid the necessity of surgery. Traditionally, this technique is used if there is a lack of skin tissue available for surgical reconstruction, in the presence of scars, following radiotherapy, for reconstruction and pigmentation of the areola complex or patient choice. 

Internal and/or external nipple prosthetics offer patients another minimally invasive NAC reconstruction option. In the case of external prosthetics, off-the-shelf and custom options exist. For a custom prosthetic, an impression is made of the contralateral NAC, from which mold and silicone prosthetic is created by a prosthetist.[29][30][31][32] The silicone NAC prosthetics have a lifelike appearance and are attached to the breast mound with silicone tape or other adhesives. They should be removed at regular intervals for the hygiene of the underlying skin. Internal prosthetics include silicone and polyurethane, in which gumdrop appearing implants are placed underneath well-vascularized nipple or local flaps.[33] Internal prosthetics carry the benefit of persistent projection, but risk infection, extrusion, and capsule formation.[29]

Postoperatively, nipple-specific dressings and/shields are placed to protect the reconstructed NAC and to avoid compression, trauma, and/or infection, which could lead to loss of NAC projection. Multiple dressings and shields have been described in the literature, including nipple-specific plastic guards, donut-shaped sponges, occlusive dressings with anti-biotics, silicone-based products, and modified ocular shields and protectors.[34][35][36][37][38]

Tissue engineering and regenerative medicine (TE&RM) nipple-areolar reconstruction with 3D-printed tissue scaffolds is presently being investigated as an NAC reconstruction method of the future.[39] While thus far only trialed in animal models, tissue-engineered construct (TEC) NAC reconstruction offers the benefit of minimal donor site morbidity, prolonged projection, and well-vascularized tissue.[40][41] Conceptually, the TEC consists of a 3D-printed nipple scaffold of natural biomaterials that are seeded with multipotent stem cells, which eventually differentiate into adipocytes. The TEC is then implanted subdermally in the desired NAC location, with the aid of a pursestring suture for contour improvement. Current challenges in the TEC nipple-areolar complex arena include generating sufficient vascular networks to support the nipple scaffolding and assessing the oncologic safety of co-administration of growth factors to facilitate ingrowth.[39]

As previously mentioned, the main complication with local flaps is the loss of nipple projection with an anticipated loss of 45% to 75% projection. Blood supply to the reconstructed NAC is not always reliable in the setting of being located near or on prior scars; thus, the outcome may be unpredictable, and certain flap designs cannot be applied. Thus, inherently there is a risk for the flap and/or graft partial or complete failure. Finally, asymmetry and unacceptable cosmetic appearance to the patient are always risks to discuss preoperatively. 

Nipple-areolar complex reconstruction provides aesthetic and psychological benefit to the patient and can help increase acceptance of the reconstructed breast into the patient's self-image.[4][5][6] 

Breast cancer management is best managed in an interprofessional setting that involves the patient, nurse specialists, oncologists, radiologists, and surgeons. The patient should pursue NAC reconstruction once a stable breast reconstruction has been reached, and after adjuvant therapies have been completed. 

The reconstructive procedures mentioned above are often performed on an outpatient basis. Patients should be seen in close follow-up, typically 7-10 days following surgery.