Nipple-areola reconstruction is the final step of breast reconstruction. ‘Shape' and ‘color' are important to make the breast mound look natural. The nipple and areola are mostly composed of epithelium. In addition, smooth muscle changes of the shape. Local flap nipple reconstruction causes a decrease in projection because of the small amount of epithelium and no smooth muscle. In general, Asian women have a slightly larger nipple and smaller areola. Therefore, the flap scar sometimes extends beyond the reconstructed areola. We reconstructed the ‘shape' with a skate flap, and then changed to a C-V flap. Subsequently, a modified C-V flap and wheel steeling flap with or without costal cartilage were developed for long-term projection and to shorten the scar length. On the other hand, tattoos are mainly used for ‘color'. This paper reviews our methods for nipple-areola reconstruction.

Breast reconstruction consists of mound reconstruction and nipple-areolar reconstruction. Nipple-areolar reconstruction is the final step in breast reconstruction. The nipple-areolar complex (NAC) is the primary landmark of the breast, and its reconstruction results in a more perfectly shaped and naturally appearing breast. Thus, NAC reconstruction increases the patients' psychological satisfaction with their breast reconstruction. Importantly, this method requires symmetry in terms of the nipple projection, color, shape, size, texture, and position. There are 6 NAC reconstruction methods : 1) nipple-graft and areolar tattoo, 2) nipple local flap and areolar tattoo, 3) nipple local flap and inner thigh skin graft, 4) nipple and areola graft, 5) nipple-graft and labia or inguinal skin graft, and 6) three-dimensional tattoo (3D tattoo) . The indication of NAC reconstruction is determined by 2 factors : 1) the size and shape of the nipple and areola on the normal side, and 2) the mound condition and irradiation on the reconstructed side. Furthermore, the patient's ability to choose the reconstruction method in consideration of their hope to not disturb the normal side further increases their psychological satisfaction with their breast reconstruction.

The breasts are usually observed with the body in the upright position. However, they are observed in the supine position in the operating room, where they move up and outside. Therefore, we must move the patient to the sitting position during surgery under general anesthesia. Our preoperative set-up requires 4 simple procedures : 1. Flexural point adjustment of the patient's lumbar on the operative table. 2. Cranial extension of the operative table using an arm table. 3. Fixation of the patient only by two belts and a thick pad around the knees. 4. Disinfection of the bilateral arms for a mobile arm angle in the sitting position. All procedures are simulated preoperatively. The time for the operation and preparation was investigated for implant versus flap reconstruction. Preparation took 45% of the operative time in the former reconstruction but only 9% in the latter. To save time, no disinfection of the arms for patients with small and non-ptotic breasts was suggested. Attention is needed for torsion of the upper body and pad height under the knee.

Periareolar incision (P incision) for breast reconstruction has a narrow field of operation and the risk of complications, such as nipple necrosis, is of concern. However, the wound created from the operation is small and less visible, being an advantage. A total of 134 patients with primary breast cancer who underwent nipple sparing mastectomy for breast reconstruction at our hospital from July 2013 to December 2017 were examined. Regarding the skin incision method, there were 18 cases of inferiolateral inframammary fold incision (IMF incision) and 116 cases of P incision. On comparison of the two groups, the median volume of the silicon implant was significantly smaller in the P incision group than in the IMF incision group (p = 0.034) . Regarding the local recurrence rate and postoperative complications, such as nipple necrosis, there was no significant difference between the groups. Therefore, P incision may be a safe technique to improve the cosmetic outcome.