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PLASTIC RECONSTRUCTIVE AND REGENERATIVE SURGERY

Official journal of

Partner of

Breast

Vol. 4 - Issue 1-2 - April-August 2025

Nipple reconstruction after skin-sparing mastectomy: techniques, outcomes, and patient-centered decision making – a systematic review

Authors

Valerio Pasqualitto

Key words: nipple reconstruction, skin-sparing mastectomy, patient satisfaction, breast cancer, systematic review
DOI: 10.57604/PRRS-1365
Reconstruction
Publication Date: 2025-10-06

Summary

Skin-sparing mastectomy (SSM) preserves the breast skin envelope, improving reconstructive and cosmetic outcomes, but removal of the nipple-areola complex (NAC) can cause psychological distress and body image concerns. Nipple reconstruction is a critical component of post-mastectomy care. This systematic review summarizes current techniques, patient-reported outcomes, complications, and the role of patient-centered decision-making. Following PRISMA guidelines, a literature search identified 42 studies with ≥ 30 patients undergoing nipple reconstruction post-SSM. Techniques included local flaps (C-V, skate, star, five-flap), nipple-sharing, 3D tattooing, combined methods, and innovations like implants and reinnervation. Satisfaction ranged from 66.1% to 96%, with 3D tattooing and advanced flaps scoring highest. Complication rates were lowest for tattooing (1%) and highest for C-V flaps (14% necrosis). Shared decision-making improved satisfaction by 34% and reduced regret by 22%. Nipple reconstruction after SSM is safe, well-tolerated, and significantly enhances quality of life, with individualized planning being essential.

INTRODUCTION

Breast cancer, with over 2.3 million annual cases globally 1, often requires skin-sparing mastectomy (SSM) to preserve the skin envelope for better aesthetic outcomes 2. However, removing the nipple-areola complex (NAC) for oncologic safety can impact body image and self-esteem 3. Nipple reconstruction addresses this, enhancing psychological recovery and symmetry 4.

This review was prompted by the growing use of SSM and variability in reported outcomes for nipple reconstruction. Existing studies often focus on specific techniques, lacking synthesis of patient-centered factors like invasiveness preferences or long-term durability. This article aims to guide surgeons, improve shared decision-making, and identify research gaps, such as standardized outcome measures and integration of innovations, to enhance patient quality of life 5.

METHODS

A systematic review followed PRISMA guidelines 6, registered with PROSPERO (CRD420251046194). PubMed, EMBASE, and Cochrane Library were searched (January 1990 - September 2025) using terms: “nipple reconstruction”, “skin-sparing mastectomy”, “nipple-areola complex”, and “breast reconstruction”. Reference lists were hand-searched.

INCLUSION CRITERIA

  • Adult women post-SSM with immediate or delayed breast reconstruction 7
  • Any surgical or non-surgical nipple reconstruction technique 8
  • Outcomes: patient satisfaction, aesthetics, complications, psychosocial impact 9
  • Study types: RCTs, cohort studies, case series, systematic reviews (English, ≥ 30 patients) 10

EXCLUSION CRITERIA

  • Studies with < 30 patients
  • Non-English publications
  • Studies lacking relevant outcomes

SSM types were classified by incision patterns: Type I (peri-areolar), Type II (peri-areolar with extensions), Type III (separate incisions), Type IV (elliptical for ptotic breasts) 11. Studies covered all SSM types, focusing on reconstruction feasibility.

Data extraction was performed using standardized forms to ensure consistency and reduce bias, conducted by a single reviewer due to the independent nature of the study. Quality was assessed via the Newcastle-Ottawa Scale 12 and CASP checklist 13. Narrative synthesis was used due to outcome heterogeneity, with funnel plots assessing publication bias where feasible.

RESULTS

From 1,478 articles (updated to September 2025), 42 studies met inclusion criteria.

TECHNIQUES AND OUTCOMES

  • Local flaps (C-V, skate, star): common, with 7-10 mm initial projection but 30-50% loss at 1 year 15,16.
  • Five-flap technique: higher satisfaction, lower necrosis 17.
  • Nipple-sharing: Ideal for unilateral cases, excellent symmetry 18.
  • 3D tattooing: highest satisfaction (mean 4.7/5), minimal complications, no projection 18.
  • Innovations: FixNip NRI implants maintain 3.7 mm projection at 12 months 19; targeted NAC reinnervation (TNR) achieves 88% sensory recovery 20.

PATIENT-REPORTED OUTCOMES

  • 3D tattooing: highest satisfaction (92-96%) 18.
  • Local flaps: good projection but prone to flattening 15,16.
  • Nipple-sharing: best symmetry for unilateral cases 18.
  • TNR: 88% erogenous sensation recovery 20.

COMPLICATIONS

  • C-V flap: 14% necrosis 15,16.
  • Five-flap: 5% asymmetry 17.
  • Tattooing: 1% fading/allergy 18.
  • Infection: rare across techniques 23.
  • FixNip NRI: 8.3% infection/removal 19.

PATIENT-CENTERED DECISION-MAKING

  • Shared decision-making increased satisfaction by 34% and reduced regret by 22% 22-24.
  • Preferences: 62% prioritized avoiding surgery, 28% valued projection, 14% declined reconstruction due to fatigue or risk aversion 25-27.
  • Tattooing gained popularity for minimal invasiveness (Tabs. I-II) 28.

DISCUSSION

Nipple reconstruction post-SSM significantly improves psychosocial and aesthetic outcomes 34,35. Technique choice should consider anatomy, expectations, and comorbidities 36,37. Shared decision-making enhances satisfaction and reduces regret 22-24. Optimal timing is 3-6 months post-reconstruction for vascular stability 36. Flap-based methods struggle with projection loss 15,16, while tattooing offers high satisfaction with minimal risk 18. Tattooing and nipple-sharing are cost-effective, reducing surgical burden 18,37.

Comparative reviews provide context. A 2023 meta-analysis found nipple-sparing mastectomy (NSM) superior in sexual (MD 7.64) and psychosocial well-being (MD 4.71) versus SSM, with similar complications but higher NAC necrosis in NSM 38. Its strength lies in BREAST-Q data, but non-RCT designs limit generalizability. This review, focusing on SSM, offers broader technique coverage. A 2022 NSM review reported low recurrence (3.4%) and high survival (96.3%) 39, relevant as NSM may reduce reconstruction needs. Its large sample is a strength, though short follow-up is a limitation. Recent 2025 trends highlight tattooing’s rise and innovations like FixNip NRI (3.7 mm projection) and TNR (MD -1.73 for sensation) 19,20,40, suggesting hybrid approaches for future research.

LIMITATIONS

Outcome heterogeneity and reliance on observational studies 27,29. Publication bias may inflate satisfaction rates 27.

CONCLUSIONS

Nipple reconstruction after SSM is safe and enhances satisfaction and aesthetics 34,35. Individualized, shared decision-making is crucial 22-24. Further research should standardize outcomes and evaluate innovations 27.

Conflict of interest statement

The author declares no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical consideration

Ethical approval was not required for this systematic review as it is based on previously published studies and does not involve human or animal participants. The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.

History

Received: May 22, 2025

Accepted: September 26, 2025

Figures and tables

Technique Initial projection Satisfaction (%) Major complications (%) Best indication References
C-V flap 7-10 mm 70-85 14 (necrosis) Bilateral/unilateral SSM 15 , 16 , 29
Skate flap 7-9 mm 72-88 8 (necrosis) Bilateral SSM 15 , 16 , 30
Five-flap 8-10 mm 90-93 5 (asymmetry) Bilateral SSM 17 , 31
Nipple sharing 7-9 mm 88-92 2 (minor) Unilateral SSM 18 , 32
3D tattooing 0 mm 92-96 1 (fading/allergy) Any, especially comorbidities 18 , 28 , 33
FixNip NRI 3-4 mm 90 8.3 (infection/removal) Post-mastectomy durability 19
TNR Variable 88 (sensory) Variable (delayed recovery) Sensory restoration 20
Table I. Comparison of nipple reconstruction techniques Post-SSM.
Review focus Year Key findings Pros Cons References
NSM vs SSM PROs/complications 2023 NSM superior in sexual/psychosocial well-being (MD 7.64/4.71); similar complications Validated BREAST-Q meta-analysis Heterogeneous follow-up; non-RCTs 38
NSM oncologic outcomes 2022 Low recurrence (3.4%); high survival (96.3%) Large pooled analysis Short follow-up in some 39
Recent trends in reconstruction 2025 Shift to minimally invasive; tattooing trends up Highlights patient decisions Case series dominant 40
Table II. Comparison of related systematic review.

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Valerio Pasqualitto - UNISS, Sassari, Italy; Breast Surgery Unit of San Francesco Hospital, Nuoro, Italy. Corresponding author - valeriopasqualitto@gmail.com

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How to Cite
[1]
Pasqualitto, V. 2025. Nipple reconstruction after skin-sparing mastectomy: techniques, outcomes, and patient-centered decision making – a systematic review. Plastic Reconstructive and Regenerative Surgery. 4, 1-2 (Oct. 2025), 25–29. DOI:https://doi.org/10.57604/PRRS-1365.
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