Restoring the Nipple with Dermal Filler

By Dr Magdalena Szymanska Bueno / 10 Jan 2022

Dr Magdalena Szymanska-Bueno outlines how to add volume to the nipple using dermal filler and presents a case study showing successful results

Breast reconstruction is an important factor to consider when women are gaining a full recovery from breast cancer. Patients who undergo a breast mastectomy are very often seeking for full reconstruction, including in the nipple-areola complex (NAC).1 In this article I will present a case study evidencing how aesthetic practitioners can meet the expectations of patients looking to obtain nipple projection after areola reconstruction, through the use of dermal filler.

Main issues of the NAC

The reconstruction of the nipple-areola complex is the final step in the breast reconstruction process. Whenever possible, the surgeon will spare the NAC, otherwise, it will be surgically removed together with the cancerous breast tissue.2,3

The reconstruction of the NAC is usually performed between four and six months after the breast reconstruction. It plays a very important anatomical part for the woman and the reconstruction has considerable aesthetic and psychological impact.4 Women attach great importance to the presence of a three-dimensional nipple in the process of the breast reconstruction. Patients expect from NAC reconstruction symmetry in position, size, shape, texture, and colour.5 However, regardless of the technique, loss of nipple projection can be expected as the skin used often gets necrosis or becomes flat, lessening the appearance of a natural nipple.

There are different techniques for NAC reconstruction, but the most common are: the arrow flap, the C-V flap and the C-H flap. The main issue is maintaining the nipple’s projection over time since the new local flap tends to flatten.4,6,7 The reconstruction of the areola can be performed with a skin graft from areas such as the inner thigh skin, the axillary region or the labia minora skin. The first areola reconstruction using a full-thickness skin graft (FTSG) from the labia minora was described in 1949.8 This technique is easy to perform, and the healing process is generally fast. The main issue associated with FTSG for the areola reconstruction is the loss of pigment over time. In some cases, there is an indication to perform the skin graft again, one to two years after the initial one.9 It is also reported that tattooing the nipple has been associated with a decrease in nipple projection.10

A safe solution

The loss of the three-dimensional contour of the NAC following surgical breast reconstruction is a technical challenge for the physician and a psychological burden for many breast cancer patients. In 2005, a study established that nipple projection is the main reason for unsatisfactory NAC reconstruction,11 and many techniques have been proposed to maintain projection of the reconstructed nipple.

For 70 patients, 90 nipples were reconstructed using either a small wedge from the labia minora (n=70) or nipple sharing (n=20). Two months after reconstruction, each reconstructed nipple was injected with the hyaluronic acid filler DermaLive. Second and third injections were performed two and five months later. The described method is simple and safe, and it provides precise projection with no need for intraoperative forecasting of tissue reabsorption. The result was better for the labia minora wedge patients, perhaps because of their higher distensibility.11

A 2019 study of 12 patients saw an average increase of 3.0mm in nipple height, with all results stable at a median of seven and a half months follow-up and there were no complications observed.12 Patients that have used dermal filler to treat the nipple have noted that they gained self-confidence from the treatment, that they felt more feminine, and were much happier when they looked in the mirror as their breasts no longer reminded them of what they went through during cancer treatment.11,13 As such, the use of injectable dermal fillers to enhance nipple projection can be considered a simple non-invasive procedure with immediate and adjustable volume results that positively impact patient satisfaction.

Potential complications

More serious complications that can appear following dermal filler injection in this area are nipple necrosis, tip loss, wound infection and wound breakdown.14 In my experience nipple necrosis is a rare event, due to the dual nature of the local flap. In the case of previous postmastectomy radiation, the reconstruction of the nipple is associated with an increased complication risk. If an implant is used in breast reconstruction it might be associated with a higher rate of nipple reconstruction issues. Fading after tattooing or skin grafts is common over time; therefore, it is recommended to choose a darker pigment for the tattoo skin area as a place to harvest the skin graft.14,15

Case study

Patient overview and consultation

A 39-year-old female patient was diagnosed with breast cancer on the left-hand side. Eight months later, after a course of neoadjuvant chemotherapy, a mastectomy was performed, followed by radiotherapy which lasted two months. A year later, a full reconstruction of the breast was completed. Another five months passed, and the patient had NAC reconstruction using the labia minora graft technique. The patient originally chose this technique as she wanted her reconstructed nipple to have a similar colour and look to the one on her right breast. She also suffered with hyperplasia of the labia minora which qualified for surgery, and this graft could be used in the procedure. The next step for a full recovery was a tattoo of the NAC. Although the breast reconstruction and tattoo gave a good result, the patient still was not satisfied with the final look. The patient came to my clinic to talk about the possibilities of improving the projection of the nipple, as it was flat compared to her healthy breast. During the consultation, we discussed the different treatment options available, and she emphasised that the most important factor for her was to obtain natural looking breasts. During the physical examination, the NAC was symmetric compared to the other breast, and the colour was matching, however I found that the nipple was slightly flat, and the volume was decreased. I proposed to perform nipple volumisation with dermal filler. Prior to treatment I informed the patient that this was an off-label use of the filler and got her to sign consent forms acknowledging she was aware of this.

Treatment approach

The treatment was performed using a cross-linked hyaluronic acid filler. Specifically, I used Juvéderm Ultra 4 due to its density increase volume of soft tissue, which allowed me to obtain better nipple projection and volume.

The filler was slowly injected using a needle, which is my preference over a cannula to be able to control the amount of product injected into this area, until the desired result was achieved. I chose to distribute around 0.25ml of the product. Two months later, the patient had a second areola tattoo, and she then returned to my clinic for a follow-up appointment to assess the results. She observed that after the filler, the pigment used for the tattoo was actually producing better results. I decided to add another 0.15ml of hyaluronic acid filler into the nipple because it had dissolved slightly, which achieved the desired projection and matched to the unoperated breast.

This area of the body can be sensitive for the patient, and some bruising and swelling is to be expected in the first few days. In my experience, full results can usually be seen around two weeks after the treatment, when the side effects have settled.

This patient reported that she was very happy with the result and noted that she felt more confident in her body. I advised her that in order to maintain the result she will need to come back for a top-up treatment once a year.

Improving patient confidence

It is likely that aesthetic practitioners will see patients looking to restore their breasts following breast cancer, with many women particularly looking to volumise the nipples. By using hyaluronic acid to restore volume and nipple projection, we can help patients overcoming breast cancer to obtain the most natural looking NAC and help restore any lost confidence in their appearance. There is not a lot of published literature around different techniques for areola volumisation using HA, so this would be welcomed.

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