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Nipple-areola Complex Reconstruction: A Study On Aesthetic Preferences
Pooja S. Yesantharao, MS, Halley Darrach, BS, Erica Lee, MS, Justin M. Sacks, MD, MBA, Kristen Broderick, MD.
Johns Hopkins Medicine, Baltimore, MD, USA.

PURPOSE: Nipple areola complex reconstruction is a critical component of post-mastectomy breast reconstruction and contributes substantially to patient satisfaction and overall patient quality of life outcomes. The goal of the reconstruction procedure is to create a natural-appearing breast/nipple areolar complex. This study sought to study both the general public's and plastic surgeons' perspectives on the aesthetic outcomes of nipple areola complex reconstruction based on size, color, and position of the reconstructed nipple on a breast. Secondary endpoints were to determine whether survey participants' demographics, skin color, and history of breast surgery impacted their perceptions of nipple reconstruction. Presently, few studies have investigated this topic from either the general public or plastic surgeon standpoints. Because the breast reconstruction process involves a dynamic interplay between surgeon and patient, comparatively studying the opinions of the general public versus surgeons can help inform the surgeon-patient conversation regarding nipple reconstruction, and it can help to standardize guidelines for nipple reconstruction in order to maximize aesthetic outcomes.
METHODS: This is a cross-sectional study of perceptions on nipple reconstruction. Participants were recruited anonymously through Amazon Mechanical Turk, and surgeons were recruited anonymously through the American Council of Academic Plastic Surgeons. Survey participants were asked to answer a series of questions on postoperative photos depicting various nipple reconstruction options varying by color, size, and positioning, taken from patients who underwent breast reduction (Figure). Survey images were generated using Adobe Photoshop to artificially adjust the size, shape, color, and location of the nipple-areola complex with respect to the breast mound. Survey data was analyzed using one-way ANOVA and chi square analyses where appropriate. Univariate followed by stepwise inclusion into multivariate regression was used to correlate nipple reconstruction preferences to underlying demographic characteristics of survey participants.
RESULTS: A total of 500 individuals from the general public and 100 plastic and reconstructive surgeons were sent surveys. Preliminary analysis has demonstrated that preferences amongst surgeon and non-surgeon respondents vary in terms of size and position (p=0.02 and 0.03, respectively), but not in terms of color (p=0.21). Furthermore, in the overall study cohort, the underlying shape of the breast mound significantly impacted positioning of the nipple, while the underlying skin tone of the breast mound significantly impacted the degree of color difference that participants preferred between the breast the nipple. After adjusting for survey participants' skin color, profession (i.e. plastic surgeon versus non-plastic surgeon), and age, having had a history of breast surgery significantly impacted participants' preferences with regards to size. Participants who had a history of breast surgery preferring on average smaller nipple diameters (millimeters) upon multivariate linear regression (beta value:-1.2; p=0.02).
CONCLUSIONS: By characterizing the aesthetic perceptions of nipple-areola complex reconstruction, this study aims to help facilitate the dialogue and decision-making process between surgeons and patients when considering options for nipple reconstruction. Data from this study may help inform the standardization of recommendations for nipple reconstruction.


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