This is an informed-consent document that has been prepared to help inform you about nipple reconstruction surgery, its risks, as well as alternative treatment(s). It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your plastic surgeon and agreed upon by you.
Nipple reconstruction involves the restoration of the nipple-areolar complex lost due to injury, breast cancer or other conditions. A variety of different techniques exist for reconstruction of the nipple and its surrounding areolar tissue. These include the use of skin grafts taken from other regions of the body, local flaps of breast skin that are shaped into a nipple, or the sharing of tissue from the opposite nipple-areolar region. Additional techniques such as tattooing may be used to add color to the tissue if needed. Nipple reconstruction may be performed as a single surgical procedure, or combined with other breast reconstruction procedures.
Nipple reconstruction surgery is an elective surgical operation. Alternative treatment would consist of not undergoing the surgical procedure or the use of external nipple areolar prostheses.
INHERENT RISKS OF NIPPLE RECONSTRUCTION SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your plastic surgeon to make sure you understand all possible consequences of nipple reconstruction surgery.
SPECIFIC RISKS OF NIPPLE RECONSTRUCTION SURGERY
Scarring: All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may occur in both the nipple reconstruction site and the donor site for tissues used in the nipple reconstruction. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. In some cases, scars may require surgical revision or treatment.
Skin Grafts: Skin grafts are used in some nipple reconstruction techniques. The location of where the graft is taken may have residual scarring, poor healing, or abnormal color. Chronic itching sensations have been reported. Skin graft loss can occur due to infection or other causes. Additional skin grafts may be needed.
Hair Growth: Skin grafts used in nipple reconstruction may contain hair follicles. Unattractive hair growth may occur in the reconstructed nipple. Additional treatment may be required to remove the hair follicles.
Tattoos: If tattooing is required as an additional procedure, it may be impossible to precisely match the color and texture of the opposite nipple-areolar complex.
Change in Nipple Sensation: Nipple reconstruction cannot restore normal sensation to the breast or nipple.
Skin Contour Irregularities: Contour and shape irregularities may occur. Nipple position and shape will not be identical one side to the next. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility when there is excessive redundant skin. This may improve with time, or it can be surgically corrected.
Breast Implant Damage: Breast implant damage can occur during a nipple reconstruction surgery. A damaged or broken implant will require surgery for replacement or removal.
Damage to Opposite Nipple: Some nipple reconstruction procedures use a tissue-borrowing technique from the opposite nipple region. It is possible that the donor nipple region may be damaged or lose normal sensation.
Breast Disease: Current medical information does not demonstrate an increased risk of breast cancer in women who have nipple reconstruction surgery. Individuals with a personal history or family history of breast cancer may be at a higher risk of developing breast cancer than a woman with no family history of this disease. It is recommended that all women perform periodic self-examination of their breasts, have mammography according to American Cancer Society guidelines, and seek professional care should a breast lump be detected. In the event that suspicious tissue is identified prior to or during breast surgery, additional tests and therapy with corresponding expenses may be warranted.
GENERAL RISKS OF SURGERY
Healing Issues: Certain medical conditions, dietary supplements and medications may delay and interfere with healing. Patients with massive weight loss may have a healing delay that could result in the incisions coming apart, infection, and tissue changes resulting in the need for additional medical care, surgery, and prolonged hospitalizations. Patients with diabetes or those taking medications such as steroids on an extended basis may have prolonged healing issues. Smoking will cause a delay in the healing process, often resulting in the need for additional surgery. There are general risks associated with healing such as swelling, bleeding, possibility of additional surgery, prolonged recovery, color changes, shape changes, infection, not meeting patient goals and expectations, and added expense to the patient. There may also be a longer recovery due to the length of surgery and anesthesia. Patients with significant skin laxity (patients seeking facelifts, breast lifts, abdominoplasty, and body lifts) will continue to have the same lax skin after surgery. The quality or elasticity of skin will not change and recurrence of skin looseness will occur at some time in the future, quicker for some than others. There are nerve endings that may become involved with healing scars from surgery such as suction-assisted lipectomy, abdominoplasty, facelifts, body lifts, and extremity surgery. While there may not be a major nerve injury, the small nerve endings during the healing period may become too active producing a painful or oversensitive area due to the small sensory nerve involved with scar tissue. Often, massage and early non-surgical intervention resolves this. It is important to discuss post-surgical pain with your surgeon.
Bleeding: It is possible, though unusual, to experience a bleeding episode during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or you may require a blood transfusion, though such occurrences are rare. Increased activity too soon after surgery can lead to increased chance of bleeding and additional surgery. It is important to follow postoperative instructions and limit exercise and strenuous activity for the instructed time. Do not take any aspirin or anti-inflammatory medications for at least ten days before or after surgery, as this may increase the risk of bleeding. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding. Hematoma can occur at any time, usually in the first three weeks following injury to theoperative area. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets.
In breast implant surgery, hematoma may contribute to capsular contracture, infection or other problems.
Infection: Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. It is important to tell your surgeon of any other infections, such as ingrown toenail, insect bite, or urinary tract infection. Remote infections, infection in other part of the body, may lead to an infection in the operated area.
Infection in Breast Implant Patients: Subacute or chronic infections may be difficult to diagnose. Should an infection occur, treatment including antibiotics, possible removal of the implant, or additional surgery may be necessary. Infections with the presence of a breast implant are harder to treat than infections in normal body tissues. If an infection does not respond to antibiotics, the breast implant may have to be removed. After the infection is treated, a new breast implant can usually be reinserted. It is rare that an infection would occur around an implant from a bacterial infection elsewhere in the body, however, prophylactic antibiotics may be considered for subsequent dental or other surgical procedures. In extremely rare instances, life-threatening infections, including toxic shock syndrome have been noted after breast implant surgery. Individuals with an active infection in their body should not undergo surgery, including breast augmentation. Although infection is
unusual after this type of surgery, it may appear in the immediate post-operative period or at any time following the insertion of a breast implant. It is important to tell your surgeon of any other infections, such as ingrown toenail, insect bite, or urinary tract infection. Remote infections, infection in other part of the body, may lead to an infection in the operated area.
Scarring: All surgery leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. In some cases scars may require surgical revision or treatment.
Firmness: Excessive firmness can occur after surgery due to internal scarring. The occurrence of this is not predictable. Additional treatment including surgery may be necessary.
Change in Skin Sensation: It is common to experience diminished (or loss of) skin sensation in areas that have had surgery. Diminished (or complete loss of) skin sensation may not totally resolve.
Skin Contour Irregularities: Contour and shape irregularities may occur. Visible and palpable wrinkling of skin may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility when there is excessive redundant skin. This may improve with time, or it can be surgically corrected.
Skin Discoloration / Swelling: Some bruising and swelling will normally occur. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time and, in rare situations, may be permanent.
Skin Sensitivity: Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery.
Usually this resolves during healing, but in rare situations it may be chronic.
Major Wound Separation: Wounds may separate after surgery. Should this occur, additional treatment including surgery may be necessary.
Sutures: Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures may spontaneously poke through the skin, become visible or produce irritation that requires suture removal.
Delayed Healing: Wound disruption or delayed wound healing is possible. Some areas of the skin may not heal normally and may take a long time to heal. Areas of skin may die. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to tissue from past surgery or radiation therapy may be at increased risk for wound healing and poor surgical outcome. Smokers have a greater risk of skin loss and wound healing complications.
Damage to Deeper Structures: There is the potential for injury to deeper structures including nerves, blood vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent.
Fat Necrosis: Fatty tissue found deep in the skin might die. This may produce areas of firmness within the skin. Additional surgery to remove areas of fat necrosis may be necessary. There is the possibility of contour irregularities in the skin that may result from fat necrosis.
Seroma: Infrequently, fluid may accumulate between the skin and the underlying tissues following surgery, trauma or vigorous exercise. Should this problem occur, it may require additional procedures for drainage of fluid.
Surgical Anesthesia: Both local and general anesthesia involves risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation.
Shock: In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or extensive procedures are performed. Although serious complications are infrequent, infections or excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization and additional treatment would be necessary.
Pain: You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist after surgery. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or due to tissue stretching.
Cardiac and Pulmonary Complications: Pulmonary complications may occur secondarily to blood clots (pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary emboli can be life threatening or fatal in some circumstances. Inactivity and other conditions may increase the incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important to discuss with your physician any past history of swelling in your legs or blood clots that may contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require hospitalization and additional treatment.
Venous Thrombosis and Sequelae: Thrombosed veins, which resemble cords, occasionally develop in the area of the breast or around IV sites, and usually resolve without medical or surgical treatment. It is important to discuss with your surgeon any birth control pills you are taking. Certain high estrogen pills may increase your risk of thrombosed veins.
Allergic Reactions: In rare cases, local allergies to tape, suture material and glues, blood products, topical preparations or injected agents have been reported. Serious systemic reactions including shock (anaphylaxis) may occur in response to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.
Drug Reactions: Unexpected drug allergies, lack of proper response to medication, or illness caused by the prescribed drug are possibilities. It is important for you to inform your physician of any problems you have had with any medication or allergies to medication, prescribed or over the counter, as well as medications you now regularly take.
Asymmetry: Symmetrical body appearance may not result after surgery. Factors such as skin tone, fatty deposits, skeletal prominence, and muscle tone may contribute to normal asymmetry in body features. Most patients have differences between the right and left side of their bodies before any surgery is performed. Additional surgery may be necessary to attempt to diminish asymmetry.
Surgical Wetting Solutions: There is the possibility that large volumes of fluid containing dilute local anesthetic drugs and epinephrine that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to these medications. Additional treatment including hospitalization may be necessary.
Persistent Swelling (Lymphedema): Persistent swelling can occur following surgery.
Unsatisfactory Result: Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. The body is not asymmetric and almost everyone has some degree of unevenness which may not be recognized in advance. One side of the face may be slightly larger, one side of the face droopier. The breast and trunk area exhibits the same possibilities. Many of such issues cannot be fully corrected with surgery. The more realistic your expectations as to results, the better your results will be in your eye. Some patients never achieve their desired goals or results, at no fault of the surgeon or surgery. You may be disappointed with the results of surgery. Asymmetry, unanticipated shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur after surgery. Size may be incorrect. Unsatisfactory surgical scar location or appearance may occur. It may be necessary to perform additional surgery to improve your results.
Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray): Patients who are currently smoking or use tobacco or nicotine products (patch, gum, or nasal spray) are at a greater risk for significant surgical complications of skin dying and delayed healing and additional scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of this type of complication.