Case 18 2026: Nipple reconstruction on a DIEP-flap after breast cancer

Alaa Jady; Pia Cajsa Leth Andersen

Journal of Plastic, Breast & Reconstructive Surgery·Begutachtete Open-Access-Fallberichte aus der ChirurgiePeer-Review · Open Access

Case 18 2026: Nipple reconstruction on a DIEP-flap after breast cancer · JPBRS

Fallbericht

Case 18 2026: Nipple reconstruction on a DIEP-flap after breast cancer

Alaa Jady¹, Pia Cajsa Leth Andersen¹

¹University Hospital, Rigshospitalet. Denmark

Veröffentlicht 28. Mai 2026136 Aufrufe6 Min. Lesezeit

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Zusammenfassung

Nipple reconstruction is an important final step in breast reconstruction after mastectomy. This case describes a 42-year-old woman with prior right-sided breast cancer who underwent successful breast reconstruction using a DIEP flap followed by nipple reconstruction with the Tennessee technique. Pre-operative planning focused on achieving symmetry through detailed bilateral measurements and nipple–areola sizing. The procedure involved designing a flap with two arms and a rounded head, careful preservation of the subdermal plexus, and staged suturing. Postoperative follow-up showed good healing, maintained nipple projection, and satisfactory symmetry three months after surgery. Patient medical history A 42-year-old woman with a known history of Hashimoto’s thyroiditis was diagnosed with right-sided breast cancer in June 2022. She received neoadjuvant therapy followed by a right-sided mastectomy in December 2022 and adjuvant radiotherapy. Following completion of these treatments, the patient was deemed cancer-free. In November 2024, she underwent uncomplicated right-sided breast reconstruction using a deep inferior epigastric perforator (DIEP) flap and a contralateral mastopexy for symmetry. Subsequently, right-sided nipple reconstruction was performed in December 2025. Before and After Patient examination Physical examination revealed well-healed scars on both breasts that appeared soft and symmetrical. At the site of the DIEP flap on the right breast, the nipple was absent. Pre-operative considerations Since the patient planned to undergo subsequent nipple–areola complex (NAC) tattooing following our reconstruction, a nipple reconstruction using the “Tennessee” technique was chosen. To achieve symmetry, bilateral measurements were obtained with the patient in the

Wichtigste Lernpunkte

Pearls

This flap is a versatile and reliable method for breast reconstruction. It uses local tissue and is most applicable and predictable after autologous tissue reconstructions with thicker subcutaneous tissues. The volume of the flap is dependent on the volume of the underlying subcutaneous tissues as well as the tension of the skin.
This reconstruction can easily be done under local anesthesia.
When deciding the placement of the flap, the appearance of the nipples while wearing clothing such as a shirt or bra is of primary importance for some patients, whereas for others, the appearance in the absence of clothing is more significant. We advise to involve the patient in the decision of the nipple placement.

Pitfalls

The limits of this procedure are most obvious in patients with a very tight implant-based breast reconstruction. In these cases, the sparse subcutaneous tissue, along with the tight skin, most often results in the new nipple significantly reducing height and ending up absent.
When designing the flap, it is important to avoid placing the base of the flap in close proximity to a scar, as adequate vascular supply must be ensured to maintain flap viability.

Patient history

A 42-year-old woman with a known history of Hashimoto’s thyroiditis was diagnosed with right-sided breast cancer in June 2022. She received neoadjuvant therapy followed by a right-sided mastectomy in December 2022 and adjuvant radiotherapy. Following completion of these treatments, the patient was deemed cancer-free. In November 2024, she underwent uncomplicated right-sided breast reconstruction using a deep inferior epigastric perforator (DIEP) flap and a contralateral mastopexy for symmetry. Subsequently, right-sided nipple reconstruction was performed in December 2025.

Examination

Physical examination revealed well-healed scars on both breasts that appeared soft and symmetrical. At the site of the DIEP flap on the right breast, the nipple was absent.

Pre-operative considerations

Since the patient planned to undergo subsequent nipple–areola complex (NAC) tattooing following our reconstruction, a nipple reconstruction using the “Tennessee” technique was chosen.
To achieve symmetry, bilateral measurements were obtained with the patient in the upright position, including the distance from the nipple to the sternal notch, the inframammary fold, and the midline of the sternum, as well as the areolar diameter.
The size of the NAC on the right breast was also taken into consideration. Preoperatively, NAC prostheses/stickers of varying sizes were applied to the left breast to ensure bilateral symmetry, and a medium-sized NAC was ultimately selected for our patient. This process ensured that the reconstructed nipple on the left breast was positioned at the same vertical level as the nipple on the right breast (Jalini et al., 2017).

Schritt 1 — Step 1: pre-operative nipple design

The basic concept of the “Tennessee” nipple reconstruction is that the nipple design is composed of two ‘arms’ and one round ‘head’. The diameter of the head will be similar to that of the final nipple diameter, and the overall circumference of the two arms will approximate the circumference of the new nipple (Bermudez et al., 2025).