Necrosis of the nipple areolar complex (NAC) is an infrequent but devastating complication of reduction mammaplasty and mastopexy. However, with strategic management and properly timed reconstruction, it is possible in most cases to restore a natural-appearing NAC.

To prevent necrosis of the NAC, it is most important to maintain a pedicle of adequate thickness, be cognizant of the length to width ratio of the pedicle, prevent kinking the blood supply when insetting the flap, and avoid an excessively tight skin closure, no matter what type of technique is performed. Especially in the case of secondary reduction mammaplasty or mastopexy in the previously augmented patient, great care must be taken because the breast anatomy and physiology has changed because of the previous procedures.

In the immediate postoperative period, the ischemic NAC can be transferred as a full-thickness graft. When it is elected to convert to a graft, all the circulatory changes have to be stabilized to confirm that the ischemia is irreversible and the recipient site is healthy enough to accept a graft.

The guiding principle in surgical management of ischemic complications of the NAC is to avoid aggressive treatment until the tissue necrosis obviously demarcates. When the missing part is small, the nipple can be reconstructed by composite grafting from the contralateral nipple. When a major part of the nipple is lost, reconstruction using a local flap can yield a favorable result.

The areola can be reconstructed using a full skin graft from the contralateral areola, the labia minora, or the upper inner thigh. Intradermal tattooing can be used to obtain a desirable color match.