Long-term Nipple Projection Retention Following Local Flap-based Reconstruction: Insights From 3D Imaging Analysis

Background: Loss of nipple projection is a common concern following local tissue nipple-areolar complex (NAC) reconstruction, with contracture leading to inevitable projection loss over time. While multiple techniques have been developed, few studies have measured long-term projection loss, and none have utilized 3D imaging for accurate assessment. This study aimed to analyze long-term nipple projection loss using 3D imaging to improve patient education and expectations. Methods: A retrospective analysis of patients who underwent skin-sparing postmastectomy breast reconstruction with local flap-based (C-V flap) NAC reconstruction between 2010 and 2022 was conducted. Patients with available 3D images were included. The VECTRA Analysis Module (VAM) was used to measure nipple projection at 3, 6, 12, and 24 months postoperatively. Subgroup analysis was performed for autologous and implant-based reconstruction. Results: Among 136 patients (281 observational time points), nipple projection decreased by 14% at 3 months (P = .002), 15% at 6 months (P = .001), and 19% at 1 year (P < .001) compared to 1 month postoperatively. After 1 year, projection stabilized, with only a 2% decrease in height by year 2 (P = .13). C-V flap limb length was not significantly associated with long-term projection retention (P = .10). Subgroup analysis showed similar nipple projection retention patterns for autologous and implant-based reconstruction, stabilizing at 1 year postoperatively. Conclusions: Nipple projection following flap creation decreases significantly up to 1-year post-reconstruction and plateaus from year 1 to 2. Patients opting for local flap-based reconstruction should be counseled preoperatively regarding expected projection loss and when they can expect their nipple height to plateau.