Case 18 2026: Nipple reconstruction on a DIEP-flap after breast cancer
Alaa Jady1, Pia Cajsa Leth Andersen1
- 1University Hospital, Rigshospitalet. Denmark
Abstract
Keywords: Nipple reconstruction, plastic surgery, DIEP flap, C-V flap, Tennessee flap Authors: Alaa Jady, MD, Pia Cajsa Leth Andersen, MD. Copenhagen University Hospital, Rigshospitalet. Denmark. Abstract 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
BeforeAfterA 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.
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).
The measurements for our patient’s nipple were as follows: each arm had a short side on 7 mm (green line on the illustration) and a long side at 12 mm (orange line on the illustration), while the circumference of the head was the same as the height as the nipple (blue line on the illustration). These markings are illustrated on the patient in the above picture.
Incisions are made to define the two arms and the head. Care should be taken not to divide the base of the flap or the attachment of the head to the vertical wall. The blood supply to this flap comes from the underlying subcutaneous tissue, and thus it is important to leave the subdermal plexus in those subcutaneous tissues intact.
3
The two arms are then elevated from the underlying subcutaneous tissue (see picture 4). The subdermal plexus is left on these as well as some fatty tissue, depending on the requirements for the fullness of the nipple. The flaps are thinned more toward their periphery than centrally to avoid devascularizing the tip of the flaps.
The head is also thinned, and the subcutaneous tissue preserved in the central area of the proposed new nipple. This central tissue will provide blood supply as well as central bulk for the nipple.
The flap is gradually lifted by elevating the flap and releasing some of the tightness while preserving the blood supply to the base of the flap, which also supplies the two arms and the head flaps.
4
The initial flap closure involves suturing the donor base of the head flap to the base of the arm flap on both sides with an absorbable suture. We used Vicryl 4-0 for inverted subcuticular stitches. This effectively closes the donor site and brings the site of the head flap in as a circle to define placement of the nipple reconstruction.
After the donor sites are closed, the two arm flaps and the head flap are trapped outside with a non-absorbable suture. We used Prolene 4-0 for simple interrupted stitches. When these flaps are positioned, it can be seen that the width of the arm flaps determines the vertical height of the nipple, and the head flap is the top of the nipple reconstruction.
The area was dressed with Jellonet, a donut-shaped foam dressing, and a large Tegaderm dressing.
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The immediate postoperative result is as seen on the picture.
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The patient returned to our clinic 14 days postoperatively for suture removal. The procedure was performed without complications; there were no signs of infection and the cicatrice appeared well healed. The patient additionally stated that she would independently seek a medical tattoo artist for NAC-tattooing.
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Patient sent in a picture of her breast as a 3 month follow up (see picture 8). Here can be seen a good nipple symmetry and projection.
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No indication for further follow up or surgery postoperatively.
How to cite this article
Alaa Jady, Pia Cajsa Leth Andersen. Case 18 2026: Nipple reconstruction on a DIEP-flap after breast cancer. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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