Nipple-areolar complex neurotization in implant-based breast reconstruction: a narrative review

Nipple-sparing mastectomy with implant-based breast reconstruction preserves the visible nipple-areolar complex (NAC) but commonly disrupts protective, tactile, thermal, and erogenous sensation. Clinical interest has expanded, while donor selection, recipient targeting, bridge choice, implant-pocket constraints, outcome measurement, and candidacy remain unsettled. This narrative review addresses when native nerve preservation or reconstruction is anatomically credible, how implant-specific constraints affect operative planning, what the available outcomes support, and when selective non-use is appropriate.

PubMed was the primary indexed database; Google Scholar and reference chaining were supplementary discovery methods. English-language, peer-reviewed sources relevant to predefined clinical questions were considered from database inception through 15 May 2026. Publications used for substantive claims were assessed in full text. Evidence was organized by directness and synthesized narratively according to study design, consistency, applicability, outcome methodology, and follow-up. No formal risk-of-bias instrument, quantitative pooling, dual independent systematic-review screening, or duplicate extraction was performed.

The direct evidence consists predominantly of technical reports and small single-center observational cohorts, with limited comparative and randomized evidence. Follow-up is generally short, sensory instruments and testing zones are inconsistent, and many reports do not provide denominators for planned, attempted, modified, or abandoned neurotization. The T3-T5 lateral intercostal corridor, particularly T4, is the principal donor region; safely preservable superficial branches may remain in continuity when oncologic resection and flap perfusion are uncompromised. Implant base width, donor length, route feasibility, and coaptation sequencing are supported technical considerations, whereas validated thresholds for acellular dermal matrix or capsule interfaces, compression, tissue expansion, route vascularity, or protected slack are absent. Subareolar stumps, retroareolar or subdermal NAC fields, posterior areolar tissue, and nipple-base targets have been used, without evidence of target superiority. Processed allograft has the strongest implant-based precedent, while direct repair, branch elongation, and autograft are anatomy-dependent alternatives; comparative biological and economic superiority is unestablished.

NAC neurotization is selectively feasible and may improve sensation, but the evidence is heterogeneous and insufficient for firm technique or patient-selection recommendations. The proposed conditional framework supports clinical reasoning and transparent reporting; it is not a validated guideline.