Immediate nipple reconstruction as part of one-stage total breast reconstruction: a vascular design-based narrative...

Autologous breast reconstruction restores breast volume and contour after mastectomy, but reconstruction of the nipple-areola complex remains central to the perception of breast completeness. Traditionally, nipple reconstruction has been delayed until the reconstructed breast mound has stabilized, allowing the final nipple position and projection to be adjusted after soft-tissue settling and scar remodeling. However, in selected patients undergoing autologous reconstruction, simultaneous nipple reconstruction can be integrated into breast shaping, thereby reducing additional procedures, avoiding a second local incision and making use of redundant skin and soft tissue that would otherwise be discarded during flap tailoring. This strategy also allows surgeons to plan breast contour, nipple position, projection and symmetry as a single three-dimensional aesthetic unit. Nevertheless, accurate intraoperative positioning, reliable perfusion and durable long-term projection remain major technical challenges. In this case-based narrative review, we discuss the rationale, potential advantages, patient selection and limitations of immediate nipple reconstruction during autologous breast reconstruction. We further present three representative approaches from our center: a local flap, a pedicled perforator-based flap and a free perforator-based flap. These cases suggest that immediate nipple reconstruction should not be regarded as a single standardized operation, but as a flexible reconstructive strategy that should be tailored to tissue availability, vascular anatomy and aesthetic goals.