While we do not have your complete history, in reviewing your pictures, I think you have a difficult problem. Unfortunately, mastectomy skin necrosis or necrosis of the nipple is something that all plastic surgeons performing breast reconstruction may face at some point. The breast oncologic surgeons are faced with the difficult task of removing all of the breast tissue for treatment of the cancer but leaving healthy, thick, vascular flaps behind for reconstruction. As reconstructive plastic surgeons have continued to ask the breast oncologic surgeons to work through smaller and smaller incisions their job has become even more difficult. This is particularly true in the setting of nipple sparing mastectomy where they need to remove a core of tissue from behind the nipple and all of the breast tissue through a small often remote incision.Your course appears to have been managed very conservatively with wound care to date. The options that exist would be continued conservative management with wound care and hope that the implant does not become exposed or infected versus removal of the implants. Without examining you it would be difficult to determine if continued wound care is truly a viable option. At a certain point, the capacity for wound healing is not going to get the job done. It can be hard to accept having the implants removed but often this is the best course. If there is no evidence of infection, one could consider removing your implants, debriding (surgically removing) the mastectomy skin necrosis and nipple to healthy tissue and inserting a smaller implant or tissue expander and closing the healthy skin. If there are signs of infection, removal of the implants, debridement of unhealthy tissue, and closure over drains without new implants would be advisable. In that setting, the recommendations would be to wait as long as 6 months before pursuing further reconstruction to allow your body to clear any infection.I hope this adequately answered her question. Good luck.
As has been discussed below, nipple areolar reconstruction can be performed a number of ways: local flaps, skin grafts, cartilage grafts, nipple sharing grafts, tattooing, and even as simple as the application of stick on silicone.Regarding your specific question, no breast implant is available with a nipple in the US. However, there is at least one commercially available nipple reconstruction cylinder made of a biologic material that can be wrapped in local flap tissue to achieve a projecting nipple. (Cook Biodesign Nipple Cylinder). I do not personally have experience with this nipple cylinder, but I wanted to provide this information for completeness sake.
I believe you would be a candidate for skin sparing mastectomy, possibly nipple sparing but that would depend on the size of your breasts and the location of your nipples following weight loss. Often following rapid weight loss (post bariatric) the breasts have significant degree of ptosis (sagging) and a deflated upper pole appearance, and even if one could preserve the nipples during mastectomy, the ultimate location following reconstruction could be less than ideal. Autologous reconstruction (using your own tissue) following bariatric surgery is an excellent option, particularly the Deep Inferior Epigastric Perforator (DIEP) Flap reconstruction. This type of reconstruction would take advantage of the excess skin and fat in your low abdomen following weight loss. I would consider getting an abdominal CT scan to assure that good vessels are available following your previous surgeries. I would recommend talking to a board certified plastic surgeon who offers microvascular breast reconstruction to determine if this a good choice for you.
