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Department of Plastic Surgery, Loma Linda University, Loma Linda, California, USA Correspondence: Dr Wendy W Wong, Department of Plastic Surgery, Loma Linda University, 11175 Campus Street, Suite 21126CP, Loma Linda, California 92350, USA. Telephone 909-558-8085, fax 909-558-4175, e-mail [email protected] As more women undergo breast reconstruction following mastectomy, the necessity of excellent nipple-areola reconstruction becomes increasingly relevant. The creation of a pleasing nipple-areola complex is the final stage in breast reconstruction following the recreation of the breast mound. This is an important procedure in recreating a ‘breast’ that is visually analogous to the preoperative breast. Often, breast reconstruction is an important facet of both physical and psychological healing for women who have been diagnosed with breast cancer. As the final stage in the reconstructive process, it is imperative that the procedure provide a pleasing aesthetic outcome with consistent projection, minimal adjacent tissue distortion and excellent symmetry. In practice and in the literature, the use of local tissue flaps has become the primary contemporary technique. Local flaps preclude the creation of an additional donor site, minimizing perioperative discomfort and additional comorbidities. While each local flap exhibits its own advantages, certain common limitations are ubiquitous. Paramount among these limitations is the loss of projection seen with all local flap techniques. Objective measures assessing long-term nipple projection in the literature are sparse; however, studies that have evaluated long-term follow-up cite a loss of projection of 40% or more (Table 1) (1-19). This problem has led many to advocate creating overprojection of the nipple to at least 150% of the contralateral side to allow for loss of projection. This technique is less than ideal, however, because it increases the necessary local tissue required, creates more potential distortion of the breast mound, places a larger demand on the vascular pedicle that is already susceptible to necrosis and provides an inconsistent result. With regard to projection, reliability and a range of application, a simple and reliable method appropriate for all scenarios remains elusive. The ideal formula for nipple reconstruction would maintain longterm nipple projection, texture and shape, and have minimal donor site morbidity. To enhance reproducibility of the technique and results, the design should be relatively simple and with a short learning curve. When using local tissue, an adequately wide base should be formed to avoid vascular compromise and necrosis, while limiting the length of incisions and local tissue use to minimize alterations in breast shape. Ideally, long-term results should demonstrate adequate projection, an overall aesthetically pleasing appearance and, in appropriate cases, satisfactory symmetry with the contralateral nipple. The surgical technique we present for nipple reconstruction uses local tissues to form an ‘angel flap’ – a modification of the skate flap. We believe that this technique fulfills the ideal formula for nipple reconstruction.