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Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) optimizes aesthetic outcomes, yet transection of intercostal sensory nerves commonly results in persistent nipple-areolar complex (NAC) anesthesia and, in some patients, denervation-related symptoms. NAC neurotization has emerged as an intraoperative strategy intended to improve protective sensation and potentially erogenous sensation by reconnecting donor intercostal nerves to the retroareolar plexus or to targets within the nipple. Here, we provide an anatomy-first narrative synthesis of the medial and lateral sensory corridors, with emphasis on the lateral cutaneous branches of T3–T5 and the reported anatomical landmarks that facilitate donor identification during NSM. We then review the biological constraints governing regeneration across the long trajectories typical of IBBR, including evidence suggesting reduced performance of acellular nerve allografts with increasing gap length and the rationale for autologous nerve transfers. Technical approaches are organized by (i) donor selection and harvest depth, (ii) graft choice, and (iii) distal coaptation strategies ranging from subareolar stump coaptation to targeted NAC reinnervation and direct nipple neurotization techniques. We also summarize the current clinical evidence regarding sensory recovery kinetics, safety and complications, operative time and cost, and propose practical checkpoints for intraoperative decision-making and standardized postoperative assessment. Collectively, available data support NAC neurotization as a feasible adjunct to NSM-IBBR, while highlighting the need for harmonized outcome reporting and longer follow-up to define comparative effectiveness among techniques.