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Nipple hypertrophy is an occasional deformity in Asians and a rare one in Caucasians. Lately, it has been showing up more often in plastic surgeons’ offices across North America and elsewhere, owing to the influx of Asian immigration worldwide, as well as to the rising interest in esthetic surgery among Asian communities.
A simplified technique for nipple reduction is described herein. It is very easy to execute, delivers accurate results and is extremely safe. It tackles both the excessive ‘projection’ and the less frequent excessive ‘width’ of the nipple. It may be used separately or incorporated as an adjunct to mammary augmentation or mastopexy. Excellent esthetic results are obtained, while both the nipple innervation and its lactiferous ducts are preserved. The patient’s and surgeon’s satisfaction is high.
L’hypertrophie mamelonnaire s’observe à l’occasion chez les femmes asiatiques et rarement chez les femmes de race blanche. On a remarqué dernièrement une augmentation du nombre de consultations en chirurgie plastique, en Amérique du Nord et ailleurs dans le monde, en raison de l’accroissement de l’immigration asiatique sur la planète et de l’intérêt accru que porte la communauté asiatique à l’égard de la chirurgie esthétique.
Les auteurs décrivent, dans le présent article, une technique simplifiée de réduction du mamelon. Celle-ci est très facile à réaliser, donne des résultats précis et est extrêmement sûre. Elle vise autant la « projection » exagérée que la « largeur » excessive du mamelon. Elle peut être pratiquée seule ou en complément de la chirurgie mammaire d’augmentation ou de la mastopexie. La technique donne d’excellents résultats esthétiques tout en préservant l’innervation du mamelon et les conduits lactifères. Les patientes et les chirurgiens se disent très satisfaits des résultats.
Nipple hypertrophy and its reduction have been described in a limited number of articles throughout the medical literature (1–8). Nipple hypertrophy is an uncommon esthetic problem. The epidemiology of this deformity remains largely unknown; it is mostly encountered in the Asian population and, occasionally, in Caucasians. It is sometimes familial, appearing after the onset of adolescence or following pregnancy, and persisting through menopause (1). It may lead to psychological distress because of its association with a negative esthetic image. As well, women may feel embarrassed by their hypertrophic nipples, which are hard to conceal under light clothing because of their prominence.
No formal definition of nipple hypertrophy exists. Some clinicians have suggested that the normal female nipple is roughly 1 cm in diameter, with an almost equal amount of anterior projection (1). In cases of nipple hypertrophy, the size of the nipple may reach 2 cm or even more, and the shape usually becomes spherical.
The aim of the correction is primarily to shorten the nipple length, while secondarily establishing harmony between its diameter size and projection. The patient seeking a correction for nipple hypertrophy is usually also concerned about the functional results of the surgery, in addition to the esthetic outcome.
The ideal nipple (Figure 1A) is shaped like a cylinder, with a slightly curved ‘dome-like’ top. The height (projection) of the nipple is by far the most common disturbing factor in nipple hypertrophy. An ideal projection, in our opinion, is approximately 8 mm (with an acceptable margin of 6 mm to 10 mm). The second but less important component of nipple hypertrophy is its diameter, which ideally should be approximately 8 mm (6 mm to 10 mm). Nipple hypertrophy, in our experience, has always presented bilaterally.
The marking of the hypertrophic nipple is performed in three steps. Firstly, the new projection of the nipple is delineated. This is done by measuring 8 mm from the top of its dome, and drawing a circumferential perimeter (Figure 1B: p) representing its new base. Secondly, a line (Figure 1B: b) is drawn around the present base. Finally, a vertical line (superior to inferior) and a horizontal line (from right to left) are drawn across the areola and the nipple to orient the surgeon during the final closure.
The infiltration of the base and trunk of each nipple is done using 2 mL to 3 mL of 1% xylocaine with 1/100,000 adrenaline, delivered through a 30G needle.
A circular incision is made at the bottom of the new nipple (circle p, Figure 1C). Another circular incision is made at the base of the present nipple (circle b, Figure 1C). The extra skin between these two incisions is meticulously dissected as a very thin cutaneous flap and then excised (Figure 1C: Sk), using an Adson-Brown forceps and a No 15 blade. Fine electrocautery is used for hemostasis.
Interrupted inverted 4-0 or 5-0 vicryl sutures are used to approximate the four corners (superior, inferior, medial, lateral) of the new nipple to its base (Figure 1D), using the drawn vertical and horizontal lines as references. This suturing leads to invagination of the naked section of the nipple (between incisions ‘p’ and ‘b’). The rest of the closure is done by using a continuous or interrupted inverted 4-0 or 5-0 vicryl structures.
Figure 3 shows the step-by-step technique for the surgical reduction of the excessive nipple projection.
In approximately 10% of cases of hypertrophic nipples, in addition to the excessive projection, the diameter may also be too large (larger than 1 cm), and needs to be reduced. In such a case, the same marking described for the overprojecting nipple (Figure 1B) is completed. Then, the width of the present base is measured (Figure 2A: w). The excess width (exceeding 8 mm to 10 mm) is divided in two ([w–8 mm]/2), resulting in the width of each of two rectangles, placed at opposing sides of the nipple. These two small rectangles of skin, each measuring 2 mm to 5 mm in width, are marked on both the inferior and superior surfaces of the new nipple (Figure 2A: R; and Figure 2B: R and R2). Two transverse incisions, on both sides of the top of each rectangle, measuring approximately 2 mm to 3 mm, are marked just below the dome (Figure 2C: i). These two incisions will eventually allow the creation of two advancing flaps that will close each rectangular defect and narrow the new nipple in the process.
For the nipple diameter to be reduced, the two skin rectangles (Figure 2C: R and R2) are excised as two very thin skin pieces by superficial dissection.
Two incisions (Figure 2C: i) are made on both sides of the superior limit of each bare rectangle. A minimal subcutaneous dissection of about 2 mm to 3 mm bilaterally is performed to raise two advancing skin flaps that are approximated with inverted 4-0 or 5-0 vicryl sutures (Figure 2C: f; Figure 2D).
To narrow the circular defect in the areola (Figure 2C: b), a small triangle (Figure 2C: t), with its base measuring 2 mm to 5 mm in width, is marked and excised at the inferior and superior midline of the basal incision ‘b’. Closure of these triangular defects is facilitated by minimal bilateral dissection.
Figure 4 shows the step-by-step technique for the uncommon surgical reduction of the excessive nipple diameter.
A simple band-aid is placed over the nipple and areola to press down and stabilize the new nipple. A light gauze dressing is added on top of the band-aid to absorb any potential blood oozing.
The patient is seen the next morning, regardless of whether the nipple reduction is accompanied by a mammaplasty or a mastopexy. The dressing is changed and a new one is applied. The patient is then seen a week later, then in six months, then yearly.
A total of 30 operated nipples in 15 healthy female patients, aged 27 to 47 years (average 36 years) were included in the present series. The follow-up ranged from six months to 62 months (five years and two months), with an average of 29 months (two years and five months).
All scars healed nicely. There were no complications. The nipple sensation was preserved in all cases, as per the patients’ assessment. However, preservation of lactation function could not be tested in this series because it was not tried by any patient during the follow-up period. Theoretically, the ability to breast feed should be unharmed because this technique does not injure or alter the lactiferous ducts.
Overall, all patients (100%) had a breast augmentation performed at the same time as the nipple reduction procedure. All patients were Asian, except for one Caucasian.
Ideally, nipple reduction has to take into account the sensation and the function of the nipple, not just its esthetics. The procedure should thrive to preserve the nipple’s nerve supply, as well as its network of lactiferous ducts. Both Vecchione’s nipple amputation (3) and Marshall’s core excision (4) intersect the lactiferous ducts, thus disrupting lactation and possibly affecting nipple sensation as well. Both Sperli’s (6) and Ferreira’s (7) methods correct the height and the diameter of the nipple, but the residual skin flaps may be compromised, resulting in a prolonged oedema and an increased risk. Bostwick (8) described two techniques for correcting the hypertrophic nipple, depending on whether lactation needs to be preserved. In the case of a patient who has successfully completed lactation, Bostwick suggested performing a simple resection of the top of the nipple, leaving the wound exposed to reepithelialize. On the other hand, if the patient wanted to preserve the ability to lactate, he opted for a circumferential ‘sleeve’ skin resection, followed by ‘telescoping back’ the exposed part of the nipple into the breast. This later technique is similar to the one presented in the present article. However, in the Bostwick technique, the analysis of the nipple esthetic was absent, the suggested new nipple projection of 2 mm to 3 mm seemed incredibly short, and the details of the technique were completely omitted. As well, the correction of the occasionally associated condition of excessive nipple diameter was not addressed.
Our nipple reduction approach has advantages. It is a very simple technique to plan and execute when compared with other classical techniques, such as Regnault’s (5), or even more recent techniques such as Lai’s (1,2). It may be used to address both nipple overprojection and excessive diameter. It is a physiological technique that preserves the nipple sensation and, in theory, does not interfere with its lactation function. It is a highly safe procedure with, so far, no recorded complications. It causes minimal edema and has a very short recovery period. It can be safely combined with areolar reduction, breast augmentation or mastopexy. Finally, it delivers a controlled and excellent esthetic result with a main (basal) scar that is hardly noticeable because it is located at the nipple-areola junction.
In summary, this simple and safe technique leads to gratifying results and a high patient and surgeon satisfaction rate.
The authors express their thanks to Ildiko Horvath, medical artist, Montreal General Hospital (Montreal, Quebec), for her assistance in preparing the artwork; to Maria Iancu, administrative assistant, for the typing of the manuscript; to Minerva Khalife for her photographic contribution; to Barbara Armbruster MA for the editing, to Michael Fanous for the literature search, and to Stephanie Luetticken MBA for organizing the manuscript.