James J. Romano, MD
The above are all situations that I so often find that many women have endured and lived with for years simply because they were not aware of just how common these conditions are and how easily they are remedied. Many times my patients are delighted with how the repair is so simple, straightforward and comfortable with a rapid and normal recovery.
NIPPLE INVERSION
Features of inverted nipples are usually evident as a slit or hole in the breast at the location of the nipple. It may be possible to pull the nipple out or not. It may be present on one or both sides. It is usually a congenital situation but may be related to scarring from breast-feeding or infection in the ducts or a previous breast surgery. Nipple inversion can cause functional problems such as irritation, rash, and discomfort. It may prevent the ability to breast-feed. Correction is sought most often because it is a cosmetically undesirable condition, and women simply do not like the way it looks and want it improved. It occurs in about two out of every 100 women. It is anatomically related to the degree of scarring and retraction of the milk ducts, which pulls the nipple down, and to the degree of the lack of tissue bulk at the base or neck of the nipple.
There are varying grades of retraction:
- Grade I: The nipple can easily be pulled out fairly easily and maintains its projection.
- Grade II: The nipple can be pulled out but not easily. It tends to want to retract fairly quickly.
- Grade III: It is difficult or impossible to evert the nipple.
Treatment has involved many various procedures over the years and these date back to as early as 1888. The procedures are classified into two main groups; one is where the milk ducts are preserved, the other is where the milk ducts need to be divided. Over 20 different surgical procedures have been described, and the methods include tightening the neck or base of the nipple, adding more bulky tissue at the base of the nipple, incisions to release scar contractures, and internal cuts with sutures to support up the nipple. Depending on the grade of contracture and patient expectations, sometimes the milk ducts need to be cut and other times not. Correction depends on cutting the milk ducts if they are scarred and contracted (Grade III) or not cutting them if little or no contracture is present (Grades I and II). If the milk ducts are cut, breast-feeding will not be possible. Since it is not possible to breast-feed with Grade III inverted nipples, most patients want them repaired.
The procedure can be done under local anesthesia in the office. It is so comfortable and well tolerated that patients usually do not need any sedation at all. Small incisions are made directly in the nipple and the repair is completed. A light dressing is used. Drains are not needed. The procedure can be combined with other procedures including breast enlargement, lift, or reduction.
Recovery is very rapid. Return to work and most activities can be within hours. Showers are permitted the next day. Sutures are removed in four to seven days. There is minimal pain or swelling. Sensation is normal immediately or returns fully within several days.
The results are very natural appearing nipples that have normal sensation and projection. The nipple will maintain the result forever. Rare complications may occur, such as recurrence of the inversion, and this may be complete or partial. Sensation is usually completely normal, as is muscle activity and response to touch and hot and cold. The scar is imperceptible.
NIPPLE REDUCTION
Large nipples may present as very long and overprojecting, long and droopy, or as having a wide diameter. Many times this occurs after breast-feeding or prolonged stimulation to the point that the tissues have been stretched and do not retract back to normal size. It occurs commonly in both men and women. It may occur on one or both sides. Correction is sought for cosmetic reasons and to look more normal and in proportion. Enlarged nipples do not usually cause any pain or problems.
The procedure depends on the anatomy of the enlargement and what degree of reduction the patient desires. It may involve removal of just the top of the nipple and closing this with tiny incisions. It may also involve removal of a cylinder of skin around the neck of the nipple then pushing the nipple back into the breast and suturing this closed. Sensation is always normal, and the ability to breast-feed later depends on the anatomy and the procedure performed, but this is most often easily preserved.
Like nipple inversion, the procedure can be done under local anesthesia in the office. It is so comfortable and well tolerated that patients usually do not need any additional sedation at all. Small incisions are made right on the surface of the nipple and the excess tissue is removed. A light dressing is used. Drains are not needed. The procedure can be combined with other procedures including breast enlargement, lift, or reduction.
Recovery is very rapid. Return to work and most activities can be within hours. Showers are permitted the next day. Sutures are removed in four to seven days. There is minimal pain or swelling. Sensation remains normal. The results are very natural appearing nipples that have normal sensation and less projection. The nipple will maintain the result forever.
SMALL NIPPLES
This is usually when the nipples are normal in projection and shape, and the patient just wants them to be larger overall. This can be accomplished by various means. Often grafting tissue from one part of the body into the nipple accomplishes this; in such cases, a small amount of fat or some cartilage is used. Rarely during healing scarring may occur and result in the return of the nipple to the original size or even smaller, or at times it can prevent breast-feeding. Patients have to be chosen carefully for this surgery since success depends on the anatomy of the nipple, as it may or may not be suitable for enlargement.
PUFFY LARGE AREOLAE
The pigmented portion surrounding the nipple is called the areola, and it may be enlarged or puffy. This may occur on one or both sides. This may occur in women or in men. It can be enlarged in diameter and have different degrees of coloration. This is often a congenital situation, or it may be related to massive enlargement during breast-feeding, after which the areolae never went back to normal diameter. Puffy areolae are often related to an anatomic situation called tubular breast where the areolae “herniate” or protrude from the breast tissue as if a tight ring were present around the base. Either situation can be improved with the surgery known as areolar reduction. This involves an incision around the edges of the areolae and then removing a thin donut-ring-like width of areolar skin, and closing the incision. It ends up as a ring around the reduced areolae. The surgery is also easy to perform in the office under local anesthesia. Return to work and activity is just as described above for the nipple surgery. There is no risk of sensation or nipple duct problems. There is a slight risk of unsightly wide scars, but this is often prevented by taping, massage, and cream therapies early after surgery.
