Treatment of inverted nipples, enlarged nipples, small nipples, and large puffy areolae

Dr. James J. Romano, MD

by Dr. James J. Romano, MD | August 16, 2010 @ 10:00AM

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Nipple

Nipple Inversion

Features of inverted nipples are usually evident as a slit or hole in the nipple of the breast. It may be possible to pull the nipple out. It may be present on one or both breasts. It is usually a congenital situation but may be related to scarring from breast-feeding, 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. The condition of inverted nipples 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 pull the nipple down, and the amount of tissue bulk lacking at the base or neck of the nipple.

There are varying grades of retraction:

  • Grade I: The nipple can 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.

Inverted Nipple Correction Before and After Photo

Inverted Nipple Correction

Treatment has involved various procedures over the years and these date back to as early as 1888. The procedures are classified into two main groups - one preserves the milk ducts, the other divides the milk ducts. Over 20 different surgical procedures have been described with methods that vary from tightening the neck or base of the nipple, adding more bulky tissue at the base of the nipple, incisions to release scar contractures - to internal cuts with sutures to hold up the nipple. Depending on the grade of contracture and the patient's 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 then breast-feeding will not be possible. Since it is not possible to breast-feed with Grade III inverted nipples most patients want them repaired.

Inverted Nipple Correction Before and After Photos

Anesthesia

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 surgery can be combined with other procedures including breast enlargement, lift, or reduction.

Recovery

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 result is natural appearing nipples that have normal sensation and projection. The results will remain 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 barely visible.

Nipple Reduction

Large nipples may be present as very long and over projecting, long and droopy, or wide in diameter. Many times this occurs after breast-feeding or prolonged stimulation where the tissues have been stretched and do not retract back to normal size. It commonly occurs in both men and women. It may occur on one or both breasts. Correction is sought for cosmetic reasons and to achieve proportion. Enlarged nipples do not usually cause any pain or problems.

The Procedure

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 closed. Sensation is always normal, and the ability to breast-feed later depends on the anatomy and the procedure performed, but this is often easily preserved.

Anesthesia

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 surgery can be combined with other procedures including breast enlargement, lift, or reduction.

Recovery

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 result is natural appearing nipples that have normal sensation and less projection. The results last forever.

Nipple Enlargment

This is evident when the nipples are normal in projection and shape and the patient desires larger nipples. Nipple enlargement can be accomplished by various techniques. Often, grafting tissue from one part of the body into the nipple accomplishes this, in such cases using a small amount of fat or some cartilage. Rarely will scarring occur. Patients are carefully chosen for this surgery since success depends on the anatomy of the nipple, as it may or may not be suitable for enlargement.

Puffy and 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 breasts of women or men. The areaolae can be enlarged in diameter and have different degrees of coloration. This is often a congenital situation or may be related to massive enlargement during breast-feeding and never decreasing back to normal size. Puffy areolas are often related to an anatomic situation called tubular breast where the areolas "herniate" or protrude from the breast tissue as if a tight ring were present around the base. Either situation can be improved with surgery known as areolar reduction. This involves an incision around the edges of the areolae then removing a thin donut-ring like width of areolar skin, and closing this incision. It ends up as a ring around the reduced areolae. It 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 taping, massage and cream therapies often prevent this after surgery.

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