Dr. Linder's Blog
Category: Nipple Reduction
Patients often present for nipple reduction. This is a procedure where the patients present with nipple hypertrophy. Symptoms of nipple hypertrophy can include pain, excoriation, rash, embarrassment, psychological and self-esteem issues. It can also be difficult to wear clothing due to enlargement of the nipple with exposure. Excoriation, rashes and irritation of enlarged nipples also have been seen in our patients.
The operation is a procedure usually performed in combination with breast augmentation or breast lifting in which I perform a superior pedicle flap. Resection of the inferior half of the nipple is performed down to the base with a 15-blade. Subsequently, the superior pedicle is inferiorly rotated, fits down with simple 5-0 Prolene sutures. The 3 and 9 o’clock position of redundant skin is then trimmed carefully and those edges are sutured as well. Stitches usually remain in for approximately 14 days. Scarring is minimal to none in that the scars feel extraordinarily well. I have never experienced a hypertrophic keloid or widespread scar of the superior pedicle nipple reduction. The key to nipple reduction surgery is proportionality of the nipple to the areolar size.
Notice in the preoperative photographs this patient has an extremely large nipple in proportion to the areola. It is approximately 65% in diameter to that of the areola. Her postoperative view shows this has been reduced to approximately 45%. The vertical height and the base have also been reduced, allowing for more proportionality with the actual implant as well as the areola.
The patient below presents with a 125-pound weight loss after a laparoscopic banding procedure leaving her with severe asymmetry, grade 3 ptosis (right breast significantly larger than the left with asymmetry), a significant abdominal pannus, skin laxity, rectus diastasis and lipodystrophy of the hips. The patient is now two months postoperative with 500 cc high profile Natrelle saline implants placed in the dual plane technique, formal mastopexy or Wise-pattern skin excision was performed, creating a tightening procedure of bilateral breast, as well as a full abdominoplasty with plication tightening of the rectus sheath and liposculpturing of the muffin-top area was accomplished. Preoperative photos show severe asymmetry requiring slightly different volume implant placement (right smaller than left in terms of volume of implant size) and bilateral complete mastopexies reducing the large areola to 4.2 cm. Notice the right areola preoperatively was approximately 9 cm wide. She also has skin laxity in the lower abdomen which requires a full abdominoplasty with plication of the midline muscles of the rectus sheath. Her oblique views show excellent contouring with nice fullness to the upper pole of her breast associated with the high profile saline implant. She has good nipple positioning without skin laxity along the inframammary fold. The lower abdomen shows nice concavity with tightening of the rectus muscles, excellent definition of the midline and smoothing out of the hip region. Patients who undergo gastric bypass surgery from Rouen-Y procedures, gastroplasties or laparoscopic banding, once they have lost a significant amount of weight, reaching the baseline, will do well with reconstructive surgery of both the breast and abdominal areas, as this patient is an excellent example.
The above patient presents with significant nipple hypertrophy, left breast greater than right as well as hypoplastic breasts. She is a good candidate for augmentation mammoplasty procedure using high profile smooth round saline implants in the dual plane technique through a periareolar approach and a left nipple reduction reducing the left nipple through a superior pedicle flap. The inferior portion of the nipple was resected straight down to the base. The nipple was then inferiorly repositioned, sutured and the medial and lateral positions of the nipple were then resected and sutured down. Her results now show a five-week postoperative with excellent symmetry to the nipple areolar complexes with still some scarring healing around the periareolar incisions with good symmetry to the upper poles, cleavage and the inframammary folds are even. Nipple reductions should be done carefully through a pedicle base. I prefer the superior pedicle in order to allow viability of the blood supply through the nipple and allow for reduction in size and shape.
GIGANTOMASTIA SURGERY: BREAST AMPUTATION
WITH FREE NIPPLE GRAFTING
The patient below is a 48-year-old female presenting with massive gigantomastic breasts/breast hypertrophy, 40KK breasts, with symptoms of severe back pain, neck strain, grooving around the shoulder blades and coracoid aspects of the shoulders, including ulnar neuropathy, rashes and ulcerations of the breasts due to poor circulation associated with the massive skin laxity and grade 3 ptosis. This patient is a perfect candidate for bilateral breast reduction using the breast amputation technique with a free nipple graft. The pedicle will probably be approximately 30 cm long, if not longer, and therefore will require most likely a free nipple graft in the operating room in order to prevent avascular necrosis of the nipple areolar complex due to the length of the pedicle and inadequate blood supply through osmotic diffusion.
The frontal and oblique views of this patient will be shown. This patient is an extraordinary case due to the massive size of her breasts as well as the severe degree of skin laxity and ptosis. These surgeries require skillful Board Certified Plastic Surgeons who specialize in breast reduction to reduce the risk of fat necrosis, bleeding, infection and nipple areolar necrosis.
Patients are seen who have nipple hypertrophy and will do well with reduction in the size of the nipple to make it more symmetric with the areolar complex. These patients often are from Asian, Korean or Chinese descent. Often, the nipple will be excoriated with the skin. They can develop dermatitis due to rubbing and will do well with functional reduction in size. Dr. Linder’s perform technique includes the superior pedicle and excision of the inferior portion or lower portion of the nipple and the nipple is then brought down and sutured down and the sides are then trimmed. This makes for a significantly smaller nipple, both along the AP projection as well as the width. Nipple reduction surgery patients are very satisfied both for cosmetic as well as the functional reasons, with reduction in pain, irritation and the dermatitis which occurs due to the raw surface of the tip of the nipple region.
The nipple specimen is always sent to pathology to make sure that there is no evidence of cancer or Paget’s disease.