Plastic surgery involves changing or remodeling tissues to restore function, improve appearance or both. In many instances, cosmetic plastic surgery involves major procedures on the face, breast or body that produce significant results. When it comes to the chest and breasts, however, it is the smallest and most central anatomical area, namely the nipple and areola—the circular, pigmented skin around the nipple—that can draw the most attention. As with many other physical attributes, some features are congenital and present since birth, whereas others are acquired and develop as a consequence of developmental, hormonal or medical factors.
Many patients who are dissatisfied with some aspects of their nipples or areolas may not be aware of the cosmetic procedures designed to improve their appearance. This discussion will address only aesthetic procedures of the nipple and areola, although there are other reconstructive techniques which create a new nipple and areola in cases of nipple absence (whether due to removal for cancer or following trauma). The following are some of the most commonly sought after aesthetic procedures of the nipple and areola.
One of the primary cosmetic concerns women have about their breasts is when the position of their nipples is too low, referred to clinically as ptosis. This appearance is often seen in patients with enlarged breasts or may develop with time as the skin ages and the nipples appear to hang lower or point downward. Nipple ptosis correction, which lifts the nipples into a more aesthetic position, can also reposition nipples that are too widely or too narrowly set apart. Nipple lift is part of both breast lift and breast reduction surgery, which are procedures that correct hanging breasts and enlarged breasts, respectively. In patients with small breasts and only a small degree of ptosis, increasing breast volume with implants often produces a small degree of nipple lift and does not require a separate procedure.
Any surgical procedure that involves moving the nipple will produce a scar around the circumference of the areola. During surgery, preserving the nerves and blood vessels that supply the nipples is essential in order to maintain nipple sensation and breastfeeding ability. Nipple lift surgery may be indicated on either one of both breasts, yields immediate results and can improve symmetry in patients whose nipples are at different levels.
Enlarged, hanging, downward-pointing nipples often occur in women after breastfeeding as a result of repetitive suction created by the baby while nursing, but they may also be a normal variant of breast development regardless of overall breast size. Patients who seek nipple reduction for unusually large nipples, called hypertrophic nipples, are usually concerned about the prominence of the nipples, which can make them too conspicuous or unsightly under clothing. In addition, nipple hypertrophy may lead to chafing and irritation from constant rubbing against clothes, which can cause further discomfort.
Nipple hypertrophy may be corrected surgically by a number of techniques and results in a smaller, less pendulous, more attractive nipple. In cases where only one nipple is enlarged, nipple reduction of the larger nipple can improve symmetry of the nipples. In addition, irregularly shaped nipples can be surgically corrected to appear rounder and more symmetric. Nipple reduction surgery may be performed as a standalone surgery under local anesthesia with minimal downtime, or concurrently with other types of cosmetic breast surgery such as breast augmentation, breast lift and breast reduction.
Inverted or retracted nipples exist when the nipples are withdrawn below the surface of the skin and lack the normal protrusion. This condition may present early in childhood, during breast development in adolescence or appear later in adult life. In some women, inverted nipples result from the changes that occur as breast tissue diminishes after breastfeeding. In rare instances, this may be caused by an underlying breast cancer. Inverted nipples are due to scarring around milk ducts or shortening of the milk ducts themselves, which pass through the breast and open into the top of the nipples. There is a range of conditions from mild to more severe degrees of nipple inversion. In mild cases, the nipples are occasionally inverted, but will spontaneously become erect with stimulation; whereas in more severe types of inversion the nipples are retracted below the surface of the areola and cannot be made to protrude manually. Surgical correction involves a procedure to release the underlying tissues and may require transection of milk ducts, which could potentially preclude future breastfeeding. Surgery is performed under local anesthesia or with IV sedation. Results are immediate and patient satisfaction high. The procedure may be combined with other aesthetic surgical procedures on the breast.
Developing extra breast tissue with associated nipples or pigmented areolas may sometimes occur, in both men and women. These findings, referred to as accessory breast tissue and supernumerary nipples, usually appear along the mammalian milk line, which forms in a wide V-shape from in front of the armpits along the sides of the chest and abdomen. When present as small, circular, pigmented skin lesions they may resemble moles or other benign skin pigmentation. Alternatively, they may develop as more noticeable masses under the skin due to the influence of hormones, such as with pregnancy or during lactation. Although they usually do not require any treatment, they can be unsightly and become a source of embarrassment for patients, especially in cases where the accessory nipples lactate. Surgical excision is the typical treatment and results in permanent removal of breast tissue as well as complete removal of extra nipples or areolas.
Some degree of asymmetry of the breasts, such as different shape or size, is normal. In mild cases of breast asymmetry, only the pigmented areolas are involved. Most often, there is a slight difference in diameter or shape of the areola, such as oval or teardrop shape rather than round. Surgical correction of the areola involves removing some of the skin adjacent to or within the pigmented areola and suturing it in order to provide better cosmetic result and symmetry. For patients who seek areolar reduction or enlargement, centered circles may be used to define the areola at the desired circumference.
Women who undergo breast lift or breast reduction surgery will also benefit from repositioning the nipples to a more aesthetically pleasing level, which is part of the surgical procedure. In these operations, the incision used to lift the nipples may also serve to achieve changes in circumference and shape of the areola.
In women who have tuberous breasts, a condition in which the breast tissue is constricted, the areolas appear significantly enlarged and somewhat distorted relative to the amount of breast tissue and breast skin. In these patients, and depending on considerations such as specifics of the deformity and degree of symmetry, surgical intervention to produce the best cosmetic result involves reduction of the areola in combination with a breast lift or breast augmentation with implants.
For men who seek a more attractive chest, their primary concerns usually pertain to extra breast tissue development overlying the pectoral muscles. This medical condition, called gynecomastia, often occurs in adolescent boys, or later in middle age. In more severe cases, it causes stretching of the overlying skin and allows breast tissue to become pendulous. Along with the excess breast tissue, the nipple and/or areola may be misshapen or in an unattractive position on one or both sides. When there is significant development of breast tissue, the nipple can be displaced downwards and appear to hang off the breast mound. In addition, the areola itself may become disproportionately enlarged, whereas the nipple may appear retracted or inverted below skin level. Repositioning of the nipple into a more attractive location, correction of nipple inversion and reduction of the areola may be performed with correction of gynecomastia using similar incisions. These procedures have a positive impact on both a man's physical appearance and emotional well-being.
When considering plastic surgery to address any of the above concerns, always choose a board-certified plastic surgeon who is knowledgeable about and experienced in the many options available. Discussing surgical alternatives and understanding the pros and cons of each prior to proceeding with any surgery will lead to highest patient satisfaction.