Raleigh-Durham Nipple Surgery doctors

First of all, a couple of definitions: the areola is the pigmented skin that surrounds the nipple.  Most surgeons pronounce this uh-REE-oh-la, but are-ee-OH-la is also used.  Areolar skin has not only a different color but usually a different texture compared to the surrounding breasts skin, and both features help to conceal scars placed at the areolar border.  The term nipple refers to the projecting tissue at the center of the center of the areola, which contains the openings of the lactiferous (milk) ducts.  These two structures comprise what plastic surgeons refer to as the 'nipple / areola complex'.

Areolar Reduction

A youthful, aesthetically ideal breast has an areolar diameter of about 38-42mm (about one and a half inches).  Some breasts have large areolas from the time that they develop during puberty, and some enlarge later in life with pregnancy and lactation.  A large areola tends to make a breast look 'matronly' even if it is not droopy.  Areolar diameter can definitely be reduced, and this can be performed as a stand-alone procedure or as part of larger cosmetic breast procedure such as a lift, reduction or augmentation.

The surgical technique involves removing the excess areolar skin, in the form of a donut-shaped skin excision.  A circular incision is made around the areola at the desired diameter of about 40mm, then a second circular incision is made at the outer border of the large areola.  The epidermis is shaved off between the two incisions, leaving the dermis behind.  A 'purse-string' suture is then placed in the dermis at the outer incision that allows the surgeon to reduce the outer diameter to 42-44mm by cinching together the two ends of the suture.  The suture acts as a drawstring to reduce the outer diameter, and allows closure of the areola with reduced tension on the healing incision.

The purse-string suture is critical for maintaining areolar shape and size.  Without the purse-string suture, areolas will almost always enlarge over time.  When that suture is tied, the skin of the outer portion of the areola is gathered somewhat, as the circumference of the outer incision is much larger than that of the inner incision.  The gathered or 'pleated' appearance of the outer margin of the areola gradually flattens out over time; this generally take a few months.

Occasionally I see a patient purely for areolar reduction, but the majority of patients I see have their areolas reduced as part of a mastopexy (breast lift), augmentation mastopexy (breast lift plus implant placement), or breast reduction procedure.  The circumareolar scar (scar all the way around the areola) usually heals very well and is camouflaged by the color difference between areolar skin and breast skin, but if you are going to have a scar around the areola you might as well do something to improve breast shape and/or size at the same time.  Keep in mind however that most breast lift and reduction procedures require a vertical scar from the bottom of the areola to the inframammary fold (crease below the breast), and in some cases a scar in the inframammary fold as well.

A word of caution: many surgeons perform what they call a 'circumareolar' (or 'donut' or 'Benelli' ) mastopexy.  In my opinion there is absolutely no such thing as a 'circumareolar mastopexy'.  Removing skin around the areola may enable a surgeon to elevate the position of the nipple/areola complex perhaps 1-2 cm on the breast mound, but it DOES NOT lift the breast itself.  In most cases, unfortunately, it serves to distort the shape of the breasts, making them appear flattened at the top.  If the breast needs to be lifted, it absolutely requires some internal rearrangement of breast tissue to create a projecting, aesthetically ideal and lasting result - which in turn requires that vertical incision and vertical surgical scar below the areola (and sometimes in the inframammary fold as well.

Nipple inversion, where one or both nipples point inward instead of outward, is actually quite common and in most cases can be easily be corrected with a minimally invasive surgical procedure. I have corrected inverted nipples at the time of breast augmentation and mastopexy (breast lift) procedures, and also have preformed correction of nipple inversion alone as an office surgery under local anesthesia.

Most cases of nipple inversion occur during breast development, although on occasion the problem may arise due to scarring from breast feeding, from an infection in the ductal system, or from previous breast surgery. Inversion may occur on one or both sides. Correction of nipple inversion is usually performed to improve overall breast appearance but may also have a functional benefit in terms of assisting lactating women with breast feeding.

There are varying degrees of nipple inversion, and the degree of inversion generally dictates the kind of corrective procedure that is preformed. Some inverted nipples evert easily and tend to stay everted temporarily, while others are difficult to evert and tend to retract back to the inverted position almost immediately. In severe cases the nipple or nipples remain retracted cannot be reverted manually.

Some procedures used to correct the inversion preserve the milk ducts (and thus the ability to lactate), while other require that the ducts be divided which prevents later lactation. Milder cased of nipple inversion can usually be corrected by duct-preserving techniques, while more severe cases usually require complete division of the ducts. Any surgical procedure to correct nipple inversion can reduce nipple sensibility to some degree, and reduction of nipple sensation is more common with duct-dividing corrective procedures. I always strive to use the least invasive technique which is likely to provide a patient with a permanent correction, and in most cases patients regain most or all of their nipple sensation postoperatively.