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Many women have concerns about their nipples. These concerns usually involve poor location on the breast itself, nipples that are too large or project outwards too far, areolas (the pigmented skin surrounding the nipple) which are too large or too small, dome-like areolas or nipples that are inverted and are rarely seen. Fortunately, surgery can offer a solution to many of these problems. The only problem that (so far) defies surgical treatment is nipples that are very, very small. There is no safe and permanent method to enlarge them, although some physicians have temporarily enlarged them with injections of hyaluronic acid gels, such as Restylane and Juvederm.

With the exception of re-location of the nipples on the breast itself, most procedures to treat nipple problems can be performed under local anesthesia in the operating room on an out-patient (ambulatory) basis. Sedation anesthesia is an option if the patient prefers to sleep during the procedure. Dissolving sutures are utilized in all cases.

Let's discuss each of these problems individually.

POOR NIPPLE POSITION

On occasion, the nipples may not be properly or aesthetically positioned on the breast itself. The ideal location of the nipple is on the mid-line of the individual breast at a level at or just slightly above the fold beneath the breast. Problems arise when the nipples are located too far inwards or outwards, or too low or too high. Each case is very individual. Sometimes placement of a breast implant can be helpful, particularly when the nipple is too high. At other times, removal of a small crescent of skin at the edge of the areola can help to "nudge" the nipple towards a better location. If the areola is too wide, this can be corrected at the same time. Movement of the nipple in any direction will leave a permanent scar at the edge of the areola where the incision has been made. These scars tend to heal extremely well over time. There is usually no change in nipple sensation or in the ability to nurse.

If the breast is very large and/or droopy, then a breast uplift or breast reduction would be necessary - this is a much more major operation. Please read the appropriate sections on this website.

VERY LARGE OR ULTRA-PROJECTING NIPPLES

These are not uncommon conditions and treatment is relatively simple and straightforward. The operation can be performed either to decrease the projection of the nipples from the breast or to decrease the diameter of the nipples themselves (or both at the same time). Surgery can be performed as a stand alone operation or in conjunction with many other breast procedures, such as enlargement, reduction, uplift, etc.

The operation is usually performed under local anesthesia in the operating room. Sedation anesthesia, provided by an anesthesiologist, is an option. All suturing is performed utilizing dissolving stitches so there are no stitches to be removed. There is no pain during the procedure and only some soreness afterwards for a few days. Healing takes about 2-4 weeks. Once healed, it is possible that there may be some reduced feeling in the nipples and nursing ability may also be reduced. Although some incisions are made, the nature of these tissues allows for healing with virtually no visible scars.

INVERTED NIPPLES

This condition, in which one or both nipples are inverted (depressed) below the level of the areolar skin, can be corrected through minor surgery under local anesthesia. If desired, sedation anesthesia, provided by an anesthesiologist, is an option. The most important point, however, is to note whether you have ever seen your nipples - even if very briefly. Very rarely, some women do not develop nipples and in that case a very different procedure would be required (nipple reconstruction).

In most cases, however, the nipples can be forcibly everted by traction (pulling) on them by the patient. But when they are released, the nipples invert again. This situation is due to tightened and constricted milk ducts which literally pull the nipple inwards. The cause for this is unknown. Surgical treatment involves cutting and releasing some of these tightened milk ducts which thus allows the nipple to extend fully and protrude. During surgery, some of the milk ducts will be divided and therefore future nursing may not be possible. During the same process, some of the numerous nerve fibers which provide nipple sensation will be divided as well. However, since there are many spare nerve fibers, the remaining ones soon take over and provide some if not full nipple sensation. All stitching is performed with dissolving sutures so there are no sutures to be removed. Healing will take about 2-4 weeks and there will be only some soreness after surgery. The scars resulting from this operation soon become virtually unnoticeable.

LARGE AREOLAS

Very wide areolas can be surgically reduced in diameter. This is often performed when moving a nipple which is not located properly on the breast itself (see "Poor Nipple Position" above) or in conjunction with a breast uplift or breast reduction. It can also be performed as a stand alone operation if desired. In these cases, local anesthesia is often all that is necessary, although sedation anesthesia remains an option.

Surgery involves removing a circle or "doughnut" of excess areolar skin. The edges are then sutured together with a variety of sutures - some permanent and some which dissolve. This procedure may result is some temporary "ruffled" edges of breast skin which will smooth out on its own within a month or two. There will be some soreness for 2-4 weeks but nursing ability and nipple sensation are unaffected. There will be a permanent scar at the edge of the new, smaller areola.

SMALL AREOLAS

There is no surgical method to enlarge a small diameter areola. Sometimes placement of a breast implant will stretch the areola somewhat just as it stretches the breast skin to accommodate the implant itself.

The only method to permanently enlarge the diameter of a small areola is with medical tattooing. In these cases, local anesthesia is administered. The entire areola (and sometimes the nipple as well) is tattooed so as to achieve uniform coloration. A second tattoo session is sometimes necessary to assure permanent tattooing. The ultimate size of the areola is your own choice.

"DOME" SHAPED AREOLAS

This condition, sometimes called a "puffy" nipple, is due to excess breast tissue concentrated just below the nipple/areola without the breast tissue being distributed more evenly over the entire chest wall. It is a variation of the tubular breast deformity (discussed under "Breast Deformities" on this website). Surgery to correct this problem can be minimal or major, depending upon the extent of the problem. Obviously, each case is unique and treatment is individualized as necessary.



Dr. Elliot Jacobs, M.D., Plastic Surgeon
815 Park Avenue
New York, New York 10021
Telephone (212) 570-6080

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