Inverted Nipples: One or both sides may be affected and to varying degrees. If the inversion of the nipple has been of recent onset, it is very important that a thorough investigation as to the possibility of breast cancer be pursued. Breast cancers can be associated with nipple inversion. Most cases, however, are essentially a simple nipple tissue abnormality that was actually present since birth but only first became noticeable during breast development and puberty. These are simply aesthetically objectionable. Mild cases often respond quite well to simple maneuvers performed during a breast enhancement (augmentation with implants) and are a welcomed “side benefit” to the procedure. More severe cases require some rather sophisticated and tiny incisions which are made in and around the nipple but usually with good success and minimum required in the way of a recovery. Most patients have these issues addressed while having a cosmetic breast procedure – such as a breast augmentation with implants, breast lift or breast reduction – in the operating room. Otherwise, it is quite realistic to have the nipple inversion correction performed alone as an office procedure (usually with local anesthesia and mild sedation).
Inadequate Nipple Length or Poor Projection of the Nipples: This can actually be due to a disproportion in sizes between the nipple and areola rather than a true nipple deficiency. The areola diameter may need to be decreased to make a better match. True length problems can be often be corrected with a minor surgical procedure similar to that used to correct inverted nipples as described above. Sometimes a long-lasting, injectable filler (such as we use for the face) can help in the improvement.
Overly Long or Large Nipples: Again, the possibility that this is actually due to a disproportion between the nipple and the areola sizes must be determined first. The areola diameter may need to be increased. Cosmetic tattooing is the simplest way to do this. In more severe cases of small to absent areola tissue, skin grafts of darker pigmented skin can be used. Otherwise, a surgical reduction in the actual length of the nipple is a very straightforward and relatively simple procedure which can be performed in an office setting. Puffy or overly “fat” nipples can also be thinned down a bit by a similar technique.
Overly Large Areola Diameter: Areola diameter reductions are often performed in coordination with a breast reduction or breast lift procedure in the operating room. We want the already excessively large areola to have good proportion to the newly lifted, compacted and re-shaped breast. Occasionally, an areola reduction will be performed alone. The new, smaller diameter is planned and the intervening ring of tissue is removed with the outer “circle” edge tightened in to fit. The scars tend to blend within the natural circle of the areola circumference. The human eye and brain are wired to expect to see this circle-like line which automatically makes it less likely that a scar mimicking this line will be visible.
Irregular Areola Border: The same techniques which are used to decrease the size of the areola are modified to create a smoother, more circle-like shape to the border of the areola. The scars generally hide within the natural circle that characterizes the areola margin.
Nipple is Off Center within the Areola: Usually fixed as part of a breast reduction or breast lift as this would be much harder to surgically fix otherwise. Cosmetic tattooing to balance the areola out is a good non-surgical option. Skin grafting is a much more aggressive alternative and rarely done for this particular problem.
Too Light, or Inadequate Areola Pigmentation: The best option for this, hands down, is cosmetic tattooing.
Nipple/Areola Complex Too High on the Breast: This is usually best treated by a breast enhancement with implants because in most situations the displacement is an optical illusion created by poor breast volume and awkward positioning of the tissue on the chest wall. True high displacement of the nipple/areola complex on the breast/chest is a tough problem otherwise – all existing techniques to move the complex lower will most likely result in an obvious scar on the upper pole of the breast/chest.
Nipple/Areola Complex Too Low on the Breast: This is a very common problem, often associated with large and/or drooping breasts. During a breast lift or a breast reduction, the complex is lifted to its proper position, resized proportionately and properly centered on the breast mounds. The nipple/areola complexes are placed so that they are in mirror image symmetry to the size, shape and position of the each other as much as possible. The scars hide within the circular edges of the areolas.
Nipple/Areola Complex Not Centered on the Breast: Many women have nipple/areola complexes which seem to be out toward the sides of the breasts. Bringing them inward so that the complexes are closer to the midline of each breast makes for a much more desirable look. Most effective solutions to this problem are as a part of a breast lift or breast reduction procedure as described above. More minor procedures which are modifications of some of the steps in a lift or a reduction can be performed for less severe cases or where the breasts are otherwise acceptable and not in any need of reshaping, resizing or lifting. When the complexes appear to be too close together (i.e. “cross eyed”) a well-done breast augmentation will often result in a more centered and more pleasing look to their positions.
Overly Prominent or Numerous, Highly Visible Bumps within the Areola: These are known as “Montgomery Glands” and although perfectly normal, they are sometimes aesthetically offensive if too prominent or too numerous; they are very edgy, irregular and “bumpy”. Simple excision works well – they do not typically recur.
Prominent Nipple/Areola Complex Hair Growth: Electrolysis is probably a better choice for this than would be laser hair removal. There are usually only a few hairs to treat and electrolysis is usually less expensive, more reliable and more definitive. Depigmentation – the loss of the darker areola color which it is supposed to have as compared to the surrounding skin – is always a risk with almost any procedure. But depigmentation is a well-known side effect of lasers. Lasers used on or near the pigmented areola can result in permanent, spotty depigmentation – very undesirable!
Pale, Depigmented Scars in the Areola: These can occur from previous trauma, procedures, surgery or lasers. The depigmented scar in the areola is unfortunately a very common occurrence in women who have had breast augmentation with implants placed via the areola incision approach. The best option is usually cosmetic tattooing.
Extra Nipple/Areola Complexes: Some patients have what might appear to be small moles on the chest or abdomen – but these may actually be extra nipple/areola complexes! These are also known as “accessory” or “supernumerary” nipples. Small, extra complexes can occur anywhere along the so-called “milk-line” which extends from the armpit through the center of the breast and down to the groin crease. A bump or lump underneath could also represent a small amount of breast tissue as well. It is generally agreed upon that it is important that these extra collections of breast related tissues be removed because of risks for malignant changes. Simple excision of these extra nipples is usually all that is required.
Post-Mastectomy Nipple/Areola Reconstruction: This is somewhat beyond the scope of this article, but certainly there are cosmetic issues involved in this very important aspect of breast reconstruction following any breast cancer treatment involving a mastectomy. Typically, nipple/areola reconstruction is not definitively planned and performed until all other aspects of the reconstruction of the breast are deemed complete and stable. Combinations of some of the techniques as described above – such as skin grafting, minor surgical procedures and tattooing – are all commonly employed.
Dr. Lyle Back is originally from New York City, receiving his medical and surgical training at Rutgers Medical School, Cooper Hospital – University Medical Center, and Ohio State. He is Board Certified in General Surgery (ABS) and Plastic Surgery (ABPS). He is a Fellow of the American College of Surgeons (ACS), the American Academy of Cosmetic Surgery (AACS), and a longstanding member of the premier American Society of Plastic Surgeons (ASPS). He served as a Professor of Plastic Surgery at Temple University and St. Christopher’s Hospital for Children and performed reconstructive surgery with “Operation Smile” in Vietnam. He specializes in the full range of the most modern and state of the art cosmetic surgery procedures for the breasts and non-surgical cosmetic enhancement techniques available today.