Surgical correction of nipple hypertrophy in male gynecomastia: case report

Current surgical techniques for nipple reduction: A literature review

Background

Macrothelia, enlarged nipples, is a relatively uncommon condition causing psychological distress in both sexes. However, to date, there is no comprehensive comparison of the spectrum of surgical techniques for nipple reduction. This review summarises the current practices to guide surgical approach to macrothelia.

Methods

A literature review was performed using the PubMed database by searching for the following words: nipple areola plasty OR nipple areola complex plasty OR nipple areola reduction OR nipple areola complex reduction OR nipple areola hypertrophy OR nipple areola complex hypertrophy OR nipple-areola complex hypertrophy OR macrothelia AND techniques OR classification OR indications OR treatment OR reduction. Additional articles were selected after reviewing references of identified articles.

Results

Thirty articles were selected after applying inclusion criteria to identify prospective and retrospective studies evaluating and/or describing different techniques, outcomes, complications and patient satisfaction. Reduction of the nipple was described in 639 patients, 582 females and 57 males. The thirty articles selected were case reports and clinical observations. No systematic or unsystematic reviews were found. Five different techniques were described, namely, circumcision, amputation, wedge resection, simple grafting and flaps. Patient satisfaction rates were high. Only a few cases documented sustained ability to breastfeed after the procedure. Complication rates were low and mentioned in only few studies.

Conclusion

All techniques resulted in high patient satisfaction and low complication rates. However, current practices are exceedingly diverse, and there is currently no common classification system, which makes comparison between surgical techniques for nipple reduction challenging. The choice of surgical technique must be based on individual assessment. Clinical guidelines are challenging owing to the heterogeneity of the studies reviewed.

Windmill Flap Nipple Reduction: A New Method of Nipple Plasty

BACKGROUND

Nipple hypertrophy is a common aesthetic issue for Asian women. Thus, methods to correct this problem are needed. Several nipple reduction procedures have been reported, but all have shortcomings. In this article, we propose a new method to reduce both the height and diameter of the nipple without affecting its function.

METHODS

Sixteen female patients, between the ages of 24-41 years, underwent a new nipple reduction method in our department between May 17, 2010, and May 5, 2014. Three crescent-shaped lines were drawn from the top of the side wall of the nipple, extending to the areola. This design reduces both the diameter and height of the nipple with minimal tissue manipulation.

RESULTS

Before surgery, the mean diameter and height of the nipple were 15.9 ± 2.7 and 18.3 ± 3.1 mm, respectively, with the patient in the supine position. Immediately after surgery, the mean diameter and height of the nipple were 9.1 ± 1.7 and 7.9 ± 2.1 mm, respectively. No major complications, such as nipple necrosis, infection, delayed wound healing, or loss of sensation, were noted.

CONCLUSIONS

This new surgical technique allows the creation of a new nipple of the desired height and diameter with excellent aesthetic results and without significant complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple Reduction With the Chullo-Hat Technique

BACKGROUND

Although various techniques of nipple reduction have been described in the literature, many are difficult to design or have unreliable outcomes. For men, as well as women who do not plan to breastfeed, it is not necessary to apply a complicated technique that protects the lactiferous ducts.

OBJECTIVES

The authors introduce a simple technique for nipple reduction that has achieved consistent, reproducible results.

METHODS

The desired nipple length is marked, and a chullo-hat excision pattern is drawn. After infiltration of a local anesthetic solution around the nipple, excision of the excess nipple tissue is performed, comprising 2 triangular flaps. The remaining 2 pillars are approximated with 5-0 Nylon simple interrupted sutures. However, the wound is not completely closed in the central area of the nipple, which promotes the drainage of discharge.

RESULTS

Fifty-three women (106 nipples) underwent this surgery between December 2009 and December 2013. The follow-up period ranged from 6 months to 2 years (mean, 10 months). No major complications occurred, and the scars were very inconspicuous. The postoperative appearance of nipples was consistently similar in size and shape.

CONCLUSIONS

This simple technique was safe and effective in nipples of different sizes. The results were reliable and consistent with expectations. Although this study included only women, the authors believe that outcomes would be successful in men as well.

LEVEL OF EVIDENCE

4 Therapeutic.

Nipple reduction using a three-dimensional Z-shaped incision technique

BACKGROUND

Nipple hypertrophy is a seldom-discussed aesthetic problem. Many patients feel uncomfortable with it and seek for correction. However, it is difficult to reshape nipples to an actual cylindrical form with the published methods. This study presented a novel three-dimensional Z-shaped incision technique, which can not only decrease the height and diameter of a hypertrophic nipple but also narrow the nipple base without destroying its function.

METHODS

A total of 44 nipple reductions were performed for 22 women using the three-dimensional Z-shaped incision technique between July 2008 and June 2011. It consists of two circles, one quadrangle and one triangle incision lines on the top, body and base of the nipple to reduce the nipple's height, diameter and base. Bilateral nipples were designed symmetrically.

RESULTS

A total of 44 operated nipples in 22 healthy female patients, aged 18-42 years (mean age, 28 years) were corrected with this method. The mean follow-up period was 28 months (range, 14-48 months). A survey was also performed to evaluate long-term patient satisfaction. Our survey showed that our surgical technique was capable of producing satisfactory results. No complications such as nipple necrosis, infection or numbness occurred.

CONCLUSION

The three-dimensional Z-shaped incision technique could reduce the height and diameter and, most importantly, reduce the basal shape of all types of hypertrophic nipples to create a desired new nipple cylindrical in shape without compromising neurovascular supply and functions.

Treatment of nipple hypertrophy by a simplified reduction technique

BACKGROUND

Nipple hypertrophy is associated with physical and psychological sequelae, leading patients to seek corrective treatment.

OBJECTIVES

The authors present a simple surgical technique to reduce nipple height with minimal tissue manipulation.

METHODS

Between November 2000 and October 2010, the senior author (CM) employed a nipple amputation technique to correct nipple hypertrophy in 30 consecutive patients. A horizontal incision was made through the distal portion of the nipple in the nonerect state to remove the predetermined nipple height. After nipple amputation, epinephrine-soaked gauze was applied to the surgical site for 5 minutes, followed by a postoperative dressing of nonstick gauze with antibacterial ointment. In 29 of the 30 patients, simultaneous breast procedures were also performed, primarily breast augmentation.

RESULTS

A total of 60 nipple reductions were performed on 29 women and 1 man (mean age, 37.8 ± 7.14 years). The mean follow-up was 35.9 weeks. All patients reported being satisfied with the procedure. Three patients noted decreased sensation, 1 noted a size discrepancy requiring further surgical intervention, and 1 noted persistent oozing from the surgical site on postoperative day 1. One patient who became pregnant postoperatively was identified; this patient was able to lactate in the postpartum period but was not able to produce enough milk bilaterally to perform breastfeeding.

CONCLUSIONS

This simplified surgical technique for correction of nipple hypertrophy was easy to perform, both alone and in combination with additional surgical procedures, and provided reproducible, satisfactory aesthetic results in this case series.

LEVEL OF EVIDENCE

4.

Geometric incision design for reduction nippleplasty

BACKGROUND

Nipple hypertrophy is a frequently encountered problem in Asian women. It may be congenital or caused by hormones, breast feeding, or gestation. The hypertrophy has been linked primarily to aesthetics. The nipples of Asian women usually are 6-10 mm in diameter and 5-8 mm in height, and women with nipples larger than 1.5 cm in diameter or height frequently ask for reduction nippleplasty.

METHODS

Women with nipple hypertrophy seeking reductive surgery at the authors' hospital between 2004 and 2009 were considered for nippleplasty. A new design consisting of three dermal flaps and sparing of the central column was used. This design can reduce the diameter, height, and most importantly, the basal shape of the nipple without compromising neurovascular supply and functions.

RESULTS

During the aforementioned period, 86 nipples of 43 patients were corrected with this method. All the patients were satisfied with the aesthetic results, preserved lactation, and sensory function. No major complications such as necrosis, infection, or numbness of the nipple occurred.

CONCLUSIONS

This reduction nippleplasty method can be applied for all types of nipple hypertrophy to create a new nipple of the desired height and diameter without significant complications.

Nipple reduction - An adjunct to augmentation mammaplasty

Nipple hypertrophy is an occasional deformity in Asians and a rare one in Caucasians. Lately, it has been showing up more often in plastic surgeons' offices across North America and elsewhere, owing to the influx of Asian immigration worldwide, as well as to the rising interest in esthetic surgery among Asian communities.A simplified technique for nipple reduction is described herein. It is very easy to execute, delivers accurate results and is extremely safe. It tackles both the excessive 'projection' and the less frequent excessive 'width' of the nipple. It may be used separately or incorporated as an adjunct to mammary augmentation or mastopexy. Excellent esthetic results are obtained, while both the nipple innervation and its lactiferous ducts are preserved. The patient's and surgeon's satisfaction is high.

Easy method for reduction of nipple height

BACKGROUND

This report presents an easy method for reducing nipple height with a buried purse-string suture.

METHODS

A total of 38 nipple reductions were performed for 19 women. After the desired projection was determined, the nipple was marked for the extent of resection. A horizontal circle at 130 to 140% of the desired nipple height was drawn on the circumference of the nipple. The nipple was pulled away from the base of the nipple with a traction suture. Following the incision through the marked line, nipple bulk was dissected from the core of the nipple. Nipple tissue was excised piece by piece, starting from the periphery and proceeding toward the center, around the circumference of nipple. A buried purse-string suture with absorbable suture brought the remaining flaps closer together and reduced nipple diameter. The knot was deeply buried under the tip of the approximated nipple flap.

RESULTS

For 14 patients (28 nipples) of 19 patients (38 nipples), the final nipple height ranged within 90 to 110% of the intended height at the last follow-up visit after a mean period of 18 months. Of the 19 women, 14 were satisfied with the final nipple height.

CONCLUSION

The authors' surgical method is primarily aimed at reducing the nipple height and has some limitations in reducing the diameter of the nipple. However, circumferential resection of the nipple core effectively reduces muscle bulk in the remaining nipple and has a secondary effect of reducing nipple diameter.

The Triple-Flap Nipple-Reduction Technique

BACKGROUND

Pure nipple hypertrophy (macrothelia) is a known but rare condition. Nevertheless, minor disproportions between nipple diameter or height and the areola are quite common. During breast surgery, the surgeon often faces the patient's wish to perform nipple reduction. However the methods described are difficult or have drawbacks. This article proposes a simple technique for both height and diameter, or height only, nipple reduction.

METHOD

A technique consisting of the creation of 3 symmetrical triangular flaps in a "Y" fashion and excision of the core of the nipple was performed on 15 consecutive patients between 2001 and 2004. The esthetic results, scars, sensibility, erectility, and complications were evaluated.

RESULTS

All patients presented good to excellent esthetic results, with inconspicuous scars. No major complications occurred in this series. Erectility function of the nipple was preserved in all 15 patients, which is a significant difference when compared with previously published techniques. Alterations in sensibility were temporary and were comparable with summarized alterations in representative published clinical series of both breast reduction and augmentation.

CONCLUSION

The triple-flap nipple-reduction technique has the advantage of feasibility, applicable in both height and diameter nipple hypertrophy, with excellent esthetic results and the preservation of both sensibility and erectility.

Nipple Reduction Using the Modified Top Hat Flap

BACKGROUND

Large nipples, disproportionate to the small areola and breast size, are an ethnic characteristic frequently encountered among Asian female patients. Patients seek correction to improve cosmesis and alleviate psychological and physical discomfort. The authors present a new technique of nipple reduction and describe its potential advantages over other techniques.

METHODS

Between March of 2003 and April of 2005, 34 nipple reductions were performed in 19 female patients (mean age, 40.5 +/- 5.6 years) using the modified top hat flap. The neonipple is designed to reduce the nipple diameter at the superior pole of the nipple while preserving the subdermal plexus. A crescent-shaped section of nipple skin below the proposed neonipple is excised, maintaining the integrity of the neonipple and the central nipple core. Two lateral wing flaps are elevated and trimmed to reduce both nipple height and diameter at the lateral walls of the nipple. The flaps of the neonipple are then sutured to the areola.

RESULTS

Postoperative recovery was rapid and uneventful and no complications were encountered. The mean diameter of the hypertrophic nipple was 16.3 +/- 2.6 mm (range, 16 to 30 mm). The mean diameter of the neonipple was 7.9 +/- 1.7 mm (range, 5 to 11 mm), with an average reduction of 8.4 +/- 1.6 mm (range, 5 to 20 mm). At 17.2 +/- 2.9 months of follow-up, the neonipple had a natural appearance, with less projection and an inconspicuous scar. There was no statistically significant difference on monofilament sensation testing (p = 0.5829) between reduction nipple and areola in 11 nipples of seven patients.

CONCLUSIONS

The modified top hat flap requires minimal preoperative planning, is easy to perform, and yields reproducible results. This technique decreases both the diameter and height of any size nipple and can be modified to meet patient preferences. Because the continuity of the neonipple with the subdermal arterial plexus is maintained and the majority of the parenchymal elements are preserved, nipple sensation and circulation remain largely unaffected.

Nipple reduction with a modified circumcision technique

Several methods of reduction of the hypertrophic nipple have been reported. All of them have some drawbacks. We propose a technique that can be easily performed and can produce excellent aesthetic as well as good functional results.