Mountlake Terrace, Wash. -- Simultaneous breast augmentation and reduction of the nipple or areolar region can be achieved with excellent safety and cosmetic results using a nipple incision approach, reports Richard A. Baxter, M.D., a cosmetic and reconstructive plastic surgeon with a private practice here.
In a published report (Baxter RA. Plast Reconst Surg 2003;112:1918-1921), Dr. Baxter described the surgical technique for nipple or areolar reduction and the favorable outcomes achieved in a series of 15 patients, of whom 12 underwent breast augmentation with nipple reduction and three had simultaneous breast augmentation and areolar reduction.
The nipple reduction involves removal of a ring of nipple skin beginning at the level of the nipple base, while areolar reduction, which helps address asymmetries of areolar diameter and nipple position as well as mild nipple ptosis, is performed through excision of a doughnut-shaped area of skin surrounding the nipple base.
All 15 women in the series had placement of a round saline implant (fill volume range, 240 cc to 500 cc) into a subpectoral pocket, although subglandular placement is also possible via the nipple incision approach, says Dr. Baxter.
He reported no complications, including absence of any displeasing scars, wound complications or loss of nipple sensation, and the women were uniformly pleased with their postoperative appearance.
Since submitting his article, Dr. Baxter has added another 10 patients to his case series, and he notes that with his expanded experience, the procedure continues to be successful without causing any problems of nipple sensory changes or unfavorable scars.
"Breast involution that occurs post-lactation is a common reason why women seek breast augmentation. However, breastfeeding can also affect nipple size, shape and position, and so those patients may be bothered as well by the appearance of their nipples and areolar region. This combined procedure is ideal for simultaneously addressing those multiple concerns, and while it can be a little technically challenging at first, it is well worth the effort to learn, because there are many women who can benefit from it," says Dr. Baxter.
He notes that by itself, a nipple base incision approach to breast augmentation surgery offers several advantages.
Not only is the resulting scar well-concealed, but with use of properly selected instrumentation, it also affords the surgeon the opportunity to perform the entire dissection under direct vision.
Despite its small size, because of the elasticity of the areolar skin, the nipple base incision allows for introduction of a saline implant, and surgeons have the option of placing it into a subglandular or subpectoral pocket, Dr. Baxter says.
In addition, contrary to what some surgeons and patients would assume, the nipple base incision does not increase the risk for nipple sensory changes.
"As when using any approach for augmentation, the most important factors for maintaining nipple sensation are to avoid dissection into the breast parenchyma and to pay meticulous attention to development of the pocket laterally, in order to avoid trauma to the fourth intercostal nerve," Dr. Baxter says.
To perform the surgery, markings are placed preoperatively with the patient sitting upright. The procedure is done using infiltration anesthetic and IV sedation or general anesthesia, introducing lidocaine with epinephrine into the nipple base and areola.
Next, a 4-0 nylon traction suture is placed into the nipple; then, the nipple base incision is made. When performing nipple reduction, a second circumferential incision is made around the nipple. It is located at a level above the base that is equal to the desired size reduction. In most patients, that distance will measure about 5 mm to 6 mm.
Next, a full-thickness skin excision is performed, and, working in the superficial plane, the areolar skin is undermined to its outer margin, using skin hooks for retractions. Next, the subcutaneous dissection is completed and the implant pocket formed using cautery.
For the subcutaneous dissection, Dr. Baxter notes he prefers using a custom-designed right angle, lighted retractor with a toothed blade that is 1 cm x 6 cm (ElectroSurgical Instrument Co., Rochester, N.Y.).
"Surgeons can also use a lighted Aufricht retractor, although the angle of that instrument is less optimal for visualizing the pocket," Dr. Baxter says.
To address asymmetries of areolar diameter and nipple position, the outer ring of the doughnut-shaped area is drawn in a way that will equalize the distance from the nipple base to the outer margin of the areola. That ring of tissue, located between the outer marking and the nipple base, is excised full-thickness, and then the surgery proceeds with the subcutaneous dissection and creation of the implant pocket.
Dr. Baxter added that the areolar reduction procedure can also improve mildly ptotic nipples.
"There is an upper limit of about 1 cm of areolar reduction with the nipple base approach. More severe cases would require a more extensive area of excision that could lead to an unacceptable thickened scar. In those cases, a periareolar procedure may be preferred," he explains.
Once the implant is placed and filled, the nipple base incision is closed with a 4-0 polydioxanone intracuticular pursestring suture. To optimize the cosmetic result, the skin edges may be further coapted using 6-0 fast-absorbing plain gut or nylon sutures. The site is dressed with gauze cut to allow protrusion of the nipple, thus avoiding any excess pressure on that tissue. Patients wear a postoperative brassiere with an elastic subpectoral strap as needed. Dressings are removed after five days, and thereafter, woundcare continues with antibiotic ointment application only.