Nipple Reduction Surgery Techniques
Nipple Reduction surgeries are often considered for those women with large or overly prominent nipples and are often performed in conjunction with breast augmentations and mastopexies, which can alter the aesthetic proportionality between the nipple, areola, and breast. Several techniques exist to correct nipple hypertrophy, yet the majority of the procedures traditionally used can result in scarring of the nipple, decreased nipple sensation, disruption of the innervating intercostal nerves or blockage of the 16 to 24 lactiferous ducts housed in the central portion of the nipple.
The use of flaps and excision and resection in the procedures presented by Pitungay, Vecchione, Regnault, et. al. are all quite complicated and time consuming in contrast to the method employed by this author. Serge de Fontaine M.D.  presented this same technique in 1996 wherein the distal portion of the nipple is amputated to achieve the desired height. Fontaine proposes preoperatively marking the nipple while unerected and proceeds to remove and delimit the distal portion of the nipple. Fontaine then dresses the wound and allows the wound to heal by secondary intention, with epithelialization of the new nipple surface complete after ten days.
This author has employed this technique on a series of 21 patients between June 2001 and July 2007. This author additionally applies ointment to the new surface of the nipple before dressing to achieve epithelialization in approximately seven days. 20 of the 21 patients experienced no change in nipple sensation or erectile capacity. Postoperative recovery for all 21 patients was rapid and uneventful, with no complications encountered. None of the patients have had children post-operatively yet this procedure preserves functionality and leaves all lactiferous ducts open, theoretically allowing for lactation. This series is evidence that this technique is a much safer alternative to more complicated methods in addition to being more aesthetically pleasing and preserving function of the nipple.
The history of success in healing by secondary intention was the impetus for allowing the nipple to heal in. Fingertip injuries provide for the first source of support for healing by secondary intention. Originally treated with transposition flaps, it was discovered that applying ointment to a fingertip injury which did not extend to the bone (less than 1 square cm) healed more naturally and successfully as contraction occurred and epithelialization takes place through the hair follicles, sweat glands, and sebaceous glands. The conservative management of injuries of the lip, often referred to as kissing injuries resulting from dog bites, also supports the cosmetic and functional benefits of healing by secondary intention. When treated conservatively, patients with extensive tissue loss to the lip vermillion and other local landmarks demonstrate exceptional results, often with a more rapid healing time than with surgery. Further justification is seen in the discontinuing of skin grafts after Moh’s surgeries in favor of allowing the skin to heal on its own, as well as the evidence shown by the skin of burn victims and its ability to reepithelialize through the glands given certain elements of the skin remain.
The nipple has all the same dermal appendages necessary for this proliferation to occur: with the same skin elements as the fingertip or lips to provide the basal keratinocytes necessary for epithelialization. The muscular elements of the nipple used in erection also aid in contraction while healing the nipple into a reasonable rounded appearance. While other surgical corrections of nipple hypertrophy involving local flaps and tissue transfer frequently result in the unfortunate consequence of increased associated scarring and further permanent distortion of the local anatomy, this series demonstrates how conservative management results in a much more natural new nipple.
We postulate that just as in partial depth skin loss, reepitelialization occurs by epithelial migration from skin glands to cover the end of the nipple. This technique for a nipple reduction procedure provides the most natural results and avoids the unnecessary scarring and complications of the various other methods. Vecchione  proposed a similar technique, with distal mammillary amputation and grafting of the mammillary skin obtained from the nipple apex, yet the procedure presented here demonstrates that the skin graft is unnecessary and possibly deleterious by obstructing the ducts. As the nipple can reepithelialize via the galactophoric ducts that exist throughout the length of the nipple, a new and completely natural nipple surface is achieved without duct obstruction at a more comfortable and aesthetic nipple height.
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