Combined base imbrication and top hat nipple reduction.

Abstract

Sir: The nipple-areola complex holds an important psychological place, as it is the center focus of the breast mound. Just as the absence of the nipple is debilitating, so too is the presence of hypertrophic and/or inverted nipples. The nipple is composed internally of a series of lactiferous ducts that are responsible for connecting the mammary gland and supplying milk during lactation.1 Nipple sensation is derived from the anterior and the third, fourth, and fifth lateral cutaneous intercostal nerves.2 Blood supply to the nipple is predominantly from a plexus of vessels branching from the internal thoracic artery.3 Vecchione used a split-thickness skin graft after direct tip amputation.4 This method, however, cuts through the nipple core housing the lactiferous ducts, most likely creating a functional disruption of breast feeding. Circumcision techniques around the nipple base have been used to decrease height and diameter without compromising lactation.5,6 As such, wedge resections of the nipple should be placed vertically to maximize nipple sensation.7 The “average” nipple is generally agreed to be 1 cm in diameter and 1 cm in anterior projection,6 with a ratio of 1:3.6 (or 28 percent) nipple-to-areola diameter.8 Elongated nipples are more common in postpartum women9 and also occur more frequently among Asian women than among Caucasian women.10 We present a video for documentation of a technique for nipple reduction. (SeeVideo, Supplemental Digital Content 1, which demonstrates a technique for nipple reduction, https://links.lww.com/PRS/B165.) It is a modification of the Cheng top hat technique. The wedge excision is greater in width and then imbricated as a burrow triangle to further decrease nipple height and maximize blood supply and sensation. The inferior excision can be further extended as a circumferential strip removal as advocated by Jin to maximize dimensional decrease (Fig. 1).Fig. 1: A 28-year-old woman who underwent breast augmentation surgery with nipple reduction shown (left) preoperatively and (right) 2 months postoperatively.Video: Supplemental Digital Content 1 demonstrates a technique for nipple reduction, http://links.lww.com/PRS/B165.We present this technique to maximize reduction of length predominantly. The Jin technique increases the volume of nipple within the skin with two wedges to compensate. This technique places the wedge at the 6-o’clock position only, avoiding a scar the patient can see from above, or at the 12-o’clock position. The imbrication of the base widens the relative base, which can help change the mushroom-on-a-stalk appearance that commonly occurs during the postnatal period. The modified top hat component of Cheng allows more control of the height. The wedge and top hat nipple reduction technique with imbrication of the base allows control of height, width, and shape of the new nipple. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Gabrielle LaBove, B.S. DAVinci Plastic Surgery Steven P. Davison, M.D., D.D.S. Georgetown University School of Medicine Washington, D.C.