The areola is a roughly circular, pigmented area of modified skin, normally measuring 15 to 60 mm in diameter, with an oily consistency due to sebaceous activity and numerous glandular openings known as the Tubercles of Montgomery. The areolar sensation plays an important role in erogenous sensation. The contour of the nipple and areola can, at times, matter more to the patient than the amount of breast tissue. Aesthetic reduction techniques can be divided into nipple reduction and areolar reduction.
What causes an enlarged areola?
Enlargement of the areola may be familial, appearing at puberty, and there may be an association with tuberous breast deformity. An enlarged areola may be acquired secondary to pregnancy, where it may be associated with breast and nipple growth. It may be a secondary deformity of a breast reduction or breast augmentation (especially with large or high profile implants) and areolar reconstruction. Generally, ageing and drooping (termed ptosis) is associated with gradual enlargement.
What Surgical Techniques are used?
3 Groups of techniques have been described for reduction of the areolar diameter :
- Circumferential reduction with “round block” suture
- Intra-areolar “doughnut” reduction
- Breast reduction techniques
- Circumferential periareolar reduction
This technique places the scar at the junction of the areolar skin and the surrounding breast skin. Most modifications call for a slowly absorbable or permanent purse-string suture (the “round block” technique) to prevent future stretch. The surgical technique involves marking the desired areolar diameter on stretched skin with a specific device with preset diameters of 40, 44, 48 and 52 mm. The present areola diameter is then marked, and the skin between the two rings is removed (or, more commonly, de-epithelialized). The purse-string suture is placed in the deep dermis of the breast skin and tightened to the desired new areolar diameter. The new areolar skin border is then sutured to the breast skin in a low-tension manner using continuous suture. The final scar is at the junction of the areola and the breast.
- Intra-areolar reduction
Lai and Baxter described this technique separately. Two incision lines are marked: the inner circle around the base of the nipple, and the outer circle 1.5 cm from the present areolar-breast junction. The doughnut-shaped skin in between is de-epithelialized. The remainder of the areolar is circumferentially undermined, preserving an adequate thickness of subcutaneous tissue to effect a tension-free closure around the nipple base. The areolar deep dermis is sutured to the nipple base dermis with two purse-string sutures, and the skin is closed as above. The final scar is within the areola, at the base of the nipple.
3. Breast reduction techniques
When a large areola exists with excess breast skin, a short scar or standard Wise pattern mastopexy (breast lift) is used to reduce both the areolar and surrounding breast skin. Areolar reduction is a standard part of a mastopexy or breast reduction, and it may be part of peri-areolar breast augmentation, gynaecomastia, and tuberous breast operations.
Nipple Reduction
Nipple excess may be divided into excessive length with normal base, excessive base width with normal length or excess in both dimensions. It may occur as an isolated deformity, or it may be associated with areolar enlargement.
Technique to reduce a too wide nipple
A wedge of nipple may be excised from the nipple cone may be excised, resulting in a vertical scar on primary closure. This decreases nipple base width and slightly increases projection. Moderate disruption of the lactiferous duct system and subsequent decreased breastfeeding potential are expected.
Techniques to reduce a too-long nipple
The long nipple may be reduced at the base or the tip. Tip reduction may be performed by several techniques:
- The inferior half of the tip can be excised with the remainder folded over like a cap and closed, resulting in a horizontal scar around the inferior half of the tip
- The tip can be excised as a wedge, resulting in a transverse scar through the nipple.
- The nipple tip may be amputated horizontally and allowed to epithelialize.
All these techniques will cause a disruption in the duct system and subsequent breastfeeding difficulties and are generally used in patients who have completed their families. In my opinion, the result of a tip reduction is generally more impressive and longer lasting than a base reduction.
Base reduction
A peri-nipple incision is made and a second incision is made circumferentially around the nipple cone, 5 to 6mm away, and the intervening nipple skin is removed. The nipple is drawn deeper into the breast tissue, and the skin is apposed. This technique preserves the breast ducts and is preferable in younger patients, who have not yet completed their family.