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Combined Base Imbrication and Top Hat Nipple Reduction

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... 28 The Top Hat method was modified in 2014 by combining it with base imbrication. 29 Debono and Rao suggested a sinusoidal excision technique for male nipple hypertrophy to reduce height. 30 This method was later modified by van den Berg and van der Lei to avoid dog ears. ...
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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.
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Résumé Le complexe aréolo-mamelonnaire, aussi dénommé plaque aréolomamelonnaire, est une caractéristique visuelle essentielle du sein. Ce complexe peut être affecté par diverses malformations, congénitales ou acquises. Bien que ces anomalies aient souvent un impact modéré sur la fonctionnalité du complexe, les conséquences psychologiques en résultant peuvent être importantes. Leur traitement est le plus souvent chirurgical et de nombreuses techniques ont été décrites au fil des années afin de reconstruire aréole et mamelon. Quelque soit la technique utilisée, celle-ci se doit d’être simple, rapide, permettant d’imiter au plus proche un complexe aréolo-mamelonnaire natif et d’être relativement pérenne, évitant de nombreuses retouches chirurgicales .
Chapter
The development of nipple-areolar complex (NAC) reconstruction is instructive to the surgeon performing breast surgery. From the physiologic purpose of the NAC to ideal breast, optimal breast NAC position, NAC proportions, prevention of nipple-areolar complex loss or deformity, abnormalities of the NAC, correcting improper nipple-areolar complex position, correcting the high-riding nipple-areolar complex, nipple-areola sharing, nipple-areolar body grafts, nipple inversion, congenital causes of nipple inversion, classification of inverted nipples, nipple hypertrophy, nipple-areolar complex reconstruction with flap methods, and tattooing.
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The author suggests that an aesthetically pleasing ratio between nipple and areola diameter exists which should always be taken in consideration during nipple and areola reconstruction. In a study of 40 nipple–areola complexes of 20 healthy, nulliparous, Caucasian female volunteers with a mean age of 25.5 years, the average nipple diameter measured 28% of the areola diameter, that is, a ratio of 1:3.6. A hitherto undescribed form of macrothelia is presented in which the nipple width rather than the projection (length) is increased. A successful technique for reconstruction is described, based on the new method of assessing the aesthetic relations within the nipple–areola complex and known anatomy.
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Reduction of the hypertrophied nipple core can be accomplished very simply by applying a thin split-thickness graft from the tip of the nipple to the resected nipple core. The results are esthetically acceptable.
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Hypertrophy of the nipple seems to be a familial deformity which may involve several women in the same family. It appears after puberty and becomes more obvious after pregnancy, but it does not disappear after menopause. In this series of 16 cases, it was associated with hypotrophy of the breast in 12 cases and hypertrophy in two cases.
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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.
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Many surgical procedures performed in the thoracic region can easily damage cutaneous nerves important for the sensory innervation of the female breast. A better understanding of the distribution of these cutaneous nerves will help prevent impaired sensation after breast surgery. Therefore an anatomical study was performed on the cutaneous innervation of 12 breasts of 7 female cadavers. Special emphasis was placed on the nipple-areola complex. The origin, course and final destination of each cutaneous nerve was established and the contribution of each branch was determined by the area it innervated. Differences were evaluated using analysis of variance. The cutaneous innervation of the female breast is derived medially from the anterior cutaneous branches of the Ist-VIth intercostal nerves and laterally from the lateral cutaneous branches of the IInd-VIIth intercostal nerves. The nipple-areola complex is consistently supplied by the anterior and lateral cutaneous branches of the IVth intercostal nerve, with additional innervation by cutaneous branches of the IIIrd and Vth intercostal nerves. This study shows an equal importance of both the anterior and the lateral cutaneous branches of the intercostal nerves. During surgical procedures one should try to avoid damage to the anterior and lateral cutaneous branches of the IIIrd, IVth and Vth intercostal nerves, with special attention to the IVth intercostal nerve which is the consistent nerve to the nipple-areola complex.
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Patients requesting nipple or areolar reduction often desire simultaneous breast augmentation. A technique is described for implant placement by means of a nipple base incision with either nipple reduction or intraareolar reduction. Nipple reduction is accomplished by removing a ring of skin from the base of the nipple, while areolar reduction is performed by removing a donut-shaped area of skin whose inner diameter is at the nipple base. The elasticity of the areolar skin allows for access for saline implant placement. The resulting scar is well concealed. Results from 15 patients demonstrate that the technique is safe, practical, and appears to pose no increased risk of sensory changes to the nipple.
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The main sources of blood supply to the breast are described in textbooks as the internal thoracic, lateral thoracic, and posterior intercostal arteries. Textbooks, however, do not describe the contribution of each to the nippie-areoia complex (NAC), nor do they describe the pattern of supply. To investigate this issue, 15 female cadavers were injected intraarterially with latex, and dissections were performed on 27 breasts. The results were as follows: In all the dissected breasts (27/27), the NAC received at least one or more vessels from the internal thoracic artery. In 20 of 27 dissected breasts, the NAC received vessels from the anterior intercostal arteries, In 19 of the 27 dissected breasts, the NAC received vessels from the lateral thoracic artery. Direct branches from the axillary artery supplied the NAC in 2 of the 27 breasts. The posterior intercostal arteries supplied the NAC in only 1 of the 27 dissected breasts. An underlying segmental pattern could be detected that can be explained by the embryological development. According to this study, the internal thoracic arteries are to be considered the main and constantly reliable source of blood supply to the NAC.
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The aim of this study was to use ultrasound imaging to re-investigate the anatomy of the lactating breast. The breasts of 21 fully lactating women (1-6 months post partum) were scanned using an ACUSON XP10 (5-10 MHz linear array probe). The number of main ducts was measured, ductal morphology was determined, and the distribution of glandular and adipose tissue was recorded. Milk ducts appeared as hypoechoic tubular structures with echogenic walls that often contained echoes. Ducts were easily compressed and did not display typical sinuses. All ducts branched within the areolar radius, the first branch occurring 8.0 +/- 5.5 mm from the nipple. Duct diameter was 1.9 +/- 0.6 mm, 2.0 +/- 90.7 mm and the number of main ducts was 9.6 +/- 2.9, 9.2 +/- 2.9, for left and right breast, respectively. Milk ducts are superficial, easily compressible and echoes within the duct represent fat globules in breastmilk. The low number and size of the ducts, the rapid branching under the areola and the absence of sinuses suggest that ducts transport breastmilk, rather than store it. The distribution of adipose and glandular tissue showed wide variation between women but not between breasts within women. The proportion of glandular and fat tissue and the number and size of ducts were not related to milk production. This study highlights inconsistencies in anatomical literature that impact on breast physiology, breastfeeding management and ultrasound assessment.
Article
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. 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. 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. 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.