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Is it sometimes necessary to cut the nipple area during a breast augmentation?

Q:

I am having breast augmentation to go from a size 34 B to 34 D.  My doctor wants to cut and do the procedure in the nipple area.   I am worried that this may make my nipples look deformed or leave ugly scars.  I do have a little extra skin and instead of doing a breast lift along with the augmentation, he wants to tuck the skin in and do this through the nipples. Please give me some advice.

A:

Some surgeons perform what they call a "circumareolar" (or 'donut' or 'Benelli' ) mastopexy.  In my opinion there is absolutely no such thing as a "circumareolar mastopexy."  Removing skin around the areola may enable a surgeon to elevate the position of the nipple/areola complex perhaps 1-2 cm on the breast mound, but it DOES NOT lift the breast itself.  In most cases, unfortunately, it serves to distort the shape of the breasts, making them appear flattened at the top.  If the breast needs to be lifted, it absolutely requires some internal rearrangement of breast tissue to create a projecting, aesthetically ideal and lasting result - which in turn requires that vertical incision and vertical surgical scar below the areola (and sometimes in the inframammary fold as well).

If you want a breast augmentation without having an incision around the nipple there are other options.

The axillary or underarm area incision is ideal for patients with very youthful-appearing breasts, especially younger women with no history of pregnancy.  These patients often have a small areolar diameter, which makes the peri-areolar incision less than ideal, and smaller, perkier breasts - where the inframammary fold (and thus a scar in that location) can be easily seen.

The infra-mammary fold incision works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts.  As full breasts conceal the infra-mammary fold very well, the scar is usually not visible when standing or sitting upright.  Ideally this scar is placed just above the inframammary fold on the lower pole of the breast, so that it faces down and therefore tends to be less noticeable. 

An advantage of the peri-areolar incision is that the color and skin texture difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely.  In many patients the scar is almost undetectable after only a few weeks.  This incision is commonly used in patients who have had one or more pregnancies and have a medium to large areolar diameter.

 

A:

The procedure you are most likely considering is called a periareolar breast augmentation. Often this is performed to help correct slight nipple asymmetry common after pregnancy and breast feeding for minor breast ptosis or sagging of the breast.  It is a very commonly performed method in breast augmentation. 

The two components of the appealing breast are often considered to be the size of your breast in relation to your body size and the position of the nipples.  Nipples that point out asymmetrically or downward are often not considered appealing as those that are in a more youthful position.  You should consider discussing these issues with your surgeon prior to your procedure.

Breast ptosis or sagging is a very common event that occurs in most women with aging.  As you age, youthful breast tissue is replaced with fat.  It is often classified as mild, moderate or severe.  The incision for correction of breast ptosis or sagging vary from simple croissants, circles, lollipops, or anchors.  Correction of breast sagging depends not only on severity but the actual nature of the skin and tissue of the breast.  For example, patients who have gone through massive weight loss often have very flat breasts with minimal breast tissue.  Their correction of the flat sagging breast often utilizes their own tissues formed to enhance the breast.  It can be one of the most complicated forms of mastopexy or a breast lift.  In these patients often surgeons will first perform the mastopexy and later return to enhance the breast with an augmentation to decrease the overall patient complication rate. 

Discuss your concerns with your surgeon.  If you are not satisfied then seek out another opinion from one of the members of ASAPS.  They are experts in breast surgery.

Best,

Gary R. Culbertson, MD, FACS

A:

Please see the other answer.  The incision around the nipple (areola) is the only incision I use, unless there is a specific indication to do otherwise.  The reason for this is that it is by far the best.  It disappears in the natural change in color and almost always heals exceptionally well.

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