In the human breast, the nipple area consists of the very tip called the 'nipple' and the region around it called the 'areola', which is darker in color than the surrounding normal skin. In breasts that have not sagged, the nipple is generally located between the 4th intercostal space. In breasts, as growth and sagging occur, the position of the nipple also changes; it moves lower. The color and size of the nipple change with age, skin color, and hormonal changes. 10–15 milk ducts open at the nipple. The surrounding areola may be 2–6 cm in diameter. The areola contains protrusions called Montgomery tubercles, where the glands that lubricate and protect the nipple open. The nipple is an important area for women, both for breastfeeding and for aesthetic appearance. Because of its location on the breast tissue, its size, shape and color, it is the most important part shaping the appearance of the breast. From this perspective, aesthetic deformities of this area and their correction have attracted the interest of both patients and plastic surgeons. The most common problems and their treatments are as follows:
Accessory nipple: In some people, extra nipples may be present along the so-called 'milk line' that extends from the armpit to the groin. This congenital condition does not pose a serious health problem. This condition, which causes aesthetic discomfort, is corrected by removing the excess nipple tissue under local anesthesia.
Inverted Nipple (Nipple Retraction) Correction: The nipple may be sunken or completely inverted in some women. The cause is an imbalance between the milk ducts, which pull the nipple inward, and the muscle fibers within the nipple that pull it outward. The imbalance occurs when the ducts pull the nipple inward more strongly. The best-known and most common cause of nipple retraction is a previous breast infection. Infection leads to blockage and shortening of the milk ducts. Shortening of the milk ducts causes the nipple to become sunken or completely inverted. In older age, retractions that develop later, especially unilateral ones, should raise suspicion of breast cancer. Necessary tests and diagnostic methods should be applied accordingly. The grading of nipple retraction is as follows:
Grade 1: The nipple can be easily pulled out. It stays out, but collapses again with slight pressure.
Grade 2: The nipple cannot be easily pulled out. When it is pulled out, it immediately retracts again.
Grade 3: The nipple cannot be pulled out. In this case, since the nipple has no well-developed milk ducts, milk generally does not come from the nipple. Surgery does not make milk flow.
Treatment:
Non-surgical: Special negative-pressure 'suction' devices can be successful in grade 1 nipple retraction without surgery. They work by stretching the milk ducts. They are not successful in grades 2 and 3.
Surgery: Surgically, the milk ducts pulling the nipple inward are cut, and the nipple retraction is corrected together with regional flaps. The procedure is a short operation performed under local anesthesia. The procedure does not enable patients who have not been able to breastfeed before to breastfeed or produce milk during their next possible breastfeeding period. Because the retraction in milk-producing ducts is corrected by cutting, there is also a possibility that milk will not come during the next breastfeeding period. Therefore, in women who can breastfeed and who produce milk from the nipple, correction of nipple retraction after the breastfeeding period is recommended.
Nipple Reduction (Reductoplasty): Nipples of various sizes can occur in both men and women. This can cause various difficulties when wearing tight clothing, and can also lead to psychological distress such as shyness and embarrassment in patients. The nipple may be very wide, very long, or asymmetrical. The surrounding areola may be very wide or asymmetrical, or it may separate from the surrounding normal skin and appear more dome-shaped. Nipple reduction is generally a day-surgery procedure that can be performed under local anesthesia. It is performed by reducing the problematic nipple or areola portion. Usually self-dissolving sutures are used, and the patient returns to daily life within 1 week at the latest.
Tubular breast deformity: Tubular breast is seen in some women when, due to developmental delay of the breasts during puberty, the breast tissue is gathered around the nipple and the surrounding areola tissue. The developmental problem is especially in the lower part of the breast, and like a band, it compresses the breast and prevents it from reaching a normal appearance. The breast tissue appears herniated and trapped below the nipple. The two breasts stand far apart from each other on the chest wall. This deformity, which can be observed to varying degrees, usually causes complaints of small breasts and sagging in women. It can be unilateral or bilateral. Treatment is possible under general anesthesia, depending on the severity of the problem, with unilateral or bilateral surgery. In some cases, areola reduction may be sufficient, while in others, augmentation with silicone breast implants, breast lift, and sometimes breast reduction surgery may be required. Breast augmentation and lift surgeries should be performed differently in these cases. Surgeries performed without releasing the constrictive band may lead to failure, or even to results in which the deformity is more pronounced. The breast base should be widened to narrow the separated area between the breasts, and an ideal breast appearance suited to the patient's body should be created.
Nipple reconstruction: Generally after breast cancer surgery, and sometimes as in Poland syndrome, the nipple and surrounding areola tissue may be absent. In these cases, if sufficient breast tissue is present or has been provided, nipple reconstruction is performed. Some patients may not feel the need for nipple reconstruction even after breast tissue has been created. Various methods are available:
Medical tattooing: It can be used alone, or it can also be used to create the appearance of an areola around the reconstructed nipple.
Skin graft (tissue transplant): A piece taken from the patient's own labia minora (inner lip) tissue is used to create the nipple. To create areola tissue, a skin graft is taken from the abdomen or groin area. Sutures are required at the donor sites. Since the procedure involves several areas, general anesthesia is preferred.
Nipple sharing: Creating a nipple by taking a portion of the patient's opposite nipple (nipple sharing) is no longer a commonly used method.
Local flap: The nipple portion is created using healthy skin and subcutaneous tissue from the area planned for nipple reconstruction. The areola can be created with tattooing or a skin graft.
Fat and dermal graft: To provide fullness in the nipple portion, fat or dermis, the second layer of skin, may be taken from areas such as the groin or abdomen and used as an adjunct to other methods. An acellular dermal matrix, an external material, may be used to provide projection to the nipple portion.
