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Correction of nipple hypertrophy: Nipple circumcision technique revisited
Correspondence and communications
1575
Ajay L. Mahajan Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.017
Correction of nipple hypertrophy: Nipple circumcision technique revisited Sir, Nipple hypertrophy can cause significant psychosocial problems and physical discomfort to the patient. Large nipples can affect a woman’s appearance. The patient may have problems with her choice of clothing, especially when wearing light clothes.1,2 The nipple-circumcision technique
Figure 1 Schematic drawing of the technique. First a circumferential incision is made approximately 5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is deepitelized leaving the dermal layer intact. The incision is closed with 6-0 polypropylene, vertical mattress sutures.
Figure 2 Breast augmentation with implant and simultaneous nipple reduction was performed to the patient. (aeb) Preoperative views of the patient. (ced) Final results at the postoperative first year.
1576 was first reported by Regnault, as a circumferential skin and superficial muscular layer excision between base and apex of the hypertrophic nipple.3 Lai et al. modified Regnault’s technique in order to decrease the nipple height without altering the diameter.4 Both techniques includes circumferential removal of dermal components.3,4 Although these techniques produce adequate nipple reduction, circumferential removal of dermal components may cause vascular flow impairment and decreased nipple sensation.1 At our institute, we perform a modified nipple-circumcision technique. With the modified nipple-circumcision technique, the de-epithelisation avoids the removal of dermis and preserves the subdermal arterial plexus. Nipple sensation also remains unaffected, because the dermal components are preserved. First, a circumferential incision is made w5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is de-epithelised leaving the dermal layer intact. The incision is closed with 6/0 polypropylene, vertical mattress sutures (Figure 1). A total of eight nipple reductions were performed in four female patients using the modified nipple-circumcision technique. Patients’ age ranged between 32 and 41 (mean: 36). All patients had breast hypoplasia and were requesting augmentation mammaplasty. Correction of the nipple in two patients were carried out simultaneously with breast augmentation using silicone implants, and the other two patients were operated 6 and 9 months after the breast augmentation in an outpatient procedure. First, the breast implants were placed and the incisions were closed, and then nipple reductions were performed simultaneously in these patients. Late nipple reductions were performed under local anaesthesia in the office setting. Three of the patients were uniparous and one of the patients had no history of pregnancy. Patients who gave birth had a mean lactation period of 11.3 3.4 (range: 8e14) months. Postoperative recovery in all patients was uneventful. Sutures were removed 1 week after the operation. No complications, such as ischaemic problems, venous congestion or decreased nipple sensation, were encountered. The swelling and pain were minimal. There was very little discomfort in the postoperative period. The mean follow-up period was 2.4 years. The resulting scar was well concealed and almost invisible. The results were natural in appearance and nipple sensation was preserved. Long-term aesthetic results were satisfactory, and the patients expressed a high degree of satisfaction, due to good aesthetic and functional results (Figure 2aed). In conclusion, this technique is safe and reliable. Nipple reduction can be performed in combination with breast augmentation, breast reduction or mastopexy. In addition, it can be performed as a separate procedure under local anaesthesia. If there is a nipple deformity, its correction completes the breast procedure and significantly enhances outcome and patient satisfaction.
Conflict of interest statement The authors have no commercial associations or financial relationships to disclose.
Correspondence and communications
References 1. Cheng MH, Smartt JM, Rodriguez ED, et al. Nipple reduction using the modified top hat flap. Plast Reconstr Surg 2006;118:1517e25. 2. Ferreira LM, Neto MS, Okamoto RH, et al. Surgical correction of nipple hypertrophy. Plast Reconstr Surg 1995;95:753e4. 3. Regnault P. Nipple hypertrophy. A physiologic reduction by circumcision. Clin Plast Surg 1975;2:391e6. 4. Lai YL, Wu WC. Nipple reduction with a modified circumcision technique. Br J Plast Surg 1996;49:307e9.
Serhan Tuncer Tolga Eryilmaz Kenan Atabay Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University School of Medicine, 06500 Besevler, Ankara, Turkey E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.027
The novel use of a ‘Telescopic Rod’ in a young girl with congenital radial aplasia Sir, Radial dysplasia is a clinical spectrum, ranging from hypoplastic thenar muscles to total absence of the radius, and thumb.1 When the radius is absent a severe radial deviation of the hand occurs, which is functionally compromised and poor aesthetically. The management can be difficult and challenging.2 One strategy in the treatment is soft tissue distraction followed by centralisation of the hand over the ulna, with K-wire stabilisation of the wrist. In a growing hand this K-wire requires removal or replacement.3 Intramedullary telescopic rods are used in the long bones of children with osteogenesis imperfecta.4,5 We present a novel use of the Fassier-Duval Telescopic Rod in the management of a difficult radial club hand. An 11-month old girl presented with left radial aplasia. Centralisation was performed, but recurrence of the radial deviation occurred three years later prompting treatment by gradual distraction in an Ilizarov fixator (Figure 1). Three months after gradual correction, hand centralisation (with K-wire fixation) with balancing extensor tendon transfer was performed. The K-wire was exchanged for the FassierDuval Telescopic Rod at age seven, because the K-wire became loose in the metacarpal. The rod is anchored proximally and distally by threaded portions (Figure 2). The rod telescopes with the growth of the forearm. There has been no recurrence of deformity after twoyear follow-up in a multidisciplinary upper limb clinic. The rod is anchored adequately in the ulna and the metacarpal
1575
Ajay L. Mahajan Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.017
Correction of nipple hypertrophy: Nipple circumcision technique revisited Sir, Nipple hypertrophy can cause significant psychosocial problems and physical discomfort to the patient. Large nipples can affect a woman’s appearance. The patient may have problems with her choice of clothing, especially when wearing light clothes.1,2 The nipple-circumcision technique
Figure 1 Schematic drawing of the technique. First a circumferential incision is made approximately 5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is deepitelized leaving the dermal layer intact. The incision is closed with 6-0 polypropylene, vertical mattress sutures.
Figure 2 Breast augmentation with implant and simultaneous nipple reduction was performed to the patient. (aeb) Preoperative views of the patient. (ced) Final results at the postoperative first year.
1576 was first reported by Regnault, as a circumferential skin and superficial muscular layer excision between base and apex of the hypertrophic nipple.3 Lai et al. modified Regnault’s technique in order to decrease the nipple height without altering the diameter.4 Both techniques includes circumferential removal of dermal components.3,4 Although these techniques produce adequate nipple reduction, circumferential removal of dermal components may cause vascular flow impairment and decreased nipple sensation.1 At our institute, we perform a modified nipple-circumcision technique. With the modified nipple-circumcision technique, the de-epithelisation avoids the removal of dermis and preserves the subdermal arterial plexus. Nipple sensation also remains unaffected, because the dermal components are preserved. First, a circumferential incision is made w5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is de-epithelised leaving the dermal layer intact. The incision is closed with 6/0 polypropylene, vertical mattress sutures (Figure 1). A total of eight nipple reductions were performed in four female patients using the modified nipple-circumcision technique. Patients’ age ranged between 32 and 41 (mean: 36). All patients had breast hypoplasia and were requesting augmentation mammaplasty. Correction of the nipple in two patients were carried out simultaneously with breast augmentation using silicone implants, and the other two patients were operated 6 and 9 months after the breast augmentation in an outpatient procedure. First, the breast implants were placed and the incisions were closed, and then nipple reductions were performed simultaneously in these patients. Late nipple reductions were performed under local anaesthesia in the office setting. Three of the patients were uniparous and one of the patients had no history of pregnancy. Patients who gave birth had a mean lactation period of 11.3 3.4 (range: 8e14) months. Postoperative recovery in all patients was uneventful. Sutures were removed 1 week after the operation. No complications, such as ischaemic problems, venous congestion or decreased nipple sensation, were encountered. The swelling and pain were minimal. There was very little discomfort in the postoperative period. The mean follow-up period was 2.4 years. The resulting scar was well concealed and almost invisible. The results were natural in appearance and nipple sensation was preserved. Long-term aesthetic results were satisfactory, and the patients expressed a high degree of satisfaction, due to good aesthetic and functional results (Figure 2aed). In conclusion, this technique is safe and reliable. Nipple reduction can be performed in combination with breast augmentation, breast reduction or mastopexy. In addition, it can be performed as a separate procedure under local anaesthesia. If there is a nipple deformity, its correction completes the breast procedure and significantly enhances outcome and patient satisfaction.
Conflict of interest statement The authors have no commercial associations or financial relationships to disclose.
Correspondence and communications
References 1. Cheng MH, Smartt JM, Rodriguez ED, et al. Nipple reduction using the modified top hat flap. Plast Reconstr Surg 2006;118:1517e25. 2. Ferreira LM, Neto MS, Okamoto RH, et al. Surgical correction of nipple hypertrophy. Plast Reconstr Surg 1995;95:753e4. 3. Regnault P. Nipple hypertrophy. A physiologic reduction by circumcision. Clin Plast Surg 1975;2:391e6. 4. Lai YL, Wu WC. Nipple reduction with a modified circumcision technique. Br J Plast Surg 1996;49:307e9.
Serhan Tuncer Tolga Eryilmaz Kenan Atabay Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University School of Medicine, 06500 Besevler, Ankara, Turkey E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.027
The novel use of a ‘Telescopic Rod’ in a young girl with congenital radial aplasia Sir, Radial dysplasia is a clinical spectrum, ranging from hypoplastic thenar muscles to total absence of the radius, and thumb.1 When the radius is absent a severe radial deviation of the hand occurs, which is functionally compromised and poor aesthetically. The management can be difficult and challenging.2 One strategy in the treatment is soft tissue distraction followed by centralisation of the hand over the ulna, with K-wire stabilisation of the wrist. In a growing hand this K-wire requires removal or replacement.3 Intramedullary telescopic rods are used in the long bones of children with osteogenesis imperfecta.4,5 We present a novel use of the Fassier-Duval Telescopic Rod in the management of a difficult radial club hand. An 11-month old girl presented with left radial aplasia. Centralisation was performed, but recurrence of the radial deviation occurred three years later prompting treatment by gradual distraction in an Ilizarov fixator (Figure 1). Three months after gradual correction, hand centralisation (with K-wire fixation) with balancing extensor tendon transfer was performed. The K-wire was exchanged for the FassierDuval Telescopic Rod at age seven, because the K-wire became loose in the metacarpal. The rod is anchored proximally and distally by threaded portions (Figure 2). The rod telescopes with the growth of the forearm. There has been no recurrence of deformity after twoyear follow-up in a multidisciplinary upper limb clinic. The rod is anchored adequately in the ulna and the metacarpal