Areola Reduction: The Surgery for Smaller Nipples & Areolas

Monique Ramsey (00:02):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. Now, we all know that having overly large breasts can bring about some insecurities, but something that nobody really talks about is that then your nipple area, your areola area, for some people it's quite large and maybe they feel uncomfortable with that. So I have our breast expert, Dr. Hector Salazar, to explain what can be done and how to make nipples and/or areolas or areolas, and we're going to talk about how to say it, how to make them smaller. Welcome back, Dr. Salazar.

Dr. Salazar (00:39):
How are you Monique? Thanks so much for your invitation. It's always good to come and talk to you and talk to our audience about different aspects of plastic surgery, and I think this is a very important, not so frequently discussed topic. I think you nailed it with that topic of the day and more than happy to demystify the areola and the nipple.

Monique Ramsey (00:59):
Okay, so areola, that's the first thing, cuz I hear people say, areola, areola. Then I went online, you know how you can have Google pronounce things for you, and I got even more things.

Dr. Salazar (01:11):
Yeah, exactly.

Monique Ramsey (01:12):
So tell us how to say it.

Dr. Salazar (01:13):
No, I was going to stay with areola, and I think that one of the most important things is, and when we are in consultation with our patients to differentiate between the nipple and the areola. Because sometimes the patient's actually talking about the areola, but they call it the nipple, or they call like, oh, I want my nipples to be reduced. But then they're really not talking about the nipple, they're talking about the areola.

Monique Ramsey (01:42):
Okay, so give us the lowdown, which is which? We should know this as women, but we don't.

Dr. Salazar (01:50):
And I think, I mean, yeah, colloquial language, basically everybody, I mean, people call, technically it's called the nipple areola complex, right? So nipple, which is the prominence, the part that sticks out, that stands out, and the areola, which is the circle that where you see darker skin color. But basically from now on and throughout the podcast, we're going to be differentiating and talking about the nipple as just the part that sticks out and the areola, just the circle around it.

Monique Ramsey (02:26):
Okay. So since we're going to be talking about reducing those, can the nipple itself be reduced with surgery?

Dr. Salazar (02:35):
Yes. One of the most important things for our patients to know is that they lead. So we are here to help them achieve a certain look, but in reality, it's important for them to understand that if they have, for instance, large nipples, again, understanding that the protuberant part or large areolas, the circles, that we are nobody to tell them that they are outside of the norm or outside of the aesthetic component. Why? Because beauty is in the eye of the beholder. So if a patient says, you know what, Dr. Salazar, I'm aware that my areolas are large circles, they're dilated, but I like them that way. Perfect. Or I understand that my nipple maybe it's very long, it's very pertuberant, but that's how I like it. And then there's no reason for us to decrease the size or the projection of that nipple. But yes, to answer your question, absolutely.

Monique Ramsey (03:44):
Now, because the nipple is very sensitive, that seems like it might be painful. I'm just thinking about it and going, oh, I don't know. Is this a painful surgery if you're just making it smaller by removing some of it, right?

Dr. Salazar (04:02):
Correct. The procedure itself, if it's being done under general anesthesia, then that sensation, of course, as we are repairing it, patients don't have any pain. If you're doing it under local anesthesia, well, there is a transient pain, just like when you go to the dentist, the doctor injects some local anesthesia. In our case, we're going to be injecting the local anesthesia around the nipple and areola. Of course, it is more sensitive, but once the anesthesia kicks in, then the patients are fine in the recovery period. And after surgery, when we do the areola reductions or nipple reductions, no, patients do not claim to have more discomfort or more pain compared to, let's say we did different area of their body or their tummy or the side of the breast or something. No, they don't claim more pain.

Monique Ramsey (04:54):
And does it take a long time to recover from a nipple reduction surgery? I mean, let's just pretend it was done all by itself. I know it might be done as part of a lift or it might be done as part of an augmentation. But if we were just going to talk about the nipple itself.

Dr. Salazar (05:11):
A nipple reduction.

Monique Ramsey (05:12):
Yeah, yeah. Would that be a long recovery?

Dr. Salazar (05:15):
A long recovery? No. I mean the surgery itself and to go there, if we were going to reduce the nipple, the surgery itself probably takes anywhere from 25 to 45 minutes at the most, and then the recovery process is not that long. So probably patients will feel fine after two, three days and after that weekend they can resume their activities. The only thing is we would ask them for two weeks of no exercise, and then after that, then you can get submerged in water and everything.

Monique Ramsey (05:45):
Now, before we move on to the areola, did I say?

Dr. Salazar (05:49):
You're good.

Monique Ramsey (05:49):
It's one of those things when you say it or you think, you know how, areola, where do I put my emphasis?

Dr. Salazar (05:59):
Thank God. We don't have to say this word that often in the outside world, right?

Monique Ramsey (06:04):
Sorry. Yeah. Okay. So before we move on to that part of the podcast, do men ever get nipple reduction surgery?

Dr. Salazar (06:11):
Yes. Yes. We have received that request where the nipples are a little bit more projecting the same case that can happen on women. Of course, the male nipple tends to be smaller because the mammary gland doesn't have the same function in a male patient. So the nipple tends to be smaller. But we've had, yeah, patients, absolutely, patients requesting, can you reduce the size of the projection of my nipple itself? Can we reduce it? Yes. So absolutely.

Monique Ramsey (06:38):
Alright. So now going into the more pink part or the darker part of the breast, which is the areola or areola.

Dr. Salazar (06:47):
Correct.

Monique Ramsey (06:48):
If we're just talking about that, is that, would you say typically done as part of a breast lift or breast reduction, but could it also be done on its own or could it also be done with a breast augmentation?

Dr. Salazar (07:00):
All of the above. So definitely when you are doing a breast reduction, the technique itself or a breast lift, the technique itself calls for a reduction or the possibility of a reduction of the areola. And it also makes some sense because if you are lifting a breast or you're reducing a breast, you want to have a better match between if you think about a mountain where the snowy part is and the rest of the mountain, you need to have that proportion maintained for aesthetic purposes. So when we do a breast reduction, we do reduce the areola, not necessarily the nipple, the sticking part. And the same thing when we do a breast lift, mastopexy. Now can you combine that with an areola reduction when you are doing a breast augmentation or when you are doing a breast revision case or exchanging, swapping implants for a fresh pair of implants? You can do it as well. You can actually decrease the size of the areola to give a little bit more of a youthful look to that breast.

Monique Ramsey (08:13):
Does the areola get larger typically from pregnancy or breastfeeding? Does that make it stretch or just if the, the person gained a lot of weight, let's say, does it stretch or are you sort of born with a bigger areola or a smaller areola?

Dr. Salazar (08:35):
Yes. So everything starts with genetics, of course. And then the size of the areolas and patients they've had, they're born with very, very small areolas that actually just barely go around the nipple. There are patients that are born with much larger areolas just from genetic or pedigree of areola. So just from there, that's, we are used to seeing differences. And then as the patient develops through puberty, then the areola tissue tends to differentiate more and more from the surrounding tissue from the surrounding skin tends to increase in color, tends to be a little bit more raised, tends to react a little bit more and tends to grow, it tends to dilate, tends to go bigger. And that's just for pure development. And then after that, it'll experience changes throughout life. If you, I mean on one route you have pregnancy and breastfeeding, and of course what that will do is it'll increase the size of the breast in general, and then that would increase the size of the areola. Also, as you know, the breast is also, I mean, there are two big components on a breast. One is fat and one is breast tissue per se. So when patients gain a lot of weight, if they have a significant weight gain, then their breasts are going to grow. And then the areola is also going to be submitted to stretching forces that can have that areola tissue grow in size.

Monique Ramsey (10:10):
And does anything happen with that tissue during menopause? If it grew during pregnancy, could it shrink with menopause?

Dr. Salazar (10:17):
Menopause, no, not really. We've never seen that. I mean, of course, the breast tissue throughout life also, little by little gets the breast tissue itself gets substituted for fat, and then the breast tends to start deflating and tends to succumb to gravity and start stretching a little bit more and becoming what we call a little bit more tonic, a little bit more droopy. But in reality, the tissue, since it has a skin component, once it has stretched, is really hard for it to go back.

Monique Ramsey (10:54):
So what percent of people are asking for just an areola reduction or a nipple reduction?

Dr. Salazar (11:02):
Good question. And you actually are making me think, and if I would have to call a percentage of, let's say a patient that books for a consultation and just wants to have the areola reduced or just wants to have a nipple reduction, it's very, very small. It's a very, very small percentage. I would say probably put it in the entire breast surgery gamut of treatments that we do. The isolated nipple reduction or areola reduction probably is not even going to reach 1%, probably 1% or below that. That they purely one to pursue that. If you ask me how many areolas do you reduce a week or how many nipples, then that becomes more common because we definitely combine it with other procedures for the breast.

Monique Ramsey (11:49):
And is it most commonly done with a breast lift or?

Dr. Salazar (11:53):
Exactly, with a breast reduction or a breast lift, it's definitely a routine that we do an areola reduction.

Monique Ramsey (12:00):
So what are the most common questions you hear from patients who are considering these kind of breast procedures? What are they worried about?

Dr. Salazar (12:08):
Well, the main question is going to be about sensation and innervation to the nipple and areola complex, as we were saying, it's very complex, it's very rich. So there's some papers in plastic surgery that would quote a change in sensation of the areola that can range anywhere from 20 to 30% after you do a procedure that involves the areola, meaning if you're doing a breast lift or if you're reducing an areola or if you're doing a breast reduction. But at the same time, when they talk about change in sensation, doesn't mean sensation loss. It can mean more sensation or it can mean a little bit of a different sensation. Or now I feel more the left side of my areola than the inner part of my areola, meaning more towards the side than the center, or it's a little bit numb, but after a week or two starts to come back. So there's some patients that would claim that after the procedure, everything feels completely normal. There is going to be that, which is a great majority. That's why the quote is about 20 to 30% sensation change, but that doesn't mean that it's for sure that you're going to lose sensation.

Monique Ramsey (13:30):
Okay. So the scar, let's talk about for a nipple reduction, I'm assuming there's really no scar, right? You're just kind of making it shorter?

Dr. Salazar (13:39):
Exactly. You can take a small wedge out or you can take a little band around it and then you put it back and everybody can close their eyes right now and imagine how the nipple and areola areas are. And then the nipple area has many, many dents and prominences and wrinkly skin. So in reality, when you close it and you close the way, I like to close those repairs are still in different levels to decrease the amount of tension and obtain a good closure. But the scar, there will be a scar, but it's practically invisible. You can't see it because that scar fuses pretty well. There is the terrain is not very uniform, so you can hide it really well.

Monique Ramsey (14:26):
Okay. Now, if we're doing an areola reduction, what kind of scar do we imagine and what do patients need to do mentally to sort of be like, okay, so I have this new beautiful breast that here's my goal, wear my scars. How do I take care of them?

Dr. Salazar (14:44):
So the scar, when you're doing an areola reduction goes basically around the areola and it hides well, when patients say a little bit, I'm not going to have a scar, right? So we will have a scar, we will have it because I mean, we're good, but not magicians. So as we are reducing, we cutting the tissue out, we need to have a scar. But as we do it, we do it very precisely and around areola, it will turn into the real border between lighter skin and darker skin or white skin and pinker skin to be able to be hiding. And I think by doing that, in reality, it's very inconspicuous down the road. You can still see it. You can still find it because the scar exists, but it's really hard to see.

Monique Ramsey (15:36):
And do you have any specific instructions? I mean, I would think the biggest instruction would be to stay out of the sun, don't go nude sunbathing, don't go to Europe to Capri and take off, or in France, wherever they do the topless beaches, don't do that. But what are kind of the things to help women? I think we get obsessed with scars. It's silly, but we do. And that trade-off is that beautiful result in that goal that you want, but what can we do to kind of make sure that we're going to give our body the best chance to heal and make a pretty scar?

Dr. Salazar (16:15):
And that's one of the things that I always tell my patients when the first day out of surgery, the line is so nice, thin and delicate, and it's incredible. But then literally after we finish, take off our gloves, then the patients take over for the healing part. And there's tips and tricks that all patients can do to decrease that scarring process or to make it in a better way. And we guide them through that process. We see them at one day before, one week after two to three weeks after that, and then six weeks. And so we try to catch and see how that scar has continued to heal. And what we do is we recommend how to start the scar therapy, what things to apply, we actually provide for our patients, what we believe is the best serum for scar care afterwards. So there's many, many things that we do to improve the scar, and we ask them to not to be exposed to the sun, not to swim for the first two, three weeks. And of course not to go topless, as you were saying, when they're out in the sun in the first

Monique Ramsey (17:25):
Showing off the girls.

Dr. Salazar (17:25):
Exactly off, they're not ready yet.

Monique Ramsey (17:27):
You can show off the girls, but not quite yet.

Dr. Salazar (17:29):
Not quite yet. They're not ready.

Monique Ramsey (17:31):
So if the areola reduction is done as part of a breast lift or breast reduction, I'm assuming it doesn't change how much time is in surgery, how long, but if it was done on its own, is it a long surgery, short surgery?

Dr. Salazar (17:45):
Depends on the size of the areola, but we're going to, in overall terms, we're going to keep it on the short side of surgeries because you're talking about anywhere between 20, 25 minutes to having a 45 to an hour surgery at the most, if you're dealing with much, much more dilated areola that you're reducing.

Monique Ramsey (18:06):
Now, back to nipples for a second. Could a person still breastfeed after, let's pretend she thought she was done having kids and breastfeeding and she has another child wants to breastfeed. Does the nipple reduction prevent that or does anything change?

Dr. Salazar (18:27):
So there are two different techniques. One that preserves the channels of the nipple and areola more than the other one. One where you take just a little belt around the areola and then you bring it down, and then there's one where you take out a wedge and then you close it. So definitely both techniques are going to reduce the possibility of breastfeeding or being successful, of pushing milk out through the channels that will carry out the ducts that carry out the milk. But in reality, it's rare that someone who is still having kids or in that period of time ask you for a nipple reduction per se. Remember, we're not talking about the areola. When you reduce the areola, the ducts don't get affected. But when you are talking about the reduction of the nipple per se, the ducts get affected. So yeah, it does affect breastfeeding capacities.

Monique Ramsey (19:33):
Okay. What is an accessory nipple and can it be removed? I've never heard this term, so I'm reading the question. I'm like, what's that mean? Is that when somebody who's born with an extra one?

Dr. Salazar (19:48):
Correct. So an accessory nipple or a supernumerary nipple, that's the term that we use, it's an additional nipple. It's an extra nipple. So yes, it can happen. As a matter of fact, it's more common than what we think it is because we, if you think about it, we are mammals and we have something called the mammary line. So the mammary line is a line that comes through the axillary region and then goes through the breast, comes down through the abdomen and into the groin, and along that line, there can be an accessory nipple. And that looks either like a full developed nipple or that looks more like a mole, like a little birthmark that you can actually touch and feel. Now I said it can look like a fully developed nipple, and it can along that line, and also it can come with a fully developed breast. So you can also have accessory breasts along that line. And I mean, the most common place to have them is in the axillary region.

Monique Ramsey (21:04):
So kind of the armpit.

Dr. Salazar (21:05):
Armpit area, so you would have an accessory breast with a nipple and areola. That's much more uncommon, but having accessory nipples along that line that are tiny and small, and patients probably and most likely never knew that that's what they were, they already always thought that they were like a little beauty mark or a little mole.

Monique Ramsey (21:31):
Interesting.

Dr. Salazar (21:32):
It is possible. And then there's another last name to that supernumerary nipple. You can have a nipple that it is ectopic, so that means that it's a nipple that lives outside of that mammary line. So a nipple that you develop, that's an anomalous place to develop it. And the most common place is in the anterior thigh.

Monique Ramsey (21:59):
Really? Anterior. Oh, front.

Dr. Salazar (22:02):
Anterior. Just in front, the front of your leg.

Monique Ramsey (22:04):
Well, who knew? I guess the people who have it know you'd be maybe pretty aware. So then what do you do when all these random nipples show up for, again, I think the percent is probably really low, but do you just remove them and close it up?

Dr. Salazar (22:26):
Yep. You just remove them. I mean, again, if it's only, and everything depends on the size and what we're talking about. If you're just talking about the nipple or nipple with an areola, they tend to be what we call atrophic. They don't tend to resemble a real full-blown nipple and areola with a full blown breast. They tend to be small. So the only thing we need to do is we need to just wedge that tissue out. Of course, you're exchanging the absence of the nipple for just a line, just like a little scar. But we do remove them when patients want them removed. Sometimes, I mean, rarely they're functional because as you're developing, if they're nipples, and maybe it has a little bit of breast tissue behind, it can grow during pregnancy or during puberty and whatever you thought it was like, oh, I feel like there's a little bit of tissue here.

(23:25):
And with that little mole on top, you go, and then it starts developing, it grows. So in that case, then you have to remove the nipple, the areola, and then the breast tissue if you want to do it. Sometimes, Monique, and this is more frequent, and this is something that we hear about it frequently when we do breast augmentations, for instance, that patients say, now, since you're going to do that, the tissue over here, I've always had this little fat pad right here in my axilla, in my armpit. I always had this little fatty tissue there.

Monique Ramsey (24:06):
Little pooch.

Dr. Salazar (24:07):
Little pooch that I would like to have removed. Can it be done? And it depends, in some cases it is a little bit of fat, but in some cases it's more breast tissue that that it's actually closer and related to the axilla.

Monique Ramsey (24:26):
I don't want to say migrated because it's not like it goes from here to there, but it sort of is

Dr. Salazar (24:32):
Extended.

Monique Ramsey (24:33):
Yeah. See, I always thought that was sort of just fat, but maybe that's just me because it is just fat, so you can take care of it. That sounds, exciting.

Dr. Salazar (24:43):
You can take care of it, and you can do, because breast tissue also responds to liposuction, so that's an alternative to take care of it. And then the other thing that you could do also is to wedge it out or excise it, but that's much more aggressive, and that will lead with a big scar. So it's better to do some liposuction to that area to make it better.

Monique Ramsey (25:04):
So Dr. Salazar, tell me what kind of feedback you hear from patients after surgery after they've healed? How are they feeling about the new results?

Dr. Salazar (25:13):
So they're very excited because we all associate smaller areola, smaller nipples with a more youthful look. So definitely is something that patients appreciate and they immediately say, oh my God, look, they're so much smaller. They are nice. Oh, so immediately those reactions, I mean, the patients feel re-energized by a small change, just having an areola reduced, so they're very pleased.

Monique Ramsey (25:44):
And I would assume that these results last forever, right?

Dr. Salazar (25:49):
Correct. Those results, I mean, once we reduce the areola, it's always working with soft tissue, so we take into account that. So for instance, if we reduce the size of the areola to, I don't know, let's say our goal is to go to 50% smaller. We go 45 because it's going to stretch up a little bit, but then the result's going to stay there. Of course, if there's a weight gain or another weight fluctuation, then you're going to have, again, fluctuation in the areola. And with the nipple, it's much more stable with the nipple, what would happen is that definitely it's there, it's theirs.

Monique Ramsey (26:29):
Yeah. Oh, this is so interesting because we really kind of covered a lot between, this is a small part of the body, but an important one, and especially how women feel about themselves and how they look, and just that sort of self-confidence. So thanks, Dr. Salazar. Did we cover everything you wanted to talk about?

Dr. Salazar (26:51):
Absolutely. I think it was very comprehensive. We dedicated a good amount of time to this topic, and it's a topic that, as we were saying it, it's like it's not that frequent that we discussed there, that we touch on it. I think the audience is going to like it, and potential patients may want to give us a call and talk about their areolas and nipples.

Monique Ramsey (27:11):
Right, right. We have free consultations, and so it's wonderful because you can have time with the doctor. Dr. Salazar is just so great about connecting with patients and having that one-on-one time to discuss what changes you might want to make or what are the possibilities sort of. And if you're from out of town, we do virtual consultations. That's completely possible so that you can kind of get those first steps in to find out what the surgery for you might look like and what did it entail. All right, thanks, Dr. Salazar and we'll talk to you all in the next one.

Dr. Salazar (27:50):
Thank you so much for the invitation. Bye-Bye.

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