Nipple Reduction Using the Modified Top Hat Flap

Background: 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. Methods: 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. Results: 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. Conclusions: 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.