Infographic comparing two techniques to correct Medially Positioned Nipples

When Nipples “Point In”: A Specialized Technique for Better Positioning

12 Dec 2025





The Challenge of Nipple Position





Breast reduction surgery is not just about making the breast smaller; it is about reshaping it to look proportional and centering the nipple on the new mound.





Most standard breast reduction techniques (like the popular Superomedial Pedicle) assume the nipple is starting from a standard sagging position. But what happens when a patient’s nipples are naturally positioned medially—meaning they sit closer to the cleavage or "point inward"?





In these cases, using standard techniques can be mechanically difficult. Trying to move an inward-facing nipple into a central position can restrict the blood supply or create tension, limiting how perfect the final result can be.





The Solution: The Superolateral Pedicle (SLP)





A new study published in Plastic and Reconstructive Surgery (August 2025) highlights a specific surgical approach designed exactly for this anatomy: the Superolateral Pedicle (SLP).





How It Works





In breast reduction, the nipple is kept alive on a "pedicle"—a bridge of tissue that preserves blood vessels and nerves.






  • Standard Way (Superomedial): The tissue bridge is usually kept on the inner/top side.




  • The SLP Way: For patients with medial nipples, the surgeon keeps the tissue bridge on the outer/top side (Superolateral).





By anchoring the nipple from the outside, the surgeon can more easily swing and rotate the nipple into the perfect central position without fighting the breast's natural tissue resistance.





Is It Safe? The Research Say Yes





Researchers from MedStar Georgetown University Hospital in Washington, DC, reviewed 164 breast reductions to compare the safety of this specialized SLP technique against the standard method.





The Findings:






  • Comparable Safety: The complication rates were nearly identical between the two groups (13.8% for SLP vs. 13.3% for standard), proving that this technique is just as safe as the traditional method.




  • Effective Reduction: The technique worked well for significant reductions, with an average tissue removal of over 700g.




  • No Re-operations: In this specific study group, zero patients in the SLP group required a return to the operating room for complications, compared to 5 cases in the standard group.





Why This Matters For You





Anatomy is unique. If you have noticed that your nipples sit closer to your breastbone or point inward, standard techniques might not offer you the best aesthetic result. This research confirms that your surgeon has a validated, safe "tool in the toolkit" to correct medially positioned nipples and achieve a beautiful, centered look.









Frequently Asked Questions (FAQ)





Q: How do I know if I have "medially positioned" nipples?





A: If your nipples seem to sit closer to your cleavage rather than the center of your breast mound, or if they point inward towards each other, you likely have medial positioning. Your surgeon will assess this during your consultation.





Q: Does this technique leave different scars?





A: generally, no. The Superolateral Pedicle refers to the internal tissue handling. The external scars usually follow the standard "Wise Pattern" (Anchor) or Vertical (Lollipop) shape, just like a regular breast reduction.





Q: Is the recovery harder with this technique?





A: According to the study, complications such as wound healing issues (dehiscence) or fluid collection (seroma) were comparable to the standard technique, suggesting the recovery process is very similar.





Q: Can I still breastfeed with this technique?





A: Like the standard Superomedial technique, the SLP preserves a bridge of tissue carrying blood and nerve supply to the nipple. While breastfeeding can never be guaranteed after reduction surgery, techniques that preserve the pedicle generally offer a better chance than those that do not.









Reference





Lava, Christian X. MS; Li, Karen R. BBA; Episalla, Nicole C. MD; Snee, Isabel A. BS; Bell, Alice C. BA; Fan, Kenneth L. MD; Jabbour, Samer F. MD. "Superolateral Pedicle Breast Reduction for Patients with Medially Positioned Nipple-Areola Complexes." Plastic and Reconstructive Surgery 156(2):p 174e-182e, August 2025.


Infographic on 2022 Evidence Based Safety Guidelines on Reduction Mammaplasty

The New Gold Standard: What the Latest Guidelines (2022) Say About Breast Reduction

11 Dec 2025





Setting the Standard for Safety and Results





Breast reduction surgery (reduction mammaplasty) is one of the most life-changing procedures in plastic surgery, performed on over 100,000 patients annually. To ensure patients receive the safest and most effective care, the American Society of Plastic Surgeons (ASPS) convened a multidisciplinary work group to update their clinical practice guidelines.





Published in 2022, these guidelines reviewed thousands of studies to determine what truly works. Here is what the new evidence means for you as a patient.





1. It Is About Your Symptoms, Not the Scale





For years, insurance companies often demanded a specific weight of tissue be removed (e.g., 500g or 1000g) to qualify for coverage. The new guidelines challenge this outdated metric.





The ASPS now strongly recommends that surgery be offered as first-line therapy based on symptoms, not resection weight.






  • The Evidence: Studies show that relief from back pain, neck pain, and bra strap grooving is not correlated with the amount of tissue removed.




  • The Takeaway: If you have multiple physical symptoms (pain, rashes, grooving) that aren't fixed by non-surgical methods, you are a candidate for surgery, regardless of whether you need a "small" or "large" reduction6666.





2. Drains Are No Longer Routine





One of the most dreaded parts of recovery for many patients is the use of surgical drains (tubes sticking out of the incision to collect fluid).





The guidelines bring good news: Plastic surgeons should not routinely use intraoperative drains for breast reduction patients.






  • Why? High-quality evidence shows no significant difference in complication rates (like hematomas) between patients with drains and those without.




  • The Benefit: avoiding drains means less discomfort during removal, lower costs, and less scarring.





3. Pain Management Has Evolved (Less Narcotics)





The modern approach to breast reduction focuses on multimodal pain management to reduce the need for strong opioids (narcotics).






  • Local Anesthesia: The guidelines strongly recommend administering local anesthetic (numbing medication like lidocaine or bupivacaine) at the surgical site. This significantly improves pain scores immediately after surgery and reduces the time spent in the recovery room.




  • Non-Narcotic Strategies: Surgeons are encouraged to use non-opioid medications (such as Acetaminophen or NSAIDs) to manage pain safely.





4. Technique: The Pedicle Choice





The "pedicle" is the bridge of tissue that keeps your nipple alive and sensitive during the lift and reduction. The guidelines reviewed the two most common techniques:






  1. Inferior Pedicle: The most commonly used, reliable for preserving blood supply.




  2. Superomedial Pedicle: Preserves upper-pole fullness and avoids a long transverse scar.





The verdict? Both techniques are acceptable and effective. There is no significant difference in major complications between them, so your surgeon can choose the method best suited to your specific anatomy.





5. Important Risk Factors





To ensure safety, the guidelines identified specific factors that may increase the risk of complications. Patients should be counseled if they:






  • Are older than 50 years.




  • Have a Body Mass Index (BMI) greater than 35.




  • Use chronic corticosteroids.





Additionally, there is a strong recommendation regarding Nicotine: Patients identified as nicotine users should be referred to cessation programs and encouraged to stop smoking before surgery. Smoking significantly increases the risk of wound healing problems and infection.





6. Antibiotics and Pathology






  • Antibiotics: Extended courses of antibiotics after you go home are generally not recommended. A single dose given before surgery (within 1 hour of incision) is sufficient to prevent infection without causing antibiotic resistance.




  • Pathology: It is recommended that all breast tissue removed during the surgery be sent to the lab for evaluation to check for any hidden abnormal cells or high-risk lesions.









Frequently Asked Questions (FAQ)





Q: Do I have to try physical therapy before surgery?





A: The guidelines state that reduction mammaplasty should be offered as first-line therapy over non-operative treatments. There is no evidence that non-operative management (like special bras or therapy) provides effective long-term relief for breast hypertrophy.





Q: Will I have drains?





A: According to the 2022 guidelines, routine use of drains is not supported by evidence. However, exceptions may be made for specific high-risk cases or if liposuction is also performed.





Q: Does the "Pedicle" technique affect breastfeeding?





A: The guidelines noted that techniques preserving the subareolar parenchyma (the tissue under the nipple) increase the likelihood of breastfeeding success, but more research is needed to compare specific techniques directly.









Reference





Perdikis, Galen M.D.; Dillingham, Claire D.O.; et al. "Evidence-Based Clinical Practice Guideline: Revision: Reduction Mammaplasty." Plastic and Reconstructive Surgery 149(3):p 392e-409e, March 2022.


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Infographic showing Fully Awake Breast Surgery

Awake Breast Reduction: Is General Anesthesia Necessary?

10 Dec 2025





A Revolutionary Approach to Breast Surgery





For many women considering breast reduction surgery, the fear is not necessarily of the procedure itself, but of "going under." General anesthesia, while generally safe, comes with side effects like nausea, grogginess, and a longer recovery time.





However, a study published in Plastic and Reconstructive Surgery presents a compelling alternative: Fully Awake Breast Reduction.





Authors Dr. Simon Filson, Dr. Danielle Yarhi, and Dr. Yitzhak Ramon from Haifa, Israel, successfully performed breast reductions on 25 patients who were awake, communicative, and able to move during the surgery—all without feeling pain.





How Is It Possible?





The secret lies in Thoracic Epidural Anesthesia.





Unlike general anesthesia, which puts the entire body to sleep and requires a breathing tube, a thoracic epidural numbs only the specific area of the body being operated on (the chest). The patient breathes on their own and remains conscious.





The "Awake" Cocktail: Anesthetics and Sedatives Used





To ensure the patient was comfortable, relaxed, and pain-free, the surgical team utilized a specific combination of oral medications and local anesthetics.





According to the study and the accompanying discussion by Dr. Donald Lalonde, the specific protocol included:





1. The "Sedative Cocktail"





Before the procedure began, patients were given these agents to induce relaxation and prevent pain or nausea:






  • Oxazepam : A benzodiazepine used to reduce anxiety.




  • Dipyrone : A strong analgesic (pain reliever).




  • Promethazine : An antihistamine that provides sedation and prevents nausea.





2. The Anesthetic Block (The Numbing Agents)





To perform the epidural block itself, the anesthesiologist used:






  • Lidocaine: Injected under the skin to numb the needle entry point.




  • Ropivacaine : Injected into the epidural space to provide the actual sensory block for the surgery.





Why Being Awake Changes Everything





The benefits of this technique went far beyond just avoiding general anesthesia. Because the patients were awake, they could actively cooperate during the surgery.






  • The "Sit-Up" Test: Patients could sit up on the operating table, allowing the surgeon to check the symmetry and shape of the breasts against gravity in real-time. The patient could even look and give their opinion before the surgery was finished!.




  • Faster Recovery: Patients were able to get off the operating table and walk to the recovery room immediately after surgery.




  • No "Hangover": There were zero reports of nausea or vomiting, a common side effect of general anesthesia.





Expert Debate: "Sedated" vs. "Wide Awake"





This technique has sparked interesting conversations among experts. Dr. Donald Lalonde, a Canadian expert in "Wide-Awake Surgery," applauded the move away from general anesthesia but noted that because sedatives (Oxazepam and Promethazine) were used, the patients were technically "sedated" rather than "wide awake".





Dr. Lalonde suggested that in the future, surgeons might be able to skip the sedatives entirely and use Lidocaine with Epinephrine for the block, making the procedure truly "wide awake" and eliminating the risks associated with sedatives.





The Future of Surgery





Whether using mild sedation or pure local anesthesia, the trend is clear: surgery is becoming safer, lighter, and more patient-focused. If you are considering breast reduction but fear general anesthesia, this study proves that effective, comfortable alternatives exist.









Reference










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Finally, a Solution for Nipple Reshaping Without the Visible Scars

9 Dec 2025





The Hidden Insecurity





While breast augmentation and lifts are commonly discussed, many patients struggle silently with insecurities regarding the nipple-areola complex. Whether due to genetics, hormonal changes, or the aftermath of breastfeeding, common complaints include:






  • Large Areolae: An areola that feels disproportionately large for the breast.




  • Undefined Contours: A lack of crisp definition between the nipple and the surrounding skin.




  • Herniated Tissue: Often called "puffy nipples," where glandular tissue pushes out, creating a dome-like appearance.





For years, patients have hesitated to fix these issues for one main reason: The fear of scarring.





Usual Scars











The Old Trade-Off: Shape vs. Scars





Historically, correcting the shape of the nipple or reducing the size of the areola came with a compromise. Previous techniques, such as the "petal pattern method," were effective at contouring but often limited in how much they could reduce the areola size.





More importantly, these older methods frequently resulted in visible scars from the front. For a patient seeking aesthetic improvement, trading a shape issue for a visible scar was often a difficult choice.





The Innovation: The "Crown-Shape" Method





A breakthrough study published in Plastic and Reconstructive Surgery (June 2025) introduces a refined solution: the Crown-Shape Debulking Method.





Developed by Dr. Ju Young Go and Dr. Won Lee from leading clinics in Seoul and Anyang, South Korea, this technique is a "single-stage" procedure designed to reshape the nipple without leaving obvious marks.





How It Works





The "Crown-Shape" technique is an advanced evolution of previous methods. It involves:






  1. Debulking: Removing the herniated or excess glandular tissue that causes puffiness.




  2. Structuring: Using a specific "crown" pattern to tighten the skin and define the nipple.




  3. Hiding the Evidence: The key innovation is that it allows for significant reduction and reshaping "without visible scars in the frontal areolar area".





Why This Is a Game-Changer





This new Korean technique addresses the limitations of the past. It offers greater control during surgery to ensure the new shape is aesthetically pleasing while minimizing the risk of the problem recurring (recurrence).





Key Benefits:






  • Scar-Free Frontal View: No distracting scar lines on the face of the areola.




  • Effective Reduction: Can handle larger reductions than previous methods.




  • Better Definition: Creates a distinct, attractive nipple contour.





Is This Right for You?





If you have been bothered by "puffy" nipples or large areolas but have avoided surgery because you didn't want scars, the Crown-Shape Debulking method might be the answer. This technique allows for a natural look that stands up to close inspection.









Frequently Asked Questions (FAQ)





Q: What specific problems does this fix?





A: This technique is designed for patients with large areolae, undefined nipple contours, or herniation of glandular tissue (bulging/puffy nipples) around the areola.





Q: How is this different from the "Petal Pattern" method?





A: The "Petal Pattern" was a previous technique that was good for contouring but had limitations in how much it could reduce the areola size. Furthermore, the Petal Pattern often left visible scars when viewed from the front. The Crown-Shape method improves upon this by allowing for better reduction without the visible frontal scars.





Q: Is there really no scar?





A: All surgery involves incisions, but this technique is described as "scar-free" in the frontal areolar area. This means the incisions are strategically placed and hidden so that when looking at the breast directly, there are no obvious surgical markings.









Reference





Go, Ju Young MD, PhD; Lee, Won MD, PhD. "Scar-Free Nipple and Areola Contouring: A Crown-shape Debulking Method for Enhanced Aesthetic Outcomes." Plastic and Reconstructive Surgery. June 20, 2025. Seoul and Anyang, Korea.










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Image depicts infographic of Nipple Sparing Inferior Flap Mammaplasty, the time taken, amount of tissue removed and Blood loss

Relief for Massive Breasts: A Safer, Faster Technique for High-Risk Patients

8 Dec 2025





When Breast Reduction is a Medical Necessity





For many women, breast reduction is about comfort and confidence. But for women with Gigantomastia (massive breasts), the condition is a severe medical burden.





Patients with massive breasts often suffer from debilitating back pain, skin infections, and significant mobility issues. Even more concerning, the sheer weight of the tissue can exacerbate pre-existing cardiac (heart) and respiratory (lung) problems.





For these patients, surgery is not a luxury—it is a necessity. However, because these patients often battle obesity or heart conditions, undergoing a long surgical procedure can be risky.





The Challenge: The 4-Hour Marathon





The most popular traditional methods for breast reduction (such as the McKissock or Robbins techniques) rely on complex internal sculpting. While effective, these surgeries typically require 3 to 4 hours of operative time.





For a patient with heart or lung issues, being under general anesthesia for four hours can be dangerous. Consequently, some women feel forced to consider a Total Mastectomy (complete removal of the breast) just to get relief, or they avoid surgery altogether.





The Solution: Nipple-Bearing Inferior Flap Mammaplasty





A technique published in Plastic and Reconstructive Surgery offers a powerful solution specifically designed for massive weight reduction with maximum safety.





Developed by a surgical team in Preston, England, this technique focuses on speed and blood supply safety.





How It Works





Unlike complex sculpting methods that require separating the breast tissue from the chest wall ("undermining"), this technique leaves the base of the breast undisturbed.






  1. Wide Base: The surgeon creates a wide, supportive base of tissue (the "inferior flap") that keeps the nipple attached to its natural blood supply.




  2. No Grafting Needed: Unlike some rapid reduction techniques that cut the nipple off and sew it back on as a skin graft, this method keeps the nipple connected, preserving its vitality.




  3. Efficient Removal: A wedge of tissue is removed down to the pectoral fascia, and the remaining flaps are brought together securely.





The Results: Faster and Safer





The study followed patients with massive breasts and significant medical problems who underwent this specific procedure. The results were transformative:






  • Drastically Reduced Surgery Time: The average operation took only 88 minutes (compared to the standard 3–4 hours).




  • Massive Weight Loss: The average tissue removal was 2.76 kg (over 6 lbs) per patient.




  • Safety: There was minimal blood loss (less than 500 mL on average).




  • Nipple Survival: Because the nipple was carried on a wide, robust flap, it remained well-vascularized with no complications in the study group.





Is This Right For You?





This technique is ideal for women who:






  • Have extremely large breasts causing medical distress.




  • Have been told they are "high risk" for long surgeries due to obesity or heart/lung conditions.




  • Want significant size reduction without resorting to a total mastectomy.





We believe that health and mobility should never be out of reach. If you are suffering from the weight of massive breasts, contact us to discuss if this rapid-reduction technique is an option for you.









Frequently Asked Questions (FAQ)





Q: Will I lose my nipple sensation? A: This technique is a "Nipple-Bearing" procedure. Unlike a "Free Nipple Graft" (where the nipple is completely detached), this method maintains a wide bridge of tissue connecting the nipple to the body's blood and nerve supply, which helps preserve the nipple-areola complex.





Q: How are the scars placed? A: The incision design usually results in an inverted-U or inverted-L shape on the lower breast. While scarring is inevitable in reduction surgery, the primary goal of this specific technique is massive volume reduction to improve heart and lung health.





Q: Why is a shorter surgery better? A: For patients with pre-existing medical conditions (like high blood pressure, asthma, or obesity), prolonged anesthesia increases the risk of complications such as clots (DVT) or respiratory distress. Reducing the time from 4 hours to roughly 90 minutes significantly lowers this risk.









Reference





Alvi, R. F.R.C.S.I.; Jaffe, W. F.R.C.S.; Laitung, J. K. G. Ch.M., F.R.C.S.Ed.. "Nipple-Bearing Inferior Flap Mammaplasty: A New Technique for Reducing Massive Breasts." Plastic and Reconstructive Surgery 101(1):p 174-176, January 1998.


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More Than Just Shape: Restoring Feeling After Breast Reconstruction

7 Dec 2025
The sensory innervation of the breast is derived from the medial and lateral cutaneous branches of the third through fifth intercostal nerves. These nerves are frequently compromised during mastectomy procedures. While breast reinnervation has been a known surgical option for two decades, its adoption has been limited, largely due to the technical challenge of precisely locating the recipient nerve.
Read More

Thinking About a Second Breast Reduction? New Research Makes “Revisions” Safer Than Ever

6 Dec 2025
In a primary breast reduction, the surgeon creates a "pedicle"—a bridge of tissue that keeps the nipple and areola attached to their blood and nerve supply while the surrounding tissue is removed.

The challenge with revision surgery is that the new surgeon often doesn't know which technique the previous surgeon used. If they cut into the old "lifeline" by mistake, it can lead to Nipple-Areola Complex (NAC) Necrosis (loss of the nipple tissue).
Read More