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Areola: n. The colored circle of flesh around the nipple.  The areola darkens after the second month of pregnancy and usually enlarges as pregnancy progresses, doing breast growth, weight gain or after breast augmentation. [pl. areolae, areolas]

The areolae can stretch as the breast enlarges, sometimes creating what is considered by many women to be a displeasing appearance.   Many women everywhere have chosen to have their areolae reduced with a procedure which excises the redundant tissue and sutures the breast back together to its smaller, pre-weight gain or -pre-pregnancy form.

 Who Is This Procedure For?
This procedure is suitable for any woman, or man, who wishes to have the size of their areolae reduced and is in good health, has no wound healing disorders, and has realistic expectations.  

 What Are My Options?
The goal of the surgery no matter the technique is to reduce the diameter of the areolae, and sometimes to lift the areolae to a higher position.  If this is the case a breast lift using a peri-areolar incision (also known as a Benelli, or doughnut mastopexy)  is the procedure you will need.  While this procedure is generally speaking the same as an areola reduction, more tissue is removed above the areolae and the nipple complex is moved higher and sutured.

Some plastic surgeons choose to place a permanent suture made from polypropylene, an inert monofilament suture, and sometimes nylon sutures, in a starfish or drawstring fashion.  This is sometimes called a Benelli stitch/suture or purse-string suture.  This suture is intended to reduce stretching of the incision line during the scar maturation process but has its own risks and complications to consider.

Other plastic surgeons choose to use an external suturing technique without the addition of permanent sutures but this technique may have with it the risk of incision stretching if there is much tension present on the breast, say for instance with augmentation or a heavy, large breast.  Obviously there are pros and cons to each technique so be sure to inquire at your consultation.

 What Are The Risks & Complications Of This Procedure?
Inherent risks and complications, such as an allergic or negative reaction to anesthesia are possible.  General risks such as infection, hematoma (collection of blood within the tissue), seroma (collection of fluid in the tissues), tissue necrosis (tissue death) if adequate vascularity is not maintained either during the procedure or during the healing phase are also possible.  Suture breakage and wound separation are possible as well.  Inflammation and non-infected pus may appear around permanent and resorbable sutures.

Numbness, or loss or change in sensation, is to be expected, at least temporarily.  However, numbness can become a permanent complication.  Odd sensations, including burning, prickling, coldness, crawling, etc., during the healing process are common but should prove to be temporary.  In rare instances, increased sensation is possible resulting in a painful, overly-sensitive feeling when touched even by clothing.  Itching and redness may also occur.

Aesthetic complications are asymmetry, hyperpigmented and keloid scarring, and scar stretching.

 Who Should Perform This Procedure?
Choosing a surgeon can be the most difficult and important part of the process.  While many advise only to choose a board certified plastic surgeon, meaning only choosing a surgeon who is a member of the American Board of Plastic Surgery, verifiable on the American Board of Medical Specialties website, there is more to consider before choosing a surgeon.  Please see our special Choosing A Surgeon section with tips on how to locate and decide upon a surgeon to perform your procedure.  This section will launch in a new window for ease of reference and so you don't lose your place.

 What Should I Expect At My Pre-operative Consultation?
Pre-surgical consultations are designed as meetings with surgeons so that you are able to evaluate what they have to offer, their preferred technique, before and after photos, anesthesia preferences and other protocol.  This is a very important step in the surgical process as this is how you will ultimately choose who to book with.

You may wish to ask if you may bring a friend for emotional support when you call or email to book an appointment.  Some surgeons don't allow this practice, while others fully understand and do not mind.  This fact will vary from practice to practice so be sure to inquire ahead of time.  You should also determine ahead of time if there is a consultation fee, more often than not you will have to pay a fee which may range from $50. to $500. to meet with the surgeon.  This fee is usually designed to separate the serious patients from those who are just interested but have no intention of ever having surgery.  Consultations may range from only ten minutes to several hours, depending upon the surgeon and sometimes this duration does not reflect upon consultation cost.

Upon arrival and check-in, you will be asked to fill out paperwork which will include your name, address, contact information as well as the contact information of an emergency contact.  Health information will be taken as well including known allergies, lifestyle (prescription and/or recreational drug-use, alcohol consumption, smoking, etc.).  Completely disclosing any known or possible condition is vital to your safety.  If you are having general anesthesia, something such as asthma or smoking can severely impact your health while you are under.  Also, be very truthful about medications you may be taking or have taken recently.

You will then meet with the surgeon for a physical examination of the body part you are consulting about, as well as discuss your options, the techniques available, anesthesia questions, or anything else you wish to inquire about.  This is an important meeting so do not be afraid to ask the surgeon anything, or give your input in any way.  

After the consultation you may be directed to a patient coordinator's office to discuss fees, financing, etc.  You am either choose to book at this meeting or wait until you are finished consulting with other surgeons.  Estimates are usually only valid for one to six months so be sure to inquire about this before you leave.

 What Are The Average Costs Of This Procedure?
Areola reduction procedures are usually performed in conjunction with breast lifts, breast reductions or breast augmentations in those who have lost volume.  By itself this procedure averages at $2000. to $3,500. and does not include anesthesia, operating room costs, medications or laboratory tests.  Check with each surgeon regarding costs as all practices have different fees and these fees may prove to be less if the surgeon has his or her own operating suite.  Having your procedure in a hospital often increases the associated costs.

 How Do I Prepare My Body For This Procedure?
Once you book your surgery, you are usually asked to come by for a separate meeting called a pre-operative appointment.  This procedure is designed to allow discussion of more concerns, protocol specific to the preparation, surgical and recovery process, pre-operative and post-operative instructions. At this meeting you will receive instructions on what to eat, what to take and how to prepare your body for your procedure as well as how to care for yourself after the procedure.

Typical instructions include cessation of all aspirin or vitamin E-containing products and supplements, as well as cessation of diet pills, alcohol consumption, recreational drug use, and smoking.  You should attempt to get your body in its best condition to decrease your chances of complications.  Complications can arise if you continue to consume alcohol, recreational and some prescription drugs, some supplements, and smoking.  View our chart below to give you an idea of what can happen if instructions are not followed:

Consumption or Activity What Can Happen
aspirin disrupts coagulation; excessive bleeding and bruising
vitamin E disrupts coagulation; excessive bleeding and bruising
smoking vaso-constriction; can disrupt blood flow, poor healing, necrosis
alcohol disrupts coagulation; excessive bleeding and bruising
recreational drugs disrupts coagulation; excessive bleeding and bruising, increases effects of anesthesia 
diet pills and other stimulants disrupts coagulation; excessive bleeding and bruising
other supplements

   

disrupts coagulation; excessive bleeding and bruising, negative impact on liver, increases or decreases effects of anesthesia, vaso-constriction; can disrupt blood flow, poor healing, necrosis

Although many vitamins and supplements can be harmful before and after surgery, there are also helpful vitamins and supplements recommended to stimulate healing.  These may include Alpha Lipoic Acid, Arnica Montana, Vitamin A, Vitamin B Complex,  Bromelain, Copper, Vitamin C or Vitamin C Ester, Chromium polynicotinate, VItamin D3, Folic Acid, L-Carnitine, L-glutathione, MSM (Methyl Sulfonyl Methane), N-acetyl-L-cysteine, Niacin, Selenium, taurine, Thiamine and Zinc.  Please see our Helpful Vitamins & Supplements section.

You should discuss the desired areolae size during this meeting, as well.  The areolae size is usually measured in millimeters in diameter.  Size is usually determined in relation with the size of the breast, or the preference of the patient.  it might be prudent to reduce the desired size a few mm to compensate for natural stretching.  It is often thought of to go too small than go too large as you can always have the scar and areola tattooed (micropigmented) for evenness and for scar camouflage.

Mental preparation is also a good idea as not being prepared for your experience can cause unnecessary anxiety and fear.  Also, not knowing what to expect can cause anxiety when something as normal as bruising and discomfort arises.  Be sure that you know what to expect, what is normal, and what is not so that you are better prepared during your recovery.  Support during this time is vital, so we invite you to join us on our Breast Surgery Message Boards to speak with other patients who may be feeling exactly the same as you currently are or others who have already been through your current phase in the recovery process.

 How Is This Procedure Performed?
When you arrive at the surgery center or hospital, you will be instructed to change into a surgical gown.  You may have already been told you could take an oral sedative such as diazepam or lorazepam to ease pre-surgical anxiety, as well as Zofran, or similar, to lessen the nausea often felt after anesthesia.  You may see your surgeon at this time and discuss anything which you may have thought of over night, you may also then meet the anesthesiologist who is going to administer your anesthesia during your surgery.  Your surgeon may also measure the placement of your areola and make pre-surgical markings with a Sharpie-type pen or similar single use, pre-surgical marker while you are in a standing position.

After you have changed into your gown you may be lead to the pre-surgical area for IV insertion and medication administration.  Once your IV and saline drip is in, your anesthesiologist will be able to infuse medications for nausea or anxiety, and eventually to sedate you and for pain management.  You will have a blood pressure cuff placed around your arm, and monitoring adhesive pads placed on your chest and/or arms; these will be hooked up to equipment which will monitor your blood pressure and heart rate.  You will also have an oximeter placed on your finger or toe which will be connected to this machine.  This device measures the arterial oxygen saturation and will alert the surgical and recovery teams if you are not breathing deeply enough or not getting enough oxygen, in general.  If it is removed, or it doesn't have a proper contact, an alarm will sound to alert the team.  The oximeter is just as important as your heart rate and blood pressure.  If you are not getting proper oxygen saturation, your cells are not receiving the vital oxygen they need to survive.  When this happens, it is referred to as hypoxemia.  Typical normal oxygen saturation is between 95% to 99%, some patients even 100%. 

When your anesthesiologist infuses a pre-surgical sedative, you may feel very relaxed and sleepy.  Many patients go right asleep, others drift in and out of a state of consciousness.  This assists in relieving the tension often experienced by patients before they go into the O.R. to begin surgery.  You may or may not remember this part of your procedure.

After you are anesthetized by your chosen method, and your vitals are determined as stable, your urinary catheter is then placed (which is not always necessary so inquire beforehand).  Your surgeon will begin to scrub the breasts, upper chest, abdomen and side of the ribcage with either Betadine (povidone-iodine, 7.5%), pHisoHex (hexachlorophene, 3% ) or Hibiclens (chlorhexidine gluconate, 4%) or similar-type antibacterial surgical scrub.  This will lessen your chances of a bacterial infections from naturally occurring bacteria such as Staphylococcus aureus (S.aureus) which lives on our skin.

After you are well-scrubbed and draped, your vitals are again determined as stable.  Your surgeon may then choose to draw circles on the areolae and the surrounding breast envelope either freehanded, or preferably, with an areola-stencil.  The size is usually predetermined at your pre-surgical appointment and possibly discussed again right before surgery. 

After the areola circles have been drawn, your surgeon then begins the first incision.  The areola is left on a pedicle [: n. Part of a skin or tissue graft that is left temporarily attached to the original site. pl pedicles] of underlying tissue to maintain a good blood supply.  In the diagram a superior pedicle technique has been used.  A variation might be the superior medial pedicle technique in which the pedicle stems from the 1 or 2 o' clock position.  A pedicle branching from underneath, called an inferior pedicle technique, is also a commonly utilized.  Medial pedicle techniques use a pedicle branching from the center of the chest, and the lateral pedicle technique, branching from the outside of the breast.  Another possible technique is the posterior pedicle where the pedicle is maintained underneath and does not hinder the placement of the areola complex.  You may want to discuss the technique your surgeon plans to use and inquire as to why it may be his, or her, method of choice.

After the tissue is excised your surgeon may choose to use a permanent suture technique as discussed earlier.  This would require suturing of the edge of the outer tissue to the edge areola with a nonresorbable suture material made from polypropylene or nylon.  The suture material is then gathered like a drawstring bag and the areola and breast envelope are drawn together.  This supports the tissue and relieves tension from the incision line as it heals.  After this step is completed, the incision is then fully closed with resorbable sutures.  Your surgeon will then usually apply paper tape, such as Steri-Strips, over the incision line and then you will be dressed in your support bra.

After your surgery is over, your catheter is usually removed and your anesthesiologist will turn off the anesthetic gases and increase the oxygen.  You may then have your endo-tube removed and an oxygen mask placed over your nose and mouth.  You will then be wheeled into the recovery area and your vitals monitored until you are able to breathe well enough on your own without oxygen assistance.  

 What Should I Expect During My Recovery?
Immediately after surgery, you may feel very disoriented, very confused and possibly emotional because of the anesthetics.  If you feel nauseated be sure to let the recovery nurse and anesthesiologist know.  Your anesthesiologist or surgeon may administer an anti-nausea medication intravenously.  The recovery team will continue to monitor your heartrate, blood pressure and oxygen saturation.   After a few minutes, they will begin to say your name to rouse you from your sleep.  If you were intubated, you may notice when you try to speak that your throat may be a little sore, this is a normal sensation due to the endo-tube.

You may also feel nauseated.  You may feel cold or hot depending upon your own body.  If you feel either, do let the recovery nurse know so they can either get you another blanket or remove the heated blanket you may have covering you.  if you feel any pain, do let the recovery team know so that you may be given pain medication, however, you usually will not feel pain because of the local anesthetics.  If you are nauseated you may have to be given pain medication intravenously, but your anesthesiologist may have you wait until you are more aware and capable of speaking clearly.  You will nod off and on during this time and your oximeter may sound if you are not breathing deeply enough, thereby not receiving enough oxygen.  

When you are released is usually determined by your oxygen saturation levels and level of awareness.  When your anesthesiologist and surgeon have determined if you are well enough to leave, you will be released to your caretaker and driven home.  You absolutely can not drive yourself home after a surgical procedure.   You will need a caretaker to assist you by waking you for your meds, to fix you something to eat, possibly assist you in walking to the bathroom if you are dizzy from your medications, retrieving items for you such as ice packs, drinking water, etc.

Day 1
Your surgeon should give you post-operative instructions that you should follow carefully.  These instructions will include activity levels, icing instructions, wound care, personal hygiene instructions, etc.  If you should have any questions or concerns or feel pain which is not manageable, call your surgeon or the on-call nurse immediately.  Should you begin bleeding or vomiting uncontrollably, have your caretaker bring you to the hospitable and call your surgeon or the on-call nurse immediately to have them meet you at the hospital.

You will usually sleep most of the remainder of the day, waking only for medications or bathroom breaks.  You should try to eat something light such as soups, Jell-O or protein shakes (although please check the labels carefully for problematic additives such as high levels of vitamin E or other anti-coagulants).  Eating will help keep nausea at bay and keep your strength up as well.  You should also be drinking plenty of fluids.

You may feel more alert later on that night and feel like watching TV or reading a book.  However, do not over-exert yourself any time during your recovery.  Even if you feel well, you mustn't cause your blood pressure or heart rate to raise as this can cause a hematoma to occur.   You will more than likely have slight to moderate bruising, as well as swelling and breast tenderness.  Any discomfort should be alleviated by your prescribed pain medications.  Should any severe pain develop, please contact your surgeon or the on-call nurse as soon as you can.

More than likely, you will just sleep, waking only to eat, take medications or go to the bathroom.  Be sure to take your temperature regularly.  A high temperature could mean an infection.

You should not lift any items over 3 lb., nor should you bend over nor reach above your head.  Do be careful when walking up or down stairs, or even so much as down the hallway to the bathroom.  Your medications can make you dizzy and possibly cause you to fall.  Wearing a shirt which buttons or snaps in the front is recommended.

If your hair is long, keeping your hair in a ponytail or braid is recommended as your hair can become quite tangled.  This will keep your hair tangle-free and out of your face.

You may notice sensations such as sharp pains, tingling, tickling, intermittent throbbing and other sensations during the course of your recovery.  Know your body, although these are usually normal, anything intolerable could be a warning sign.

Day 2
By the next day you may feel more alert and active.  Remember not to over-exert yourself in any way, as you are still at risk for a hematoma.  Your appetite may be increased and you may doze off throughout the day.  Continue to take your medications and temperature regularly.  Your surgeon's instructions should guide you throughout the course of your recovery.

Day 3 - 5
You will notice your awareness and restlessness will increase during these days, as well as your appetite.  Should your medications make you nauseated, you should take them with food if directed.  Be sure to continue drinking plenty of fluids.  Your surgeon might have you begin showering a few days after surgery.   Sponge baths may be taken before then if you feel as though you are in need of freshening up.  

Day 7 - 10
Your first scheduled post-operative appointment is usually within 5 to 10 days, depending upon your surgeon's protocol.  Your surgeon will be able to evaluate your recovery and make any adjustments in your care.  Your surgeon may or may not change the bandages or have you remove them completely.

Any remaining swelling, bruising and tenderness will usually dissipate over the next few weeks.  Your resorbable sutures may begin to fall out by now, if not your surgeon may have you return for removal or instruct you on removing them yourself.  If irritation develops around the sutures, please let your surgeon know.

Day 14
Your bruising should be faded or almost faded by now, however this will depend upon your body's propensity towards bruising.  You will notice the incisions will begin to darken and begin to enter the unattractive stage.  This should last about 3 months. The scars will get worse usually before they get better, so patience is a necessity during the recovery stage.

You should no longer need pain medications and should have well completed your course of antibiotics by now, barring any problems which require additional medications, of course.  You are usually still under activity restraints for another week and should still be wearing a supportive bra.  Support is vital during the scar maturation stage.  

Day 21
Oftentimes, activity restraints are lifted at the 3 week mark, but always listen to your own surgeon.  Should you be allowed to return to normal activity levels, please do so cautiously.  You may find that you tire easily during this stage as your body is still recovering.  You may feel as though you can sprint a mile, it is often advised you should not.  Go easy and always wear a supportive bra or other garment which supports your breasts.

You may still notice odd sensations throughout the course of your recovery.  This will occur as your feeling returns and your body heals.

What To Look Out For
Please contact your surgeon or the on-call physician immediately if you notice any of the following: 

  • bleeding from your suture lines 

  • pus or cloudy discharge from your incision areas, nipples or elsewhere 

  • a foul odor from your incision areas, nipples or elsewhere 

  • uncontrollable pain 

  • blisters or implant extrusion (if applicable) 

  • bottoming out of the implant (if applicable) 

  • displacement of the implant (if applicable) 

  • temperature over 100.5 F 

  • inability to pass waste (both liquid and solid) 

  • numbness of the legs (unless you had lipo as well) 

  • uncontrollable dizziness not related to the pain relievers 

  • deflation (if applicable) 

Please contact your surgeon or the on-call physician AND go to the emergency room as soon as possible if you notice any of the following:

  • passing blood through urine, feces or spitting up blood 

  • abrupt and severe swelling and discoloration (aside from normal swelling) 

  • blackening of the skin (which is clearly NOT a bruise) 

  • uncontrollable vomiting 

  • loss of consciousness not related to sedatives 

  • temperature over 105 F 

  • convulsions 

What to do in case of a complication:

  • #1 STAY CALM 

  • Have your emergency numbers handy and contact, or have your caretaker contact, your surgeon or the on-call physician to let them know of your problem as soon as you can. 

  • If you are going to the emergency room don't forget to tell your surgeon WHICH hospital 

  • Bring all of your medications with you to the hospital 

  • It may be cautionary to pack an overnight bag ahead of time "just in case" 

  • If you are able, keep a written journal (and if possible photos) of your symptoms and complaints 

Scarring Concerns
This procedure will result in scars around, at the rim of, or on the areolae itself.  For some this may be faint, for others, very obvious.  Depending upon your body's healing capability, this scar may result in a thin, light line or a darker red, or raised scar.  Clearly, there are several stages of scar tissue development, often the redness of the incision line is most visible at three (3) months post-surgery.  After this stage the scar may continue to fade and the tissue flatten.  Please discuss scar treatments with your surgeon in advance so you know what to do while the scar tissue is forming, instead of after when it can be too late.  Please see our Scar Treatment Section for more information.

Scars can also result in a hypo-pigmented [: lacking pigment, or color] line in some patients, resulting in lightened areas of skin where the melanin production has been compromised.  Areola tattooing, also know as micropigmentation, can counter these effects by depositing pigments into the scar tissue thereby blending the lightened parts into the surrounding tissue.  Please know that scar tissue is more difficult to tattoo than normal skin so be sure to choose a micropigmentation technician who is well-experienced in tattooing scar tissue.  Please see our Areola Repigmentation Section for more information.

 Anything Else I Should Know?
Temporary and permanent puckering may be an issue in areola reduction surgery.  This results in an appearance similar to the gathered section of a drawstring bag.  Oftentimes, puckering dissipates between the second and 6th week, others may take longer.  Steri-Strips, or other paper tape may assist in hastening this process, however, fluid can also collect under paper tape so use caution and only under your surgeon's advice.

Revision surgery is possible, although uncommon.  In the event of a revision surgery, this can also be performed under local anesthetic only in-office and require very little downtime. 

 Inflammation of the permanent suture, if utilized, is also a possibility and should be watched during the initial recovery stage.  Although, always an infection possibility, delayed infection is very rare.  Inflammation, however depends upon the individual.  This may result in wound opening, pus or weeping, and raised scar tissue under the areola wherever the underlying permanent suture is.  If this continues, do alert your surgeon.  Inflammation soon ceases after the removal of the nonresorbable suture.

Irregular scarring may be an issue for some patients.  If this should occur, there are options available.  Again, please see our Scar Treatment Section if this turns into a permanent issue.

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(Updated on 02/25/10)
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