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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘nipple lift’

Case Study – Breast Implant Surgery with IMF Lowering

Sunday, March 6th, 2016


Breast Sagging classification Dr Barry Eppley IndianapolisBackground: It is well known in breast implant surgery that the final shape of the breasts afterwards is highly influenced by what they looked like before. Besides asymmetry, the most common adverse breast shape problem seen in breast augmentation patients is sagging or ptosis. Such breast mound sagging can occur in many degrees of which most will require some type of breast lift technique to adequately address at the time of implant placement.

The most challenging breast sagging problem in breast implant surgery, in my experience and opinion, is the woman with a more mild or first degree breast ptosis. The amount of sagging they have is not quite enough to justify a breast lift. But there is enough sagging that the implants will likely drive down the nipple on the breast mound in a more downward direction or force most of the breast mound on the bottom side of the implant. This is a particular risk when the patients desires larger breast implant sizes.

In mild cases of breast sagging there are several strategies to help the breast mound and nipple get centered over the implants. The most common approach is to lower the inframammary folds (IMF) to center the implants over the low hanging nipple. An accompanying technique is a superior crescent mastopexy or an upper nipple lift. This simple technique helps move the nipple up on the breast mound up to 1 cm superiorly

Case Study: This 34 year-old female wanted breast implant surgery but had some moderate breast sagging after multiple pregnancies. She did not appear to have enough sagging to warrant a breast lift and did want such scars anyway. She also wanted larger breast implants.

Breast Implant Surgery with IMF lowering results front view Dr Barry Eppley IndianapolisUnder general anesthesia, 650cc silicone breast implants were placed in a partial submuscular plane through inframammary incisions. The original inframammary fold (IMF) creases were still evident above the new fold levels. The original inframammary fold creases were released right under the skin and rigotomies were also done using an 18 gauge needle. Superior nipple lifts were also done.

Breast Implant Surgery with IMF lowering result oblique view Dr Barry Eppley IndianapolisBreast Implant Surgery with IMF lowering results side view Dr Barry Eppley IndianapolisHer postoperative results show a centric nipple position on the enlarged breast mounds. Her nipple lift scars are barely noticeable at this early healing period. The original inframammary fold (IMF) creases are still present. Whether they will ever completely go away and round out remains to be determined.

Management of the persistent fold crease in breast implant surgery when the inframammary folds (IMF) are lowered can be done through several strategies. One technique is further rigotomies of the crease line with underlying fat grafting. Another technique is to reposition the implants up higher and re-establish the original inframammary fold levels.


1) Breasts that have mild to moderate degrees of sagging poses challenges in breast implant surgery.

2) Lowering of the inframammary fold (IMF) is one maneuver in breast implant surgery that can help avoid the need for a more formal breast lift.

3) Persistence of the original inframammary fold crease is one of the trade-offs, as well as the risk of bottoming out, when the inframammary fold is lowered in breast implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nipple Lift with Breast Augmentation

Tuesday, December 1st, 2015


Background: Many women who are to undergo breast augmentation surgery have asymmetric breasts. These asymmetries may be in breast mound size, breast mound shape, amounts of sagging and the nipple position. Preoperative education about how breast implants will impact these asymmetries is of critical importance as breast implants alone will not correct many breast asymmetries. In some cases they make even make them worse. This has led to the well worn phrase in breast augmentation surgery of…’they are sisters, not twins’.

Almost all differences between two breasts, however, are reflected in some degree with the position and shape of the nipple. Nipple size differences can exist but the most important and visually distracting nipple issue is that of a horizontal discrepancy. When one nipple sits lower than the other nipple based on a horizontal line drawn between the two, this is a critical preoperative diagnosis to make. It usually is the result of one breast having a little more sag than the other one and women often state this was the primary suckling breast. This diagnosis is important as the placing of breast implants will always increase any horizontal nipple discrepancy.

Managing a horizontal nipple asymmetry is almost always done through a nipple lift, also called a superior areolar mastopexy. In reality it is just a lift of the superior margin of the areola and has no breast lifting capabioity as suggested by the mastopexy name. This is a simple procedure of skin removal and areolar margin adjustment that has no detrimental effect on nipple sensation or prolongs the recovery from breast augmentation surgery.

Case Study: This 46 year-old Asian female presented for breast augmentation surgery. She has lifelong small breasts of B cup size and wanted to be a fuller C cup. On examination her right breast had more sag and an appreciable lower upper margin of the areola with a 12mms discrepancy.

Nipple Lift BAM results front viewDuring her breast augmentation surgery, 300cc high profile round smooth silicone gel breast implants were placed through inframammary incisions. At the same time a superior crescent of skin was removed above the right areolar to better match the horizontal levels of the nipples.

Nipple Lift BAM results oblique viewRight Nipple Lift Scar Dr Barry Eppley IndianapolisHer postoperative results show larger breasts that appear more symmetric in both size and nipple position. Even though she was of Asian origin, her areolar scar shows on signs of hypertrophy or hyper pigmentation afterwards.

A superior nipple lift is a simple and effective method for improving breast asymmetry in some women undergoing breast augmentation surgery. The preoperative diagnosis of horizontal nipple asymmetry is critical and one that even some women are not aware that they have. Some women may defer to wait after surgery to see whether they want to do it or not. And that is easily done under local anesthesia in the office should they so decide. But bringing it to their attention before surgery and offering the nipple lift option, either during their breast augmentation surgery or after in the office, is sound pre surgical education.


1) Many women have varying degrees of breast asymmetry of which one feature is that of a horizontal nipple asymmetry.
2) A simple nipple lift can be an effective solution to a horizontal nipple asymmetry which will become magnified with the placing of breast implants.

3) A nipple lift is not a breast lift and only changes the upper location of the areolar margin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – One-Sided Nipple Lift in Breast Augmentation

Tuesday, September 1st, 2015

Background: Differences in the size and shape of a woman’s breasts between the two sides is very common. Sometimes the breast asymmetry is very obvious and it is well recognized. Many times, however, the breast asymmetry is more subtle and the woman is not even aware of it. Women tend to pay more attention to breast mound differences than to nipple position differences.

The assessment of the horizontal nipple position in the preoperative breast augmentation consult is critical.  The position of the nipple on the breast mound draws one’s eye to it. As the breast mound increases in size with implants, almost always the differences in the horizontal nipple levels will become magnified. While a women may not have noticed that their nipples were at different levels before surgery, one can be assured that they will notice after surgery when that discrepancy becomes more noticeable.

Nipple Lifts in Breast Augmentation Dr Barry Eppley IndianapolisThe best role that the nipple lift, also known as the superior crescent mastopexy (SCM), plays is in the correction of horizontal nipple differences in breast augmentation surgery. The nipple lift is just that…it lifts the superior level of the nipple up to a centimeter. It is not a breast lift even in the most minor of ways. It can help even out minor horizontal nipple level differences.

Case Study: This 32 year old petite female wanted breast implants to improve her naturally smaller breasts. She had a slight breast asymmetry both in the mounds and in the horizontal level of her nipples. It was decided to perform a nipple lift on the lower side at the time of her breast augmentation.

Nipple Lift Breast Augmnetation results frofnt view Dr Barry Eppley IndianapolisUnder general anesthesia she had Sientra silicone gel gummy bear breast implants of 300cc size placed through inframammary incisions. The left breast had a 10mm nipple lift done through an excision of a superior crescent of skin.

Nipple Lift Breast Augmentation results oblique view Dr Barry Eppley IndianapolisNipple Lift Breast Augmentation results side view Dr Barry Eppley IndianapolisHer postoperative results showed good symmetry of her breast mounds as well as an even horizontal nipple level. The fine line superior areolar scar was still visible at 6 weeks after surgery but will go on to fade by 3 to 4 months after surgery.

The superior nipple lift is a small but valuable breast procedure that can correct one cause of breast asymmetry. If in doubt of its need before surgery it can be delayed until the breast mounds have settled and performed as an office procedure done under local anesthesia.


1) Horizontal nipple asymmetry is not uncommon in prospective breast augmentation patients.

2) Breast implants will most likely magnify a horizontal nipple asymmetry, not even it out.

3) A superior crescent nipple lift at the time of breast augmentation can ensure that the horizontal levels of the nipple improve as the mounds are made bigger.

Dr. Barry Eppley

Indianapolis, Indiana

Male Nipple Disorders and Their Surgical Correction

Monday, July 16th, 2012

The size and shape of a man’s chest can be a source of pride or embarrassment. Much emphasis on the aesthetics of a masculine chest is based on the pectoralis muscular anatomy. While this muscle provides support for the overlying skin, and clearly its size and border outlines are important, the lone remaining aesthetic feature is that of the nipple. While a man’s nipple is usually much smaller than a woman’s, it can have numerous aesthetic deformities which are both bothersome and embarrassing.

The male nipple has the same anatomic features as that of a female, a centrally elevated nipple and a surrounding areola. Men typically have much less nipple projection, even when stimulated, and a thin width to the surrounding areolar circle. This is no surprise given that it has no lactation function and has no purpose in being any larger. But despite its small size, it can have a series of aesthetic problems that men would like improved.

Nipple protrusion, or the overly projecting nipple, is a frequent source of male embarrassment. For some men, the nipple sticks out all the time. For other affected men, the protrusion is only bothersome as it occurs with stimulation, particularly when one is cold. Sticking out through shirts is the common complaint which brings men in for a nipple reduction procedure. Men want a completely flat nipple that does not become erect at all. A nipple reduction is a simple procedure that is performed in the office under local anesthesia. To be more accurate, it should be called a nipple amputation or nipplectomy. While a nub of nipple can be retained, most men want it completely gone and flat. Removing the nipple through a wedge excision to include the ducts and bringing the areolar edges together is the surgical technique.

A different form of nipple protrusion is that of the puffy nipple. The puffy nipple is not protrusion of the nipple but that of the entire nipple-areolar complex. This is caused by breast tissue pushing out from behind. This is known as areolar gynecomastia, a small form of breast tissue enlargement that causes visible projection of the overlying nipple. This is commonly seen in young men who desire a completely flat chest profile. This is treated by an open excisional approach through a lower areolar incision. The breast tissue is directly excised and feathered into the remaining breast tissues beyond the areolar margins. This is the smallest form of gynecomastia that is treated. Care must be taken during the procedure to not over-resect the breast tissue, causing a nipple inversion problem later.

The sagging or ptotic nipple is a problem of older males. As the chest tissues lose volume and sag, the nipple sits much lower on the chest wall. This is caused not by the nipple sagging per se, but by the entire chest skin on which it sists falling off of the muscle and ribs so to speak. This can be improved through a nipple lift procedure. By removing a crescent of skin above the nipple, the nipple is lifted upwards into a higher position. There is a limit to how much movement can be done, often being no more than 10 to 15mms upward. While greater upward nipple movement is possible trough different patterns of skin excision, this results in scars that extend downward from the nipple. This is usually not an acceptable trade-off for most men.

Nipple asymmetry can also occur due to either congenital deformities or some more natural amounts of chest asymmetry. Nipple asymmetries can occur in either horizontal or vertical dimensions. Most commonly, it is the difference in their horizontal positions that is disturbing. It can involve just one nipple or both. Based on the movements needed to move the nipples to more symmetric positions determines where on the nipple circle the crescent skin excision is oriented. Often moving both nipples, splitting the difference in the asymmetry, is the best way to get the most symmetric result.

Male nipple deformities can be easily treated and improved, many of which can be treated  under local anesthesia with virtually no recovery.

Dr. Barry Eppley

Indianapolis, Indiana

The Superior Crescent Breast Lift

Sunday, May 24th, 2009

One of the most important features of a good-looking breast is the position of the nipple on the mound. Ideally placed at the central meridian of the breast, the nipple-areolar complex (hereafter referred to as the nipple) and its position imparts a significant impression about the youthful or aged appearance of the breast. As the nipple drops lower from age or pregnancies, the breast shape becomes defined by the degree of ptosis or sagging. The well-known classification of breast ptosis is based on the vertical relationship of the nipple to the inframammary fold.

Minimal sag or a Grade 1 ptosis (nipple is lower but is still above or just at the level of the lower breast fold) can be improved by repositioning the nipple upward. This is known as a nipple lift or a crescent mastopexy. In this procedure, a crescent shaped section of skin is removed above the areola. The nipple is then pulled upward to a new position and sutured into place. This allows the top of the nipple to be repositioned upward by about 2 to 3 cms. and will move the nipple up about 1 to 1.5 cms. This maneuver usually makes the nipple look slightly larger or elongated.

The crescent mastopexy is the minor form of a breast lift. Because its effect is limited to the nipple and does not change the shape of the breast mound, it is rarely if ever done alone. In my Indianapolis plastic surgery practice, I have observed that it simply doesn’t make enough of a difference to be a stand alone breast procedure. It is always performed in combination with a breast implant/augmentation. The implant causes an increased fullness in the breast mound and the crescent lift moves the nipple up slightly. Their combination is synergistic in making an overall better breast look.

As the nipple and breast sags further, more extensive breast lifts may be needed to achieve an ideal shape and nipple position. However, some women are understandably concerned about breast scars and may not be willing to accept an additional scar burden. In Grade II ptosis, a crescent lift with an implant may still be used as long as the patient is willing to accept less than an ideal result.

Dr. Barry Eppley

Indianapolis, Indiana

Chest Correction (Gynecomastia) in the Male Bariatric Surgery Patient

Tuesday, April 29th, 2008

In the male bariatric surgery patient who has undergone massive weight loss, the resultant chest wall (breast) deformity is often of major concern. The appearance of the male chest, like the female breast, is of understandable significance. This male chest deformity is often called gynecomastia but this is inaccurate and actually signifies a different pathology. Gynecomastia is the enlargement of native breast tissue producing an enlarged nipple-areolar complex to a decent-sized breast. Chest deformity after massive weight loss is a deflation (loss of breast tissue) with resultant skin excess, sag, and a low-hanging nipple. As such, they are quite different from each other in many cases.

In some male bariatric patients, simple liposuction with or without a nipple lift, may be all that is needed. But in many cases, this is simply inadequate. The problem is what to do with the sagging skin and how to get the nipple positioned up higher on the chest……without creating a lot of scarring. (which may be worse than the original problem) In short, there are no easy answers to these issues.

Possibilities for correction include staged, repeat nipple lifts (each time inching it up higher), pectoral implants to add some volume (but you can’t have too much skin or this makes it look worse), or cut-outs of skin along the bottom part of the chest out to the side with the resultant scarring. Either way, getting the nipple up higher and removing excess skin often fights against each other.

Male chest ptosis (sagging) after massive weight loss is somewhat similar to that of the aging male’s chest problem. (but usually with less extra skin) Both are ‘deflation’ issues with low nipple positions. Most of the time a compromise has to be reached. Which is more important….tightening the skin or lifting the nipple? I usually encourage the male patient to avoid any significant scarring on their chest. While cut-outs of skin can very effectively tighten and lift the sagging chest, the resultant scars will usually make you feel no better about your chest problem. If your goal is only to look better in a shirt, then this might be an option. However, I caution the male patient about scarring. Even if they think it won’t matter, there is no magic eraser to take it away later.

As you can see, the male chest in massive weight loss poses a dilemma for which there is no easy solution in the extreme cases. It is the most extreme form of gynecomastia even though it does really represent true gynecomastia. A good in-depth discussion with your plastic surgeon is really needed here. The consequences of plastic surgery must be balanced against the original chest wall deformity to be certain that enough improvement can be obtained to make the surgical experience worthwhile.

Dr Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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