Many patients, whether of slender or of moderate build, commonly complain about puffy nipples. Puffy nipples may be described as an areola (the pigmented skin surrounding the actual nipple) which is elevated, like a round dome or tent, above the surrounding chest skin. When a snug T-shirt is worn, this condition may be extremely embarrassing. Young men are frequently teased about it and some bullies will actually grab the puffy nipples and twist them, causing considerable pain and occasional bruising. Boys will often hide their condition by wearing several layers of shirts or hunching over. They will avoid many activities (swimming, skins vs shirts basketball, etc.) which require them to be topless. The good news is that puffy nipples can be permanently cured – but it does require surgery.
Puffy nipples very rarely exist alone. Usually, they are found in combination with some amount of excess tissue, consisting of a combination of fat and breast tissue (ie gynecomastia)), of the entire chest. Surgery for gynecomastia will always include treatment of the puffy nipples too.
WHAT EXACTLY CAUSES A PUFFY NIPPLE?
The only cause of a puffy nipple is solid breast tissue which is concentrated beneath it and which pushes the tissues upward. Fat alone simply cannot cause a puffy nipple. Some patients try to feel for lumps to determine how much, if any, breast tissue is present. This is entirely misleading because breast tissue itself may feel soft and sometimes fat may feel firm. The best means to self-diagnose the condition is to lie on a flat surface and look down at one’s chest. If the areolas protrude above the level of the surrounding chest skin, then one has puffy nipples.
Sometimes the nipple may appear normal and not puffy. This is due to temporary tightening of tiny muscle fibers within the areolar skin itself. When these fibers tighten, the areola temporarily diminishes in diameter and it literally pushes the tissues deeper into the breast, thereby producing a flatter appearance. What causes this? Anything that stimulates the nipples such as touch, emotional or erotic stimulation or exposure to a cold environment. Unfortunately, these changes are temporary and when those small muscle fibers relax, the puffiness returns.
HOW IS A PUFFY NIPPLE TREATED?
Surgical removal of the excess breast tissue beneath the areola is the only permanent treatment. There are no other treatments that work – not Botox, creams, massage, injections, hormones, etc. Surgery to treat puffy nipples is tricky. If too much breast tissue is removed, it can create a crater deformity (where the areolas cave inwards). And if too little breast tissue is removed, the puffiness will remain after surgery. Just as important, it is imperative that the skin surrounding the areolas be undermined and loosened so that the entire skin/areolar area will re-distribute itself. If this is not done, the puffiness will recur even if breast tissue has been adequately removed because the skin has nowhere to go and it just bunches up again.
Properly performed surgery for puffy nipples will result in an immediate and permanent flattening of the areolas after surgery so that the areolas lie flat and flush with the surrounding chest skin. If the areolas are not flat after surgery, they will never be flat.
ARE PUFFY NIPPLES CONSIDERED GYNECOMASTIA?
Yes. By definition, any excess tissue on a male chest, whether a small amount of breast tissue concentrated under the areola on a slender man or un-mistakeable large breasts on a man, should be termed gynecomastia. It is simply a matter of degree. In fact, most cases of puffy nipples occur on males who have additional excess tissues on their chest.
WHAT ARE ENLARGED NIPPLES AND AREOLAS?
One must differentiate between an enlarged or protuberant nipple stalk (located in the center of the areola). This condition is technically termed “hypertrophic nipples”. Treatment for this condition consists of decreasing the height of the nipple stalk with tiny incisions and fine dissolving sutures on the outside of the nipple. On occasion, puffy nipples and hypertrophic nipples can occur together – and surgery can simultaneously cure both problems.
Oftentimes gynecomastia is accompanied by large, wide areolas, in which case there is just enlargement of the areola itself with no hypertrophic nipples or puffy nipples. The normal male areolar diameter is between 2.5 and 3.5 centimeters (roughly 1 – 1.5 inches). In some individuals, the areolar diameter may be 50 centimeters (2 inches) or more. Some patients request direct reduction of the areolar diameter. This is discouraged because many times the areolar diameter will spontaneously diminish – occasionally dramatically so – when appropriate removal of the underlying gynecomastia tissues is performed. Any attempt to reduce the areolar diameter alone is doomed to a poor result. We generally recommend performance of gynecomastia surgery first and then observation for a minimum of six months. If there is still objectionable width to the areola, then areolar reduction may be considered – but it must be realized that there will be a resultant permanent scar completely around the edge of the areola. And sometimes, these scars can widen and even stretch out the areola once again due to the pull of the surrounding tissues.
WHY SHOULD I CONSULT WITH A GYNECOMASTIA SPECIALIST FOR THIS SURGERY?
Most plastic surgeons see only a few cases of gynecomastia per year – not the hundreds per year that are seen by a plastic surgeon who has demonstrated sufficient interest, experience and expertise in this surgery. This surgery is not routine – it is tricky and every case brings its own challenges – no two cases are the same. Further, surgery for puffy nipples is exceedingly challenging, for oftentimes the excess breast tissue removal will create a divot under the areola. The surgeon must then fill in the divot with fat flaps from surrounding areas – a delicate balancing act of replacing the breast tissue with fat to support the areolas yet not making the areolas protrude and thereby re-capitulating the original problem.
IS THERE AN APPROPRIATE AGE FOR THIS SURGERY?
Surgery for puffy nipples with or without additional excess chest tissues can be done at any age – from age 12 to age 72 or more. For the younger patient, surgery should not be performed unless the gynecomastia has been present and stable for at least two – three years. On the other hand, there is no need to defer surgery until the “magical” age of 18, when according to some ill-informed doctors, the gynecomastia will disappear overnight. Why make a young teen suffer through years of bullying in the vain hope that it will spontaneously disappear? Particularly when properly performed surgery can result in a permanent cure?