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Category: Breast Augmentation

Improving Nipple Projection: Surgery for Inverted Nipples and Flat Nipples

Inverted nipples are surprisingly common, occurring in 3 – 5% of women. Instead of the nipple “pointing out,” it retracts inward, usually due to tethering bands of fibrous tissue. Most women with inverted nipples have a normal amount of nipple skin; it’s just pointing the wrong direction.

Inverted nipple repair
inverted nipple front before inverted nipple front after
Before After


Flat nipples are also quite common. This entails a lack of nipple projection due to a lack of nipple skin. Flat nipples are not tethered; they just remain flat despite heat, cold, and stimulation.

Flat nipple repair
flat nipple side before flat nipple side after
Before After


Surgical treatment of both inverted nipples and flat nipples is essentially the same. Over the last 20 years, my technique has evolved to utilize very small incisions for these repairs.


Surgical sequence (about 30 minutes per nipple in the office under local anesthesia):

  1. I mark the outer border of the nipple. In women with flat nipples, this outer border will be widened, in order to recruit adjacent pigmented areolar skin to become nipple skin.
  2. We provide laughing gas (70% nitrous oxide) to help you feel tipsy.
  3. Local anesthetic is injected to the surgical site. After this, you will experience no pain.
  4. Two sutures are placed in the center of the nipple to enable traction.
  5. A small incision (about 3 mm or 1/8th inch) is made adjacent to the nipple.
  6. Fibrous bands are divided to “release” the nipple, enabling improved nipple projection.
  7. An absorbable “purse-string” or drawstring suture is placed around the base of the nipple, further improving projection and preventing recurrent retraction or flattening.
  8. The 3 mm incision is closed with two or three absorbable sutures.
  9. A surgical dressing is applied to protect the repair and to splint the nipple in its new projecting position. The dressing “sticks out” quite a bit, so we usually refer to it as “the Madonna bra.”


Postoperative recovery:

  1. You can drive yourself home. The laughing gas wears off in about 10 minutes.
  2. We will remove your Madonna bra dressing and the traction sutures one week after surgery. Your nipple correction should be immediately apparent.
  3. You will treat the 1/8” incision with antibiotic ointment for about another week.
  4. You will need to avoid compression of the nipples for about 6 weeks. This means going without a bra or cutting large holes in the center of an existing bra.


Keep in mind that the sole purpose of surgery for flat or inverted nipples is to improve their appearance. Women with these conditions are frequently unable to successfully breastfeed prior to surgery—and will generally be unable to do so after surgery.


Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

Going Bigger With Breast Revisions

Breast enlargement, including breast augmentation revision, is the most frequently requested procedure in my practice.  Now in practice in Plano for 18 years, I am on track to perform about 150 breast augmentations this year.  In large studies, approximately 95% are happy with their choice to undergo surgery, which makes breast augmentation one of the more successful cosmetic procedures.  However, as with any other surgery, there are certainly risks, such as infection, bleeding, implant deflation, and capsular contracture.

Although most women are afraid of going “too big,” many become accustomed to their new, fuller breasts and wish they had gone even larger.  The downside is that this requires another surgery.  The upside: assuming that a. the only purpose of surgery is to go larger (i.e. you are otherwise happy with your results), b. you are not choosing an “out-of-control” size, and c. you have smooth-surfaced implants:

1. The procedure is generally straightforward.  I remove your existing implants (usually through your existing scars) and place new, larger implants.

2. The results are predictably good.  The existing capsules of scar tissue that surround your implant will limit further descent of the implants.  What does this mean for you?  More cleavage and more fullness of the upper breasts.

3. The recovery is easy.  We are simply doing a “software exchange,” so the pain is limited to the site of the incision.

4.You do not have to worry about the implants starting “too high.” To a large degree, what you see is what you get. Why?  The tissues overlying the implants were already stretched by the previous surgery, so no further stretching is necessary.

Now let me emphasize, once again, that the upsides listed above only pertain if we make three assumptions:

a. You are otherwise happy with your results.  If you are dissatisfied with your implant position, breast shape, or something else about your breasts–besides the size, the surgery may be more complicated.

b. You are not choosing an “out-of-control” size.  Remember that your body has formed capsules of scar tissue that surround and support your implants. If you choose a size that is larger than your existing scar capsules can contain, you will require a capsulotomy (surgical cut in the capsule) to make more room.  While this is certainly feasible, it increases the complexity of the surgery and reduces the predictability of the results.

c. Your existing breast implants have a smooth surface.  Smooth surface implants will not “stick” to the surrounding capsule, so there is generally room for further enlargement.  Textured implants (the surface is textured like wallpaper) do stick to the surrounding capsule, so further enlargement will require a capsulotomy (see b. above).

The bottom line: assuming that a capsulotomy is not required, further enlargement of the breasts is generally a straightforward procedure with predictably good results and a smooth recovery.

Breast Augmentation Revision going to larger Saline Implants

Before / After

Before / After

Before / After

Before / After


**Initial breast implants placed by another surgeon

Breast Augmentation Revision going to larger Silicone Gel Implants


Before / After

Before / After

Before / After


**Initial Implants placed by another surgeon.

Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

Are My Breast Implants Too High? (Part 2)

“Dr. Friedman, aren’t my breast implants still too high?”

If you read part 1 of this blog, you already know that breast implants placed below the pec major muscle tend to look too high for up to six months to a year after surgery.  This is normal and generally resolves with stretching of the muscle.  But what if you had breast augmentation performed over a year ago and your implants still look too high?  Here are the possible causes and treatment options:

1.     The implants really are too high.  Most implants eventually end up in the right place, but some really do stay too high.  This can involve one or both breasts.  After a year, it is unlikely that the implants will descend much further without surgery.  The surgery involves removal of the implants, release of the lower part of the capsule of scar tissue below the implants (inferior capsulotomy), and placement of new implants.

Before / 1 year After Surgery / After Capsule Release

Before / 1 year After Surgery / After Capsule Release

This patient’s left implant position remained too high at a year after her breast augmentation. Dr. Friedman released the lower part of her capsule and placed a new implant which allowed the implant to fall to a more desirable position.

2.     The breasts are too low.  Sometimes the implants are in good position, but the breasts are too low.  There are two possible reasons:

a. The breasts started out with some sagging, and you may have benefited from having a breastlift or mastopexy at the time of your augmentation

b. Your breasts may have fallen in the years following your breast augmentation, perhaps due to childbirth or weight changes.  If your implants remain in good position but your breasts have descended, the implants will look high relative to the breasts.

Regardless of the cause (a or b), the proper surgery is a breast lift.  It would be unwise to release the capsule under the implants, causing them to drop to the level of the breasts.  Instead, it would be better to raise the breasts to the level of the implants.


Before / After (1 month)


Before / After (1 month)


 This woman had breast augmentation performed elsewhere (before). Dr. Friedman performed a breast lift resulting in significant improvement in the contour and symmetry of her breasts (after).

3.   You have capsular contractures.  It is normal and desirable for your body to form scar tissue around your implants.  This “walls-off” the implants from the surrounding tissues and helps support the weight of the implants on a long-term basis.  However, if the capsule becomes too thick and tight (capsular contracture), it will cause one or both implants to look too high, tight, and firm.  The treatment of capsular contracture involves releasing (capsulotomy) or removing (capsulectomy) the capsule and placing new breast implants.

Before / After (2 weeks)

Before / After (2 weeks)

Before / After (2 weeks)

Before / After (2 weeks)


In order to achieve a more natural appearance of the breast, Dr. Friedman released her capsules and replaced her breast implants.

Some women will present with one or more of these problems (implants too high, breasts too low, capsules too tight) and will require a combination of procedures to address their concerns.

Before / After (2 weeks)

Before / After (2 weeks)


Before / After (2 weeks)

This patient underwent prior breast augmentation by another plastic surgeon with 270-cc subglandular saline implants complicated asymmetry, bottoming out, and bilateral capsular contractures. Dr. Friedman performed capsulectomies and conversion to 390-cc total submuscular saline implants and mastopexy.

Are My Breast Implants Too High? (Part 1)

“Dr. Friedman, aren’t my breast implants too high?”

I am asked this question at least a couple times a week.  And the answer is “Yes, they are too high.  But don’t worry; it’s normal.”

All breast implants placed under the pectoralis major muscle will start out too high and tight.  It takes time for the muscle to expand in response to the stretch of the underlying implants.   Not only is this normal, it is also exactly what we want.  All implants will fall after a first-time breast enlargement surgery.

If your implants start out too high, they will probably end up in good position within six months to a year.

If your implants start out in good position, they will probably end up too low within six months to a year.

The before-and-after breast augmentation photos below illustrate the normal descent of submuscular saline and silicone gel breast implants following breast augmentation.

Saline Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Silicone Gel Breast Implant Sequence:


Before / 1 week / 1 month / 7 months

Breast Augmentation with Lift Sequence:


Before / 1 week / 7 months / 2 years


Before / 1 week / 7 months / 2 years

If you’re wondering whether the implants keep falling after a year, the usual answer is “no.”  Why not?  The muscle has been maximally stretched by the implants, and your body has formed a capsule of scar tissue around the implants that prevents further descent.

If it has been over a year since your breast augmentation and your implants are still too high, read my next blog for an explanation of possible reasons and treatments.

Wearing A Bra After Breast Augmentation

When a patient comes in and ask if she needs to wear a bra after breast augmentation surgery the basic answer is 1. no, 2. yes, and 3. maybe.

 What am I talking about?

1.     No.  Right after surgery, I do not have my breast augmentation patients wear a bra.  Why not?  I am obsessive about making sure that there is absolutely no bleeding before I finish surgery.  Therefore, compression of the breasts with a bra or ACE bandage is unnecessary—and probably quite uncomfortable.  In addition, your implants will start out too tight and too high (please see blog, “Are My Breast Implants Supposed to Be This Tight and This High?”).  If your breasts are already too tight and high, they really don’t need the additional support of a bra.

2.     Yes.  Within a few weeks of surgery, your implants will settle to some degree.  Once they look as if they “belong” on you (and no longer look “funny”), you should begin wearing a bra close to 24/7 (yes, that means sleeping in it too).  Ideally, you should wear a sports bra that fastens in front and has no under wire. The bra should be worn all the time until you are 6 months post-op.  Why 6 months?  Your body will form a capsule (thin scar surrounding the implant) that will take approximately 6 months to mature

     Image provided by Intuition

3.     Maybe. Once the capsule surrounding your implants matures, it acts as an “internal bra,” supporting the implants.  If you had minimal breast tissue prior to surgery, regular use of a bra may no longer be required.  On the other hand, if you had a moderate amount of breast tissue before surgery, you may still want to wear a bra (but not 24/7), since the capsule will only support the implants (and not the overlying breast tissues).

Summing it up, the implants will hold themselves up at first.  Once the tissues relax, you will need an external bra for about 6 months.  After 6 months, the scar tissue surrounding the implants will act as an internal bra.

Ronald M. Friedman, M.D.

Director, West Plano Plastic Surgery Center

Former Chief of Plastic Surgery, Parkland Memorial Hospital, Dallas

© 2018 Ronald M. Friedman, M.D., P.A.

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