Can the small, thin areola muscle be paralyzed?

[kbob]

Are there any methods for permanently paralyzing the areola muscle?
When my areolas are relaxed all looks good. When they are contracted the whole areola is deformed and significantly protruding.
Counter-intuitively Botox injected into the pectoral muscle apparently causes nipple contraction not relaxation.
Quote from an article (various cosmetic surgeons perform this procedure and they report the nipple contaction): "For temporary breast lift Botox is injected into the pectoralis minor muscles in the chest.  This causes the back muscles to lift up the shoulders and lift the breasts along with them. This also improves posture.  The nipple tend to be erect for 1 month after the treatment."

Any advice, comments?
Thank you,
   Kevin

[Dr. Elliot Jacobs]

There is no sheet or expanse of areolar "muscle" under the areola.  What you DO have is muscle fibers which are contained within the thickness of the skin itself.  That is why the areola crinkles up in all directions when stimulated (emotion, cold, etc).

There is no way to permanently paralyze these individual muscle fibers.  Botox might be used to temporarily be of benefit.  But sometimes, if the areola is really lax, it may precipitate a puffy nipple look.

Dr Jacobs

[Miguel Delgado MD]

I do understand what you explain.  The muscle is very thin and difficult to predict how it will react after surgery. I have thinned and scored the area trying to get it to stay in the relaxed state. It is totally unpredictable.  Hopefully research on this topic can help answer and treat this issue.

[DrBermant]

Are there any methods for permanently paralyzing the areola muscle?
When my areolas are relaxed all looks good. When they are contracted the whole areola is deformed and significantly protruding.
Counter-intuitively Botox injected into the pectoral muscle apparently causes nipple contraction not relaxation.
Quote from an article (various cosmetic surgeons perform this procedure and they report the nipple contaction): "For temporary breast lift Botox is injected into the pectoralis minor muscles in the chest.  This causes the back muscles to lift up the shoulders and lift the breasts along with them. This also improves posture.  The nipple tend to be erect for 1 month after the treatment."

Any advice, comments?
Thank you,
   Kevin

Sorry, there is no good way to paralyze this thin muscle that exists under the areola with extensions into the nipple areola surface. It does function to make the nipple project for breast feeding. In men it normally flattens the nipple on stimulation. In some patients, it projects the nipple. I have yet to see pictures or video of a solution to stop that action. If someone claims to have such a fix, look for at least pictures of the structure relaxed and stimulated. Even better would be a video. I have been looking for years for that solution since I have seen so many patients asking me for that option.

Yes, this structure exists, and is located just under the areola with fibers extending into the areolar superficial structures. I dissect the gland off of it in almost all my male breast reductions where gland is a significant contour contribution. To optimize animation after surgery, I even repair this muscle in a separate layer when it is prominent.

For those that doubt here is one of many references in the literature: Aesthetic Plastic Surgery, Volume 33, Number 3, 298-301,Vazquez et al, The Importance of the Areolar Smooth Muscle in Augmentation Mastoplasty. "We performed dissections of the areola in ten patients undergoing total mastectomy for oncologic reasons. After removing the skin of the areola, the underlying muscle remained totally exposed. Macroscopically, it has a circular shape, copying that of the areola."

There are photographs in that particular article showing the structure.

Back to your original question, be careful of botox injections near important other muscles. It can be a disaster when you need something to work that now is out of action for an extended period of time. I would never offer such an injection for my patients.

Good luck on your investigations.

Hope this helps,

Michael Bermant, M.D.

[kbob]

Thank you Doctors for your answers. I have a followup question.
In a person without gynecomastia and without prior surgery how tightly is the areola held down to the underlying fat and connective tissue? I wonder if in my case the issue is that there is only a very soft connective tissue left under the areola (I had gyne surgery), so any contraction of the areola muscle results in a protrusion because there is no "force" keeping it down.
I was even thinking of having something like Radiesse or Sculptra injected under the areola that would result in a build up of collagen/connective tissue there and thus hopefully creating a more solid structure for the areola to attach to. Any thoughts on this?
Thank you,
   Kevin

[Miguel Delgado MD]

You do have a good analysis.  I have seen when agressive defatting under the nipple is done it can contract and shrink nicely or sometime when a robust muscle is present it can tent up.  I dont think fillers will help this.  it is not firm enough or may not attach well.  Remember, when the periarolar muscle is contracted it can be very strong; almost like a muscle on steroids!

[Miguel Delgado MD]

I was thinking  about your question and it is an excellent one.  How much tissue should a surgeon excise from underneath the areola.  The text books say to leave 1 cm of tissue.  I never do and i would be curious what dr. Berman and Jacob would say.

About 30% of my practice is redos from unhappy patients.  The most common is patients who have liposuction only and the other being fullness under the areola due to tissue left behind.  It is a balancing act. Men want to be fairly flat around the areola if not the protrusion can be seen in a tee shirt.  You must be very careful and experience plays a major role as to how much subareolar tissue to remove. The excision of to much can cause a slight depression or collapse-creasing of the areola and not enough an over protruding areola.

Each case has to be evaluated independently and always ask the patient "how would you like it to look" and to achieve that what are you willing to trade-off.  Many cases are a 'slam dunk'.  Others are not; there may be stretched  areolas,or hanging skin, or poor quality skin, or over weight and the list goes on. 

The treatment of gynecomastia is very challenging and an honor to have men intrust their fate in our hands. Gynecomastia.org is trying to answer some of these question and be available for men,boys and families in need.

[kbob]

Thank you again for your answer.
Can I please ask you (any of the supporting Doctors) to comment on how tightly the areola is held down to the underlying fat and connective tissue in a person without gynecomastia and without prior surgery?

My chest is muscular, I have very little fat, there are no adhesions, but the areolas and the surrounding skin are ... I would best describe it as "floating", like there is nothing underneath bonding it to the underlying tissue

My areolas were not protruding due to the areola muscle contraction prior to the surgery, so I am trying to figure out what happened. Another possibility is that the areola muscle got sensitized. In which case I wonder if with time this will improve (in 1 - 2 years)?

Gynecomastia is a terrible condition. It had a huge impact on my psyche. I thought that I could finally put it behind me with the surgery and forget about it, but surgery is long behind me and I now have yet another problem.

Thank you,
   Kevin

 

[DrBermant]

Thank you again for your answer.
Can I please ask you (any of the supporting Doctors) to comment on how tightly the areola is held down to the underlying fat and connective tissue in a person without gynecomastia and without prior surgery?

My chest is muscular, I have very little fat, there are no adhesions, but the areolas and the surrounding skin are ... I would best describe it as "floating", like there is nothing underneath bonding it to the underlying tissue

My areolas were not protruding due to the areola muscle contraction prior to the surgery, so I am trying to figure out what happened. Another possibility is that the areola muscle got sensitized. In which case I wonder if with time this will improve (in 1 - 2 years)?

Gynecomastia is a terrible condition. It had a huge impact on my psyche. I thought that I could finally put it behind me with the surgery and forget about it, but surgery is long behind me and I now have yet another problem.

Thank you,
   Kevin

The condition of a man who nipple projects when stimulated is rare, yet over the years of seeing so many gynecomastia patients I have seen quite a few such cases. There are no studies demonstrating what is the difference in someone who flattens under stimulation vs. projects and you cannot easily take that rare case and ask them to let me dissect the tissue, like that paper's surgeons did, to see muscle fiber orientation. My guess is that it is in the orientation of the areola muscle fibers that makes the the flattening or projection happen. That means before and after surgery the situation should not change.

I have seen an exception. The male inverted nipple. Male inverted nipple is tethered by the gland to the deep tissues. The areola muscle cannot project something that is tethered.  Removing / releasing the gland permits the muscle to then exert its force without tethering. That would be one mechanism for someone who did not have stimulation projection issues before surgery to develop them after.

There may be other possible causes. That is something I help patients explore during an evaluation after examination. It is difficult for pictures to show such issues and an in office exam is usually better in such atypical cases.

Hope this helps,

Michael Bermant, M.D.
Board Certified
American Board of Plastic Surgery
Member: American Society of Plastic Surgeons and American Society of Aesthetic Plastic Surgeons
Specializing in Gynecomastia and Surgical Sculpture of the Male Chest
(804) 748-7737