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Ideas and Innovations

The 4-flap Jester’s Hat Technique for Nipple Reduction

Economides, James M. MD; Pittman, Troy A. MD

Author Information
Plastic and Reconstructive Surgery - Global Open: February 2017 - Volume 5 - Issue 2 - p e1233
doi: 10.1097/GOX.0000000000001233


Macrothelia, or nipple hypertrophy, is a condition that may cause severe psychological distress to those who suffer from it. Patients most often experience embarrassment when wearing tight-fitting or light-colored clothing as well as swimwear or sports apparel. Efforts to conceal prominent nipples through taping or padding may lead to chafing or ulceration that causes physical discomfort in addition to psychological distress. Typically, this condition manifests itself during adolescence or pregnancy and may have a hereditary component.1

Although not well categorized, previous reports suggest ideal nipple proportions to be approximately 1 cm in diameter with 1 cm of projection and in a ratio of 1:3.6 nipple-to-areola diameter.2

Numerous reports on nipple reduction exist including the circumcision, geometric nipple, triple-flap, sinusoidal, “Chullo-Hat,” and top hat techniques.3–7 Although effective in their primary goal of reducing nipple diameter and projection, these techniques suffer from imperfect aesthetic outcomes with noticeable scarring patterns, anatomically anomalous shape, and a smoothing of the natural texture of the nipple. We propose a simple technique to nipple reduction that improves upon previous techniques and creates a more naturally appearing nipple.


Surgical Technique

The reduction technique involves the creation of 4 symmetric triangles with apices at the midpoint of the nipple (Video 1). (See video, Supplemental Digital Content 1, which demonstrates the 4-flap “jester’s hat” technique for nipple reduction. This video is available in the “Related Videos” section of the Full-Text article on or available at The desired projection of the nipple is determined preoperatively and marked at 4 points reflecting each of the cardinal directions. These 4 points will correspond to the bases of the resulting triangles. A 3-0 nylon suture is placed between the 2 points comprising the North–South axis and held taut with the surgeon’s nondominant hand. An 11-blade scalpel is then used to excise a wedge of tissue perpendicular to the North–South axis, thus creating 2 semicircular flaps resembling a clamshell. Next, a 3-0 nylon suture is sewn between the 2 points comprising the East–West axis and again held taut in the nondominant hand. A similar wedge of tissue is now excised using an 11-blade scalpel, this time perpendicular to the East–West axis. The resulting 4 triangular flaps now resemble a jester’s hat. The 4 points are sewn together with a 4-0 chromic suture, creating an aesthetically pleasing and anatomically accurate nipple (Fig. 1).

Video Graphic 1.
Video Graphic 1.:
See video, Supplemental Digital Content 1, which demonstrates the 4-flap “jester’s hat” technique for nipple reduction. This video is available in the “Related Videos” section of the Full-Text article on or available at
Fig. 1.
Fig. 1.:
Postoperative clinical image after 4-flap “jester’s hat” reduction of nipple demonstrating natural appearing texture of nipple.


This technique was performed on 4 patients at our single institution over the past year (Figs. 2, 3). All patients experienced symptoms of psychological distress related to the size of their nipples after breastfeeding before presentation. Each patient underwent reduction of their nipples with an average follow-up of 6 months. All patients were pleased with their results and would undergo the procedure again. No surgical complications occurred during the follow-up period, and all patients maintained nipple sensation postoperatively.

Fig. 2.
Fig. 2.:
Preoperative clinical image demonstrating nipple hypertrophy and pronounced nipple projection.


In our experience, previously described techniques in nipple reduction result in poor aesthetic outcomes, which include noticeable scars and alterations in the natural texture of the nipple. For example, the similarly described “Chullo-Hat” technique relies on the creation of 2 fish-mouth–type flaps for nipple reduction, and when sutured together, it resembles the appearance of a clamshell with a linear scar traversing the diameter of the nipple.7 The 4-flap “jester’s hat” technique for nipple reduction is a modification of this and other previously published techniques that allows for a more anatomically congruent and aesthetically pleasing result.5 The incorporation of 4 triangular flaps, which are cinched together centrally, not only hides scars within the nipple but also recreates the natural rough appearance of the nipple. This technique is easy to learn and reproduce and versatile in its application, allowing for reduction of any size nipple. In our small series of patients, all were satisfied with their results and would undergo the procedure again. Importantly, nipple sensation was maintained in all patients, and none experienced any postoperative complications. This technique will be a valuable tool in the breast surgeon’s armamentarium and can supplement other techniques when applicable.


The 4-flap “jester’s hat” technique of nipple reduction is an easy and predictable option for nipple reduction in macrothelia, which creates an anatomically accurate and aesthetically pleasing result.

Fig. 3.
Fig. 3.:
Postoperative clinical image after 4-flap “jester’s hat” reduction of nipple demonstrating decreased nipple projection.


1. Regnault P. Nipple hypertrophy. A physiologic reduction by circumcision. Clin Plast Surg. 1975;2:391–396.
2. Lai YL, Wu WC. Nipple reduction with a modified circumcision technique. Br J Plast Surg. 1996;49:307–309.
3. Cheng MH, Smartt JM, Rodriguez ED, et al. Nipple reduction using the modified top hat flap. Plast Reconstr Surg. 2006;118:1517–1525.
4. DeBono R, Rao GS. A simple technique for correction of male nipple hypertrophy: the “sinusoidal” nipple reduction. Plast Reconstr Surg. 1997;100:1890–1892.
5. Basile FV, Chang YC. The triple-flap nipple-reduction technique. Ann Plast Surg. 2007;59:260–262.
6. Lee EI, Withers EH. Geometric nipple reduction technique: an approach to management of nipple hypertrophy. J Plast Reconstr Aesthet Surg. 2014;67:1301–1303.
7. Sim HB, Sun SH. Nipple reduction with the Chullo-Hat technique. Aesthet Surg J. 2015;35:NP154–NP160.

Supplemental Digital Content

Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.