Postpartum - Inverted nipple

I didn't realize it was the Breastfeeding Week till I jumped upon a newspaper dated 1st August left in the on call room. Busy with on-calls, and having some inception (possibly from the Higher beings) that my wife going into labor soon, coupled with being in-charge of a small role in a course, I guess to actually write anything solid in conjunction with Breastfeeding Week would be a Herculean task.

Postpartum problems, especially involving breastfeeding, don't usually stump me too much along the way till when the time I was informed about a new mother unable to breastfeed due to a retracted nipple. At that time, I was a green junior medical officer. The senior nurse taught me the method of reversing the 10cc syringe and vacuumed the nipple out. And the patient did it successfully under the coaching of the particular experienced staff nurse.

I looked up the wide web and pimped a notable entry on retracted nipple, hoping to enlighten others.

Inverted Nipples

As many as 2-10% of American women have at least one inverted nipple. Most cases of inverted nipples are congenital - some people are just born that way. However, some nipples become inverted after breastfeeding when scar tissue builds in the milk ducts. The anatomic defect lies in the relative shortness of the lactiferous ducts, which tether the nipple and prevent it from projecting. (photo credit)

There are different degrees or grades of nipple inversion.

• Grade 1: The inverted nipple is easily pulled out, maintains its projection fairly well without traction. Gentle finger pressure around the areola or gently pinching the skin causes the nipple to pop back out. It is believed to have minimal or no fibrosis. There is no soft-tissue deficiency of the nipple. The lactiferous duct should be normal without any retraction (photo)
• Grade 2: The inverted nipple can be pulled out, but not as easily as in Grade I. After releasing traction, the nipple tends to fall back and invert again. Grade II nipples have a moderate degree of fibrosis. The lactiferous ducts are mildly retracted but do not need to be cut for the release of fibrosis. On histologic examination, these nipples have rich collagenous stromata with numerous bundles of smooth muscle. Most inverted nipple will fall into this category. (photo)
• Grade 3: The nipple is severely inverted and retracted. It is very difficult to pull out these nipples manually. Despite application of pressure on the nipple to force it to protrude, it promptly retracts. A traction suture is needed to hold these nipples protruded. The fibrosis is remarkable and lactiferous ducts are short and severely retracted. The bulk of soft tissue is markedly insufficient in the nipple. Histologically, there are atrophic terminal duct lobular units and severe fibrosis.

Surgical Correction of Inverted Nipples

Correction for inverted nipples can be done on an out-patient basis. A patient may opt for local anesthesia, intravenous sedation and local anesthesia, or general anesthesia. Several different techniques have been developed and currently are in use for correction of the inverted nipple. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. (sketch is from the 2nd article)

Grade I--a non-incisional, purse-string suture technique

• The nipple is popped out manually. A small vertical incision (2 to 3 mm) is made at the 6 o'clock position at the base of the nipple. By using 5-0 nylon with a straightened needle, a purse-string suture is placed around the neck of the nipple. The knot is buried under the skin. One stitch is enough to close the skin

Grade II--will require a technique that releases the fibrosis and a purse-string suture

• The nipple is pulled out manually, and a 4-0 nylon traction suture is used for easy handling. An incision is made at the 6 o'clock position and deepened to the breast parenchyma. The fibrous tissues are released in the vertical direction by using scissors, andall lactiferous ducts are identified and preserved. Fibrosis is released to a degree that the nipple can maintain its projection without any traction (this is very important). An intradermal purse-string suture is done by using 5-0 nylon. Care should be taken not to apply too much force, which could compromise the blood supply of the nipple.

Grade III--requires a technique that releases the fibrosis, often the ducts will need to be cut, dermal flaps will be needed along with the purse-string suture

• The nipple is pulled out forcibly by using a traction suture. The neck of the nipple is marked. Two or three deepithelialized flaps are elevated at the 10, 2, and 6 o'clock positions. The deepithelialized dermal flap is bigger than the skin excision. The tissue beneath the nipple is dissected, and the fibrosis is released. The retracting lactiferous ducts are cut mainly from the central portion of the nipple. All the fibrosis and retracting ducts are released until the nipple can maintain its eversion by itself without any traction. The dermal flaps are turned down through the tunnel and sutured together to give bulkiness to the nipple. A 5-0 buried purse-string suture is placed at the base of the nipple. The newly everted nipple is maintained by a sombrero splint in place with sutures for 1 week to keep the nipple projection. (diagram is from 4th article--modified Namba technique)

Recently (see 3rd reference article) a technique using nipple piercing has been described. It is worth considering in Grade I and II inverted nipples. The authors suggest trying it in Grade III also, and maybe it is worthwhile when you consider that bone length can be achieved with distraction therapy. If the patient would gently tug on the nipple ring each day, the duct/skin can often be stretched.

Correction using Nipple Piercing

• With the patient in a sitting position, an entrance and exit point is marked on the nipple base in either horizontal or vertical plane, depending on the patients’ preference. Then with the patient in the supine position, the nipple is prepared with Betadine. Local, may or may not be used. A usual piercing technique was used. A 14-gauge needle was passed horizontally through the base of the nipple. A 5/8 -inch stainless steel nipple ring is advanced following the needle and through the tract. The procedure is completed within seconds. No local anesthetic is used. The nipple ring is cleaned daily. At 4-6-month follow-up the nipple ring is removed. (photo credit)

Risks of Surgical Correction:

The most dreadful complication can be compromise of blood supply to the nipple caused by dissection of fibrosis and a strong, tight purse-string suture. This complication is more likely in grades II and III, for which retraction is more severe. Other complication/risks include re-inversion, infection, tissue injury, excessive bleeding, and adverse reaction to anesthesia. The procedure may also result in noticeable scars, permanent pigment changes, or slightly mismatched nipples. Nipple protrusion with stimulation may change. If nipple inversion recurs or asymmetry is significant, a second procedure may be needed. The temporary effects of inverted nipple surgery can include loss of breast sensation or numbness. There is no guarantee that breast feeding will be possible after correction of inverted nipples.

References

Simple Technique for Inverted Nipple Correction; Morris Ritz, Ram Silfen, David Morgan and Graeme Southwick ; Aesthetic Plastic Surgery Journ, Vol 29, No 1, pp 24-27

The Inverted Nipple: Its Grading and Surgical Correction; Plastic &Reconstructive Surgery. 104(2):389-395, August 1999; Han, Sanghoon M.D.; Hong, Yoon Gi M.D.

A Contemporary Correction of Inverted Nipples; Plastic &Reconstructive Surgery. 107(2):511-513, February 2001; Scholten, Erik Ph.D.

Surgical Correction of Inverted Nipples Using the Modified Namba or Teimourian Technique; Plastic & Reconstructive Surgery. 113(1):328-336, January 2004; Lee, Kyung Young M.D.; Cho, Byung Chae M.D.

Pictures of Correction Surgery (some may consider them graphic)