featured articles

An Integrated Approach To Inverted Nipple Repair

W. Grant Stevens, MD, FACS; David R. Fellows, MD; Steven D. Vath, MD;
David A. Stoker, MD
Marina Plastic Surgery Associates, Marina del Rey, CA

Introduction: Nipple inversion is a disfiguring condition that affects approximately 2% of all women (10). Varying degrees of lactiferous duct hypoplasia cause this inversion, which is classified into three grades (5). In Grade I, the nipple may be everted manually and maintains its projection without traction. In Grade II, the nipple is more difficult to evert and it returns to the inverted position without traction. Grade III nipples are severely retracted and inverted. The nipple is of great importance as a visual, nutritive and sexual focus of the female body. For some women, issues of hygiene are paramount as well. Because breast feeding, body image, and sexuality may be adversely affected, women with inverted nipples commonly choose to undergo surgical correction. Numerous techniques exist (1-16) and may be broadly categorized into those that divide the lactiferous ducts and those that do not. Currently, there is no consensus as to the best method for treating this deformity (1-16). A new, integrated approach to the correction of nipple inversion is presented.

Methods: 21 female patients presented for repair of nipple inversion (Fig 1,2) over the last 5 years. 17 of these patients presented with bilateral nipple inversion. Four patients presented with unilateral inversion. Two of the patients presented with bilateral recurrence after undergoing the corrective procedure by other surgeons.,,All procedures were performed on an outpatient basis. Initially, nipple eversion was achieved using gentle traction with a skin hook (Fig 3). The nipple base was approached via an inferior periareolar incision (Fig 4) made through the subcutaneous tissue to meet the lactiferous ducts (Fig 5). Blunt dissection using a vertical spreading technique parallel to the ducts restored varying degrees of projection (Fig 6). Ductal structures are easily visualized and preserved during the dissection (Fig 7,8). When necessary, selective ductal division was performed to obtain complete eversion with normal projection. This technique releases the greatest tension by incrementally dividing the lactiferous ducts under direct vision. Two internal 4-0 chromic sutures were then placed from the twelve to six o'clock, and the three to nine o'clock positions (Fig 9,10). These internal sutures draw together the opposite walls of the nipple, providing further stability and reducing dead space under the nipple. An external 4-0 chromic purse string suture was then run at the junction of the nipple areola boarder (Fig 11,12,13). Lastly, a 4-0 Nylon traction suture was placed through the center of the nipple (Fig 14) and affixed to a stent consisting of a medicine cup and gauze padding (Fig 15,16,17). This traction exerts an anteriorly directed force to maintain the nipple in an over-corrected position. Traction was maintained for two to five days. Follow-up evaluations assessed maintenance of nipple eversion and subjective patient satisfaction.

Results: To date, with a one-year minimum follow-up, there has been no recurrence of nipple inversion in the 21 patients. Nipple eversion has been consistently maintained at one year postoperatively (Fig 18,19) and patient satisfaction has been overwhelmingly high. Continued follow-up at regular yearly intervals for 5 years following surgery will be performed.

Discussion: The surgical approach described applies the structural principles of nipple inversion in order to treat this disorder effectively. Rather than dividing all lactiferous ducts, it is possible to selectively divide only those that restrict nipple projection. This technique entails vertical spreading parallel to the ducts, centrally and peripherally, followed by strategic ductal division. This duct-sparing approach may allow some women to breast feed postoperatively. Eliminating dead space and increasing tissue bulk beneath the nipple contributes to lasting postoperative nipple projection. Purse string suture placement at the nipple areolar border as well as postoperative over correction with traction stenting is critical during the healing phase to resisting initial recurrent forces. This stent not only assists in ensuring eversion, but also protects the repair while the projected position is maintained. This technique has yielded excellent results without recurrences and should be considered when contemplating surgical correction of this disfiguring disorder.

Conclusion: Repair of inverted nipple deformities can be reliably performed using an integrated surgical approach that minimizes ductal disruption and provides for post-operative traction stenting. Eversion using this technique is maintained without recurrence of inversion. This surgical method should be considered when a corrective procedure for inverted nipple deformity is contemplated.

Learn more about nipple repair and see photos. Then, to request your personal consultation, go Inside Online. At Marina Plastic Surgery Associates, appointments with our Los Angeles plastic surgeons are free at select times.

References:

1. Brent, B., and Bostwick, J. Nipple-areolar reconstruction with auricular tissue. Plas. Reconstr. Surg. 60: 353, 1977.
2. Broadbent, T.R., and Woolf, R.M. Benign inverted nipple: Transnipple-areolar correction. Plast. Reconstr. Surg. 58:673,1976.
3. Elsahy, N.I. An alternative operation for the inverted nipple. Plast. Reconstr. Surg. 57:438,1976.
4. Hamilton, J.M. Inverted nipples. Plast. Reconstr. Surg. 65:507,1980.
5. Han, S. Then inverted nipple: its grading and surgical correction. Plast. Reconstr. Surg. 105:1546,2000.
6. Hartrampf, C.R., and Schneider, W.J. A simple direct method for correction inversion of the nipple. Plast. Reconstr. Surg. 58:678,1978.
7. Hauben, D.J., and Mahler, D. A simple method for the correction of the inverted nipple. Plast. Reconstr. Surg. 71:556,1983.
8. Morris, A.M., Rai, Y.S., and Lamont, P.M. A method for correcting the inverted nipple. Br. J. Plst. Surg. 33:41,1980.
9. Rayner, C.R. The correction of permanently inverted nipples, Br. J. Plst. Surg. 33:413, 1980.
10. Schwager, R.G. et al. Inversion of the human female nipple, with a simple method of treatment. Plast. Reconstr. Surg. 54:564,1974.
11. Silsby, J.J. Nipple recostruction. Plast. Reconstr. Surg. 57:667, 1976.
12. Skoog, T. An operation for inverted nipples. Br. J. Plast. Surg. 5:65,1953.
13. Spina, V. Inverted nipple-contribution to surgical treatment. Plast. Reconstr. Surg. 19:63,1957.
14. Teimorian, B, and Adham, M.N. Simple technique for correction of inverted nipple. Plast. Reconstr. Surg. 65:504,1980.
15. Wolfort, F.G., Marshall, K.A., and Cocchran, T.C. Correction of the inverted nipple. Ann. Plast. Surg. 1:294,1978.
16. Yanai, A., Okabe, K., and Tanaka, H. Corrections of the inverted nipple. Aesthet. Plast. Surg. 10:51,1986.