A contemporary correction of inverted nipples

Central Tunnel Technique and Fat Grafting for Surgical Correction of Inverted Nipples and Introduction of a Treatment Algorithm

BACKGROUND

Inverted nipples are prevalent in 3% to 10% of women and can often cause functional, psychological, and aesthetic problems.

OBJECTIVES

The authors sought to treat inverted nipples and restore the aesthetic appearance of the nipple while minimizing ductal disruption, preserving the ability to breast-feed, and reducing recurrence rates.

METHODS

A retrospective review was performed on a total of 161 inverted nipples in 86 consecutive patients who underwent correction of inverted nipples at Oslo Plastic Surgery Clinic. Mean age at operation was 28.7 years and mean follow-up period was 14 months. A novel technique with central tunnelization of the retracted fibers/ducts was employed in 39 patients (45%); partial incision of the center of the inversion through a tunnel in 31 patients (36%); and total cut of the lactiferous ducts in 16 patients (19%). Fat grafting was utilized as support in 14 patients (26 nipples). Postoperatively, nipples were suspended for 4 weeks with a manually constructed device.

RESULTS

Most patients had moderate (grade 2, 40 patients) or severe (grade 3, 52 patients) nipple inversion. Infection occurred in 4 patients and 2 patients had local irritation. Recurrence was seen in 32 patients (55 nipples) after the first operation, in 6 patients (6 nipples) after the second operation, and in 1 patient (1 nipple) after the third operation.

CONCLUSIONS

The authors propose a treatment algorithm that addresses important therapeutic goals when treating inverted nipples. Clinical examination is crucial to determine the method to be employed. The new central tunnel method and fat grafting to support the nipple are promising, although additional follow-up is necessary.

LEVEL OF EVIDENCE: 4

Inverted Nipple Treatment and Poliglecaprone Spacer

INTRODUCTION

Nipple inversion is defined as a non-projectile nipple. It is a frequent pathologic condition, in which the whole nipple, or a portion of its, is buried inward towards the lactiferous duct and lies below the plane of the areola. Numerous strategies have been described to correct nipple inversion. All the procedures have the purpose to give a good shape to the nipple, preserving its function and sensitivity, when it is possible. To avoid recurrences and to obtain good aesthetic results, we present a modified percutaneous technique.

METHOD

We performed a retrospective study between 2011 and 2016 and included all the cases of inverted nipples treated in our department. Our modified percutaneous technique consists of a minimal incision supported by a percutaneous suture as a temporary spacer to fill the defect caused by releasing the fibro-ductal bands.

RESULTS

A total of 41 cases of inverted nipples were corrected in 32 patients. After 1 year of follow-up, no recurrence was observed and all nipples maintained complete eversion. There was only one case of partial unilateral necrosis in a patient who underwent tumorectomy and radiotherapy. All patients were satisfied with the aesthetic outcomes.

CONCLUSION

This is a simple, safe and cheap technique that should be considered as a reliable method for long-term correction of nipple inversion.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Inverted Nipple Correction with Selective Dissection of Lactiferous Ducts Using an Operative Microscope and a Traction Technique

BACKGROUND

An inverted nipple is a common congenital condition in young women that may cause breastfeeding difficulty, psychological distress, repeated inflammation, and loss of sensation. Various surgical techniques have been reported for correction of inverted nipples, and all have advantages and disadvantages. Here, we report a new technique for correction of an inverted nipple using an operative microscope and traction that results in low recurrence and preserves lactation function and sensation.

METHODS

Between January 2010 and January 2013, we treated eight inverted nipples in seven patients with selective lactiferous duct dissection using an operative microscope. An opposite Z-plasty was added at the junction of the nipple and areola. Postoperatively, traction was applied through an apparatus made from a rubber gasket attached to a sterile syringe. Patients were followed up for 15-48 months.

RESULTS

Adequate projection was achieved in all patients, and there was no wound dehiscence or complications such as infection. Three patients had successful pregnancies and subsequent breastfeeding that was not adversely affected by the treatment. There was no loss of sensation in any patient during the postoperative period.

CONCLUSION

Our technique for treating an inverted nipple is effective and preserves lactation function and nipple sensation. The method maintains traction for a longer period, which we believe increases the success rate of the surgery for correction of severely inverted nipples.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of the benign inverted nipple: A systematic review and recommendations for future therapy

The inverted nipple is a frequently encountered problem which can cause difficulties with breastfeeding, sexuality, and aesthetic dissatisfaction. Up to now, no consensus exists on a preferred treatment method. We performed a systematic review to identify the best treatment method for correction of benign inverted nipples. Treatment techniques were subdivided in the categories lactiferous duct preserving and lactiferous duct damaging. A systematic review was performed using the PRISMA statement. Inclusion criteria were: female patients with congenital or acquired inverted nipples, a minimum sample size of 10 nipples, and studies reporting recurrence of inversion with a minimum follow-up of six months. Exclusion criteria were nipple inversion caused by malignancy. Thirteen studies met the inclusion criteria which all had a level of evidence IV. No non-invasive treatment techniques were identified. In the duct preserving category eight studies were included with a recurrence rate of 0.6% (2/350) versus 9.9% (16/161) in the duct damaging category (n = 5). Other outcome parameters were not systematically reported in all studies. Because of a small number of low quality studies with heterogeneous interventions and outcomes a meta-analysis could not be performed and no preferred treatment method was identified. Based on the available data there is no statistical evidence that duct damaging treatment is superior to duct preserving treatment. We recommend that the first method of choice should be a duct preserving treatment method. In the future, more studies of better methodological quality are required and recommendations were made on how these could be conducted.

Alternative nipple suspension technique in the treatment of inverted nipple: reverse s-shaped design

The primary aim in the treatment of inverted nipple is to achieve a satisfactory and permanent projection of the nipple. The drawbacks of reported techniques include sensory disturbance of the nipple, marked scarring of the nipple and areola, destruction of breast function and incomplete correction. In the present study, the authors introduced a new modification of using two opposite nipple-based areolar dermal flap in the treatment of grades 2 and 3 inverted nipple cases. Nipple-based areolar flaps designed at 3 o'clock and 9 o'clock were raised by two linear incisions and the tip of each flap was sutured on the base of the nipple close to the base itself in a reverse S shape at 6 and 12 o'clock. Successful outcome was obtained due to a strongly suspending effect of the design of the flaps. The mean follow-up period was 6 months. The patients were satisfied with the result and the scars were minimal. The authors recommend the use of the technique that is a simple, reliable and with minimal scars for correcting grades 2 and 3 inverted nipples.

Inverted nipple correction with dermal flaps and traction

BACKGROUND

Inverted nipple occurs when part of or the entire nipple is abnormally located below the areola. Surgical repair of severe cases involves suture or flap techniques. Complications include recurrence, lactation problems, hypopigmented scar formation in the areola, and loss of sensation. We describe an alternative repair technique using a dermal flap and traction, which leads to less apparent scarring and preserves lactation function and sensation.

METHODS

Between January 2010 and January 2013, we treated 28 inverted nipples in 16 patients using two areola-based triangular dermal flaps and traction. The scar was aligned with the junction of the nipple and the areola. Postoperatively, traction was applied through an apparatus prepared from a 50-cc syringe. Patients were followed up for 8-24 months (mean = 16.5 months).

RESULTS

Adequate projection was achieved in all patients and no wound dehiscence or complications such as infection occurred. Unilateral recurrence occurred in one patient on the 10th postoperative day. This patient was reoperated on successfully using the same method. No loss of sensation was observed in any of the patients during the postoperative period.

CONCLUSIONS

This dermal flap technique for treating inverted nipple was effective and preserved lactation function. The alignment of the scar with the junction of the nipple and the areola led to a more aesthetic appearance with no apparent scarring. The traction method helped maintain traction for a longer period, which in our opinion increased the success rate of the surgery.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Nipple invagination: the umbrella effect

The authors present their technique for correction of invaginated nipple, a procedure used for the past 20 years. Most often, this condition is a consequence of a subareolar muscle diastasis associated with short fibrous septa as well as short and fibrotic ducts. The correction technique specifically divides the fibrous tracts and corrects the diastasis of the subareolar muscle. The procedure was performed for healthy patients as well as for patients with mastitis sequel treatment and surgical reduction or augmentation mammaplasty.

Usefulness of the nipple-suspension piercing device after correction of inverted nipples

The authors have devised a new piercing instrument for postoperative nipple suspension of inverted nipples. The instrument can be used not only postsurgically, but also for nipple suspension in light inverted nipple cases without surgical repair. Details of the device and the method of piercing are described.

Correction of Inverted Nipple: An Alternative Method Using Continuous Elastic Outside Distraction

Inverted nipple, which is defined as a nipple located on a plane lower than the areola, presents both functional and cosmetic problems. It is a source of repeated irritation and inflammation and interferes with nursing. In addition, its abnormal appearance may cause psychologic distress. With consideration of its underlying pathophysiologic components and severity, a number of techniques have been introduced for correction of this anomaly. Most of these techniques involve extensive skin incision around the nipple that may jeopardize the blood and nerve supply to the nipple or create much scar tissue that is esthetically objectionable. For correcting the inverted nipple, the authors introduce an alternative, simple method using continuous elastic outside distraction. Compared with other methods using outside distraction, the authors used an adjustable elastic instrument made of steel wire, spring, and plastic syringe; continuous distraction of the inverted nipples; and sustaining 3 to 6 months. From August 2002 to December 2003, 14 patients (26 nipples) were treated. 12 patients had bilateral inverted nipples. Patient age at operation ranged from 14 to 40 years (mean age, 24 years). All nipples were congenital, and they had no previous operation. Six nipples were grade I, 9 nipples were grade II, and 11 nipples were grade III according to the classification of inverted nipple by Han and Hong. The mean follow-up period was 7.3 months (range, 3-12 months). Follow-up examinations revealed no evidence of recurrence of inversion. There was no complication associated with surgery, such as infection, hematoma, permanent sensory disturbance, or nipple necrosis. All patients were satisfied with their results. The authors conclude that their procedure is reliable, a simple, safe, and effective method for correction inverted nipple. But a long-term follow-up is needed. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

Congenital malformations and developmental changes of the breast: a neonatological view

Congenital malformations of the breast and nipple-areolar complex are described from the aspect of neonatal dysmorphology. Their classification is based on the accepted nomenclature in the medical literature and on a special method of clinical examination. The embryology and the possible genes involved in breast development are also discussed to clarify the mechanisms underlying the occurrence of breast malformations. Except for amastia, polymastia and polythelia, which have received much attention, the data for many other breast malformations are sparse. Case control studies or even case series are rare, and good evidence is often lacking. In addition, more studies are needed to complete the map of genes involved in breast development. This information will contribute substantially to our understanding and clinical approach to breast malformations in the future.