The effect of interventions on flat and inverted nipple on breastfeeding: A systematic review

BACKGROUND

Some methods have been developed to solve flat and/or inverted nipple problems. This study aimed to examine the effects of flat and/or inverted nipple interventions on nipples and breastfeeding.

METHODS

Before initiating the review, the protocol was registered in the 'PROSPERO' database. This study was based on the PRISMA-P guideline. Seven databases (Web of Science, PubMed, ScienceDirect, Scopus, The Cochrane Library, TÜBİTAK Ulakbim and Google Scholar) were searched, and nine studies were included in this review.

RESULTS

Hoffman's exercise, the inverted syringe method, and the nipple exercise was quite effective in increasing breastfeeding success. The rate of exclusive breastfeeding in the first, third, and sixth months of mothers followed up with postpartum multidimensional visits was found to be significantly higher in the intervention group than in the control group (p < 0.05). A study in which a rubber band was applied with the help of an injector on flat and inverted nipples showed that 63% of mothers on the third day and all of them in the first month were able to breastfeed without a rubber band. Hoffman's exercise, the inverted syringe technique, and rubber bands corrected the flat and/or inverted nipple. There were studies reporting complications as a result of nipple interventions.

CONCLUSIONS AND IMPLICATIONS

It is necessary to disseminate the information that breastfeeding of mothers with flat and/or inverted nipples can be sustained with various interventions. Furthermore, it is believed that providing mothers with a chance to choose the interventions, and thus, the compliance of mothers to the intervention with the method of their choice may increase the success of the intervention.

A New Method for Inverted Nipple Treatment with Diamond-Shaped Dermal Flaps and Acellular Dermal Matrix: A Preliminary Study

BACKGROUND

Patients with inverted nipples experience various uncomfortable complications including recurrent infections. Regarding the level of severity of inverted nipple, those that are higher than grade II (as classified by Han and Hong) requires surgical correction. Many methods have been proposed to treat the inverted nipple. However, even after treatment, recurrence has always posed a problem. Thus, we propose a new method using the diamond-shaped dermal flap with acellular dermal matrix to treat the inverted nipple.

METHOD

Between March 2019 and February 2022, a total of five patients with grade III were studied in this study. Two diamond-shaped flaps were designed at the 3 and 9 o'clock positions of the nipple. This dermal flap was elevated and wrapped around the nipple column at the nipple base. The lactiferous ducts in female were all divided. In addition, acellular dermal matrix was inserted to fill the dead space of the nipple base. The nipple height and scar evaluation were conducted on 6 month, 12 month postoperatively. Overall satisfaction and complications were also checked at the last visit.

RESULTS

The inverted nipple was resolved and no complications such as hematoma, infection, and necrosis were reported. The projection was maintained without any recurrence, with a slight decrease of 1.5 mm (reduction in 20%) in median value. There were no major or minor complications found except for a few small scars, and the patient was satisfied with the esthetic outcomes during the follow-up.

CONCLUSION

This is a fast and simple technique for the surgical correction of inverted nipples. Using the acellular dermal matrix, projection and suspension were safely maintained without complications. This technique could be an option for the surgical treatment of severe types of 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 .

A New Technique in Correction of Nipple Inversion Using Dermal C Flaps

BACKGROUND

Nipple inversion, which is defined as a nipple located on a plane deeper than the areola, presents both functional and cosmetic problems. Surgical repair of severe cases involves suture or flap techniques. In the present study, an alternative repair technique using two cross dermal areolar flaps to correct challenging inverted nipples is presented. Releasing the inverted nipple is performed by severing the underlying tight fibrous tissue bands and canaliculi.

METHODS

This is a retrospective case series. Fifteen patients who had been operated between January 2010 and January 2016 were included in the study. Seven of these had bilateral inverted nipples. Patient age at operation ranged from 26 to 47 years (mean age, 32.5 years). All nipples were congenital, with no previous operations. The follow-up period ranged between 8 and 16 months (mean of 13 months).

RESULTS

There were no complications associated with surgery, including infection, hematoma, permanent sensory disturbance, or nipple necrosis. Unilateral recurrence occurred in one patient on the 26th postoperative day. This patient was reoperated on successfully using the same method. Adequate projection was achieved in all patients. All patients were satisfied with their results.

CONCLUSIONS

The authors conclude that their procedure is a reliable, simple, safe, and effective method for correction of inverted nipples. The alignment of the scar with the junction of the nipple and the areola leads to a more aesthetic appearance with no apparent scarring. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

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 Techniques: An Algorithm Based on Scientific Evidence, Patients' Expectations and Potential Complications

BACKGROUND

Inverted nipple is a problem that affects a large number of women, with an aesthetic and functional repercussion. The literature is abundant in terms of techniques described, from the most conservative to the most aggressive. Although different techniques have been described to correct inverted nipples, there are no established algorithms to guide the surgeon in choosing the correct technique for each patient. Therefore, the objective of this paper is to present the first algorithm to simplify the inverted-nipple approach, based on the most recent scientific evidence and the patient's wishes.

METHODS

A bibliographic review on this pathology and available treatments was carried out to build an algorithm. Then, 47 patients consulting about inverted nipple concerns were included in this study. First, the patient's breastfeeding concerns were discussed. Once breastfeeding concerns were known, exploration of inverted nipple and assessment based on the degree of severity was done. Different techniques were proposed according to the degree of inverted nipple. Our technique was indicated in the most severe cases of retraction.

RESULTS

Forty-seven surgical and non-surgical procedures were carried out, resulting in excellent outcomes and high satisfaction rates. No complications or recurrence were observed after 1-year follow-up.

CONCLUSIONS

This is the first time an algorithm to simplify the approach of the inverted nipple has been proposed based on the degree of severity and lactation wishes. Choosing the right procedure for each patient will help the plastic surgeon in achieving great satisfaction and an excellent aesthetic result.

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 .

Breastfeeding success with the use of the inverted syringe technique for management of inverted nipples in lactating women: a study protocol for a randomized controlled trial

Background

Breastfeeding provides ideal infant nutrition, conferring several health benefits to children and their mothers. Women with inverted nipples, however, face difficulties that force them to prematurely terminate breastfeeding. Whereas available conservative measures for the correction of inverted nipples are of limited success, the use of an inverted syringe may be effective in achieving high rates of infant latching and exclusive breastfeeding. This technique, however, has not been investigated in a clinical trial.

Methods/design

This open-label randomized controlled trial aims to investigate whether, in women with inverted nipples, the use of an inverted syringe increases the rate of exclusive breastfeeding at one month compared to standard care. One-hundred healthy women with grade 1 or 2 inverted nipples will be recruited as of 37 weeks of gestation. They will be randomly allocated to standard care (control group) or to an intervention group. The intervention consists of using an inverted syringe to evert the nipple before every breastfeed, starting with the first feed after delivery. The primary outcome measure is the rate of exclusive breastfeeding at 1 month. Secondary outcome measures include exclusive breastfeeding rates at 3 and 6 months, nipple eversion rate, successful latching rate, rates of any breastfeeding at 1, 3, and 6 months, breastfeeding-associated complications, maternal satisfaction with breastfeeding, maternal quality of life, and adverse events. Descriptive and regression analysis will be conducted under the intention to treat basis.

Discussion

The use of the inverted syringe to evert inverted nipples is a simple, inexpensive, and safe technique that can be performed by mothers with inverted nipples. Findings of this trial, if positive, will provide much needed evidence for a safe, affordable, readily available, and simple intervention to treat inverted nipples, and improve breastfeeding practice among affected women.

Trial registration

ClinicalTrials.gov, NCT03529630. Registered May 8, 2018.

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 .

Cross Vertical Mattress Suturing with Basilar Tightening During the Correction of Inverted Nipple in 30 Cases

OBJECTIVE

To investigate the efficacy of cross vertical mattress suturing with basilar tightening during the correction of inverted nipple.

METHODS

Thirty patients with inverted nipples underwent cross vertical mattress suturing with basilar tightening. The postoperative results were recorded.

RESULTS

All the patients were followed up for 6 months to 2 years. The results of 28 cases were satisfactory, and there was no recurrence. Two patients relapsed, and a mild depression was formed. They were satisfied with the results after the second correction.

CONCLUSION

The method of cross vertical mattress suturing with basilar tightening has been applied to treat inverted nipple, with minimal trauma, which provides a reliable guarantee for a long-term effect. It is worthy to be widely used in clinical practice.

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.