Monday, November 5, 2007

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, and all 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)

45 comments:

Chrysalis Angel said...

I know this is a serious post and interesting by the way, but I just had to say to you...boy, are you going to see your traffic jump from this post.:)

Anonymous said...

hi Doctor
i have stage 1 inverted nipples and am considering having a BA -what are the chances of the nipples being "normal" post op? Is it necessary to have a separate nipple correction surgerY??

thank you for any help

rlbates said...

Breast Augmentation does usually change the nipple shape. You can take a wait-n-see approach and see if you are an exception, but don't count on it.

Anonymous said...

Hi Doctor, Do you recommend having a doctor perform the nipple pierciing or is a safe and clean piercing parlor suitable? Thanks, S.

rlbates said...

S, if you go to a "safe and very clean" piercing parlor, you will need to be really sure that you or they can get your nipple everted prior to the piercing.

Anonymous said...

I think you meant to say "BA does NOT usually change the nipple shape" above in your answer to the Stage 1 nipple post. I also have mild nipple inversion and was considering Nipplete - do you have any experience w/ the success rate of this vacuum type product? Will nipple revert once you stop using it?

Anonymous said...

Hello,

My girlfriend has inverted nipples, and I was wondering if inverted nipples have the same level of sensitivity as those that are "outies" as far as sexual stimulation is concerned. I know I should just ask her, but she is very embarressed by them and I don't want to make her feel uncomfortable.

Thanks!

rlbates said...

Anon (7-30-08), yes, though all women have different levels of nipple sensativity. It doesn't tend to correlate to whether the nipple is inverted or not.

Anonymous said...

how soon after a nipple correction can you breastfeed ????

rlbates said...

I don't think there is a set rule, but I tend to encourage my patients NOT to get pregnant for a year after any surgery so the body has a good chance to heal fully and with the breast, the scar has a chance to mature.

Anonymous said...

hi, i have stage 3 inverted nipples, and i am hoping to get surgery. However, my insurance company won't cover me because they view it as a cosmetic procedure, when really both i and my doctor highly doubt i will be able to breastfeed because the retraction is so severe. do you have any suggestions?

rlbates said...

No, because very often correcting (see above) Grade III involves cutting the ducts. If this is the case in your situation, then you wouldn't be able to breast feed even with correction.

Anonymous said...

yes, however my plastic surgeon thinks there is a way to do it without cutting the ducts, he's been doing a lot of research for me. i've also been in contact with my insurance company, and they're telling me that if i can come up with an article proving that the severity of my nipple retraction will most likely prevent me from breast feeding, then they will cover my procedure. if you know of any articles that would be helpful. thanks!

Anonymous said...

This is good information.

Anonymous said...

Hi, I have grade I inverted nipples and I was considering getting them pierced. If I leave the piercings in for a good while and decide to take the piercings out later on, is it possible that the nipples will stay protruded permanently or will they just go back to their regular state? Thanks!!

rlbates said...

Anon (Oct 9, 08)-- if you leave the nipple ring in more than 4-6 months then it is very likely that the results for a Grade I will be maintained once the ring is removed.

Kevin said...

1 ½ years ago I noticed my left nipple would occasionally retract. I could pop it out when that happened and my mammogram was normal so my doctor said not to worry. Recently, I have noticed that it retracts more often and is more difficult to push out. I am a little concerned. My next mammogram is not scheduled for another two months. Has this happened to anyone else, and should I be worried?

Anonymous said...

My nipples looks like a stage 3 but with help they pretrude like a stage two. So what would i be considered stage 1 or atage 2.

Anonymous said...

hi doctor im a 22yr old who had a mammopexy 5 months ago for post weight loss sagging.i had some bleeding from one nipple which also became retracted.my surgeon told me it would be alright to leave it and it would evert by itself but its been months and from the description it appears to be a grade 3 as it does not come out at all.my surgeon says im young n itl resolve itself but im still worried.is he right?is this a complication i should have been told about?is there anything that can be done for it now?
Also my post-op scars,although not keloids,are quite severe.i am dark-skinned also perhaps bcoz i had an allergic reaction to the silicon sheets(very uncommom im told) given to me to reduce chances of keloid formation postop.is there anything i can try now?

rlbates said...

Anon (Dec 26), I'm sorry but I don't give medical advice on this blog (aa the disclaimer states). Ask you surgeon for suggestions or seek a second opinion.

Nicola said...

Hi,

4 years ago I had corrective surgery for nipple inversion. Mu ducts were cut and I was told that I would never be able to breastfeed. Is there a possibility of surgically re-attaching the ducts so that breastfeeding is possible? Thanks N

rlbates said...

Not that I have ever heard or read about. Theoretically possible, but it would take a microscopic repair, minimal or no scar tissue formation in healing , and the cost would be high because of the microscopic repair).

Anonymous said...

Hi there, I have a question Dr.

I am an 18 year old Female

I believe I am a Grade 2. And I was wondering, if Nipplete would work?

I am not pregnant or anything, I just have inverted nipples and I wanted to know if that product would work, or would I have to get surgery. Or are there any other alternatives other than surgery such as (based on readings) breast shells?

Thanks a ton!

rlbates said...

Anon (Feb 17, 09) -- It won't hurt to try the Nipplets.

S. said...

here's a question for ya.

I'm a relatively thin person. Before kids, I was a plump 34b. No problems at all. I had 3 babies who all breastfed up to 15 months old each. I would frequently go up to a D cup or more (I could get 8oz of milk from EACH side).

Now I'm done with kids, I'm still thin, but fit. I have shrunk down to a 34a on good days (otherwise close to aa).

So my problem is this, after my third baby (at 27 yrs old), once I was done breastfeeding and all the milk dried up, I noticed my nipple "sunk", the best way I can describe it. My nipples are pretty much always at attention, lol, but it's the areola that's wrinkled per say. They don't said, they are still quite perky for having grown so many times in 5 yrs. So it's not that my nipple is inverted, it's literally sunken in...what can I do about this? Is this still considered an inverted nipple?

rlbates said...

S, what you have is postpartum breast atrophy. You either have to live with it or have an augmentation mammoplasty.

S. said...

K, so it's S. again...so here's another question.

Since it just the areola I'm irritated by, I'm wondering if this is possible..

Since you can get things like restalyn and such in your lips to plump them up...could you get it in the the areola to just plump it up to fit the rest of the breast?

or did I just invent something?? lol

rlbates said...

S, I wouldn't inject collagen or Restylene into that area but you might find someone who would.

gg said...

Hi!

I believe I have stage II and heard that peircing them might work for a while even if it's not permanent...does it work often enough that you think it worth trying?

Thanks,
GG

Marissa said...

I was going to get surgery to fix my inverted nipples...but the Dr. told me I would not be able to breast feed afterward- so I decided to wait.
But NOW I think inverted nipples are better! When mine are stimulated they pop out and are really sensitive. During sex the stimulation helps me easily reach orgasm. I can almost reach orgasm with nipple stimulation alone. My friends say that's crazy and that their nipples are not that sensitive maybe because they always stick out.

Anonymous said...

i think i am a stage 1.... is there any chance of my nipples going back to normal because i am only 13? they havent been like this forever. so maybe its not permenent.

Anonymous said...

hello.
i am 20, i am comming from a country where a plastic surgery is not so developed and i'm emberaced to tell about my inversion to anybody, despite my boyfriend who can not give me any advice...
i have inverted nipples stage 2 and i am so worried because i haven't heard of someone in my country to have that problem.
and i don't know if there are Nippletes in any pharmacy...
i wanna ask are the Nippletes good solution? or after using them, can there be re-inversion again? or how expencive the plastic surgery correction is?
thank you

rlbates said...

Anon (Sept 14), you shouldn't be embarrassed to tell your doctor. This is a common problem. Don't know which country you are in, but Nipplets won't hurt you. They may not fix a Grade II or III though.

Anonymous said...

well, i have finally told my doctor and he says that that problem can not be solved with surgery (omg). i have forgotten to say that my nipples were normal until 11 age.
i've got one more question: can woman with inverted nipples breastfeed? i know that with stimulation of nipples, oxytocin extracts and the milk is secreting from the ducts,but does it happen with inverted nipples? i dont understand... thanks

rlbates said...

Anon (Oct 11, 2009), it is often possible to breast feed with inverted nipples.

Anonymous said...

Hello!
I have stage 2 inverted nipples and i wanna make a surgery. All i wanna ask about is that I'm alergic to Nickel and my doctor once said that surgical instruments contain Ni. Can that be a problem during an operation, i mean, can it cause an anaphylactic reaction?
Thanks

rlbates said...

Anon (4-16), surgical instruments are made of stainless steel so you should not have a problem with surgery.

Anonymous said...

Thanks for such an informative post! I have grade II (was grade III prior to nipllette) and last night I had an experience piercer pierce them.

At the moment the nipples are everted thanks to the dumbbell piercing. However 5-10% of the distal-most tip on right breast is still slightly inverted. The piercer says they will evert "soon" as the tissue accomodates. Is this correct?

rlbates said...

Anon (8-22-10), it's possible.

Anonymous said...

Dr Bates, this anon (8-22). Do you mean possible in the sense like possible but unlikely? Or possible. Am I correct to understand that this piercing is stretching the tight connective tissue and with gentle tugging (once healed) will stretch the distal portion as well? This is all so new to me!

rlbates said...

Anon (8-22), I don't know what odds to give you as there have been no large medical studies of nipple piercing to correct inverted nipples. In theory, it should (the gentle tugging to stretch the shortened ducts) work over time (again is that 6 wks or more, don't know but would leave the piercing at least a few weeks or months past acceptable correction). So the best I can say is that it is possible and worth the try, just be careful to prevent infection.

Anonymous said...

Hi. Is it true that piercing ur nipple will damage ur milk ducts and you won't be able to breast feed there after?

rlbates said...

Anon (9-23-10), nipple piercing (without complications such as infection) should not damage the ducts.

Anonymous said...

I appreciate this post. I have stage 2 inverted nipples. Almost three years ago, I had corrective surgery. My nipples reverted within weeks after the stitches were removed. I have tried to just get over it, but I would still really enjoy if it could be fixed. If I've already tried surgery and it didn't take, is that a sign that nothing will help or would it be worth trying again/or trying piercing?

rlbates said...

Anon (10-30-10), it would depend greatly on what procedure and the scarring you have. Ask your surgeon.