What is an “inverted” nipple?

Flat and inverted nipples of varying degrees of severity have been noted in the medical literature since 1840 and are more common than previous thought, with up to 10% of the normal female population having it on one or both sides. This problem causes both psychological distress and potential problem with breastfeeding later.Inverted nipple

What causes the inverted or flat nipple?

This condition usually presents from an early age and is often congenital. There are occasional acquired causes such as breast infection, very large breasts (especially when the growth is rapid) or secondary to a surgical procedure, such as breast reduction. Very rarely, it may a sign of an underlying breast cancer.

There are two schools of thought as to the anatomical problem which is responsible for the condition. One school believes the primary problem is a lack of tissue bulk in the area under the nipple, and the ductal tissue and muscular elements of the ducts then exert and overpowering inward pull. The second school is of the opinion that the cause is a relative shortness of the breast ducts, in the area just under the nipple itself, often with associated fibrosis. There is evidence to support both camps and a multi-factorial theory seems equally suitable as an explanation.

How do we grade the severity?

The severity is graded on the Han and Hong Scale (Han, S., and Hong, Y. G. The inverted nipple: Its grading and surgical correction. Plast. Reconstr. Surg. 104:389, 1999.)

Han & Hong Grade I : “The nipple can be easily pulled out manually and maintains its projection quite well without traction. The nipple is popped out by gentle digital pressure around the areola or by pinching the skin. 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.”

Han and Hong Grade II : “The nipple can be pulled out manually, but not as easily as in grade I. The nipple has difficulty maintaining its position and tends to retract. 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.”

Han and Hong Grade III: “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. We can feel the retracting forces beneath the nipple. The fibrosis is remarkable and lactiferous ducts are short and severely retracted. The bulk of soft tissue is markedly insufficient in the nipple.”

What can be done to correct this problem?

In pregnancy, several conservative methods are advocated such as : breast shells, Hoffman’s exercises, breast pumps and syringe techniques. They have been successful in grade I and sometime in grade II cases. Outside of pregnancy, their success rates are very low. Surgery is usually recommended. There are various operation which have been descried. Most techniques use one or a combination of the following techniques :

  • Sutures – both permanent and removable.
  • Release of the ducts (cutting the ducts or stretching the ducts). Most described techniques use this.
  • Addition of tissue under the nipple to add bulk

A particularly interesting technique has been described by Scholten which is applicable to all grades. This technique involves the placement of a body piercing in a specific place under the nipple and using the piercing to stretch out the ducts over a 3 to 6 month period. Most of the ducts can be preserved in this way and the piercing may even be left if the patient desires it!Scholten Technique

Will I be able to breastfeed after the surgery?

Many grade II and most grade III inverted nipples will not be suitable or able to supply enough milk to allow breastfeeding even without surgery. Although there is some evidence that after surgery milk production continues, almost every operated case will be unable to breastfeed. This is an important consideration for younger patients.

Will the sensation of the nipple be normal after surgery?

There is a well-documented loss or decrease in nipple sensation after surgery. Most patients will have a temporary disturbance in sensation but in about 20% of cases, this is permanent.

Can the inverted nipple recur after surgery?

Yes. As the surgical site heals and collagen and scar tissue is laid down as a wound healing response, there can be recurrent retraction of the nipple. Usually this occurs in cases where an attempt has been made to spare the ducts. When it happens, revision surgery with complete incision of all duct tissue is required.

What do you recommend?

There are a large number of options and operations available. The most important consideration are:

  • The age of the patient and completion of their family (Is the patient presently pregnant ?)
  • The severity (Han and Hong Grade)
  • The wishes of the patient

If the patient is presently pregnant, I recommend conservative management such as Hoffman exercises, in all grades. At a later time, surgery may be considered if these measures are not successful.

If the patient is young and has not completed their family, I try to preserve ducts where possible. If the patient is amenable to body piercings, the Scholten technique is a good first option which does not “burn any bridges”. In grade I or II, I suggest a vertical release of the ducts through a narrow incision at the base of the nipple, with a temporary suture, which is removed after 2 weeks.

If the patient has completed their family, surgery is generally recommended. These patients may also wish to consider the Scholten technique of body piercing, if they are amenable. In this group, I generally use a modification of the Filho Microincision Technique, with a tiny incision placed at the base of the nipple.

All procedures are generally done under local anaesthesia and mild oral sedation in the office as an outpatient.