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 previously 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 problems with breastfeeding later.
What causes the inverted or flat nipple?
This condition usually presents early 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 be a sign of an underlying breast cancer.
Two schools of thought differ on the anatomical problem responsible for the condition. One school believes the primary problem is a lack of tissue bulk under the nipple, and the ductal tissue and muscular elements of the ducts then exert an 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. Evidence supports both camps, and a multifactorial 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 pops out with 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 applying pressure to force the nipple 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 sometimes in grade II cases. Outside of pregnancy, their success rates are very low. Surgery is usually recommended. There are various operations which have been described. 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
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 form as part of the wound-healing response, the nipple can retract again. This usually occurs when 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 I recommend?
There are many options and procedures available. The most important considerations are:
- The patient’s age and family planning status (Is the patient currently 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. Later, 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 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 modified 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.