A truly inverted nipple is caused by adhesions at the base of the nipple that fix the skin to the underlying tissue. The most common causes of nipple inversion are Congenital, post breastfeeding, post surgical trauma or scarring and due to breast ptosis. It can also present after breast infections like breast abcess, mastitis, tuberculosis of breast and after mammary duct ectasia. Infrequently it can present as inverted nipple gynaecomastia. It is congenital in 10-20% of women. Most common nipple variations that women are born with are caused by short ducts or a wide areola muscle sphincter. It is also possible to have an inverted nipple on one breast, but not the other.
Inverted nipples can also occur after sudden and major weight loss.
Grades of nipple inversion
There are three grades of inverted nipples.
Grade 1: Placing your thumb and index finger on the areola and pushing or squeezing gently can pull out the nipple. The nipple will often stay out for some period of time. Stimulation or breastfeeding can also draw the nipple out.
Grade 2: This grade means it may be more difficult to pull out the nipple than a grade 1 inversion. When released, the nipple retracts inward.
Grade 3: It’s difficult or impossible to pull the inverted nipple out.
Treatment of Nipple Inversion
There are a number of techniques described to correct inverted nipples by non surgical means. Commonly used is Manual manipulation, the Hoffman technique which is a special massage technique to pull the inverted nipples out. Another method of reversing inverted nipples is by usingshells and suction device. Both these methods may be successful wholly or partially for people with grade 1 or 2 inversion. The chances of recurrence remain high with both techniques.
Surgery one can remove any grade of inversion.
The surgery for nipple eversion is performed in a hospital or sometimes as an outpatient procedure under local anesthesia. Inverted nipple repair generally takes an hour to performand involves division of some of the milk ducts in order to release the fibrous bands that are holding the nipple in an inverted position. This is a procedure that is performed under local anesthesia and takes about 30 minutes.During this procedure, a small incision is made under the nipple to allow the surgeon to cut the mild ducts which are tethering the nipple. This is accomplished by making a small incision in the areola while the nipple is held in the extended position. This could likely lead to loss of the ability to breast feed.After the tissues are transected, few rows of dissolving sutures are placed under the skin to hold the nipple in the projected position. Once this is done, protective devices are placed over the nipples to hold them in position, and prevent them from retracting again during healing. There is a 5% risk of sutures breaking leading to a recurrence and the need for a repeat correction.
Patients take very little time for recovery and can get back to normal life instantly. There maybesome discomfort or swelling surrounding the nipples after the surgery and this is managed with adequate pain medication. Stitches are typically removed 6-7 days after the procedure. Patients may or may not be able to breastfeed after inverted nipple surgery. Although the procedure uses a short scar, breastfeeding may be affected in a percentage of patients. Nipple sensation may be affected too.
The procedure should result in a more outward-projecting appearance to the nipples.
Nipple Areola Reconstruction
What is a nipple reconstruction?
The nipple is usually removed with a mastectomy unless a nipple-sparing mastectomy can be performed.The nipple is usually reconstructedfrom the surrounding local skin of the normal or reconstructed breast using an operation called a CV flap, skate flap or double-opposing tab flap. A specific pattern of skin and fat is raised on the breast in the area where the surgeon wishes to place the nipple. These flaps of skin are rearranged to form a projecting nipple shape. Six to 8 weeks later, a tattoo is used to color in the areola.Nipple reconstruction is usually performed with the patient under local anesthesia but may be combined with other procedures when the patient is under general anesthesia. The procedure lasts for over 30 minutes for one nipple. The areola is later recreated by either tattooing or reconstructed with a skin graft taken from elsewhere on the body. Common donor areas for the areola graft include the groin, the inner thigh, or the buttock crease. Tattooing for areola takes 45 mts.
Alternative forms of nipple reconstruction include grafting part of the nipple from the other breast, placing a piece of ear cartilage, or using a filler material such as fat. All these can be employed to reconstruct the nipple or add projection to a previously reconstructed nipple that has flattened over time.
Sutures are removed with delay at 10-14 days. A protective dressing is worn for 7-10 days. Normal activity except for vigorous exercise or heavy manual labor can resume in about 48 hours.
Common initial side effects include bruising and swelling. Also it has been noted that nipples tend to lose their bulk and projection over time so they are intentionally oversized to begin with to compensate for this. Delayed wound healing and infections may occur.