Short Notes in Plastic Surgery

May 16, 2019

63A. The Inverted Nipple of the Female Breast

Filed under: Chapter 63A — ravinthatte @ 4:35 am

This blog began almost ten years ago and was written in continuity. However the compiler of this blog has continued to attend scientific meetings in India and as and when a subject not yet covered in this blog came to his notice in these meetings those subjects are now included. In January 2019 at the meeting of the Maharashtra State Chapter of the national Association of India’s Plastic Surgeons, Shailesh Nisal of the Sparsha Clinic in Nagpur, India presented an excellent paper on the Inverted Nipple of the female breast and was invited to write on the subject. That chapter is reproduced below.

63A. The Inverted Nipple of the Female Breast

Prevalence

Several studies have shown that the incidence of congenital inverted nipples in unmarried females is about 3-4%. Of these 86% are bilateral while 14% are unilateral. 96% of these could be everted either by a cold touch, suckling or by eversion with fingers. These which can be everted do not need surgical intervention (except when cosmetic correction is desired) because the nipple comes out on suckling by the baby and normal feeding is possible.

Types or Grades

Grade I

  • Shy nipples
  • Easy protraction with gentle pressure  

Grade II

  • Brought out with difficulty
  • Retracts when released

Grade III

Cannot be brought out and in a vast majority of cases lactation is not possible in spite of a surgical correction This condition may hinder drainage of sweat or the normal discharge from the nipple leading to crusting soreness infection and a rash in the surrounding skin.

Grade III Inversion of the nipple, cannot be brought out and there is soreness and crusting in buried part. Lactating ducts likely to be cicatrized and the patient will not be able to lactate.

Nipple inversion can be Congenital/Pubertal or Acquired. When a normal projecting nipple in an adult female puckers or inverts over a period of time the cause is either an inflammation or a malignancy. This warrants serious evaluation and management based on the cause. The present discussion concerns itself purely with Congenital or Developmental (Nipple) Inversion of the nipple.

Indications for surgery

The indications for surgical intervention are both cosmetic as well as functional. Nipples that project from the areola are a part of the erotic appeal of a woman. In addition, the sensations that arise from nipples when handled are a part of the erotic experience that a female enjoys.

Grade II correction in Nulliparous women should be avoided since they may be able to lactate normally without intervention.

Grade III inverted nipples have severe cicatrisation of lactiferous ducts and usually such breasts fail to lactate successfully with or without surgery and this fact must be conveyed to the patient so as not arouse such an expectation.

Surgery

  1. Two cross stay sutures are taken to bring out the inverted nipple by traction.
 Cross sutures to evert and bring out the nipple
Small incision at 9’O clock position at the desired base of the nipple is sufficient to do the transection as well as the encircling suture which is described in the steps narrated below.

2. The incision measures a few mms (from) at the base of the nipple at 9’o clock for the right breast and at 3’o clock for the left breast assuming that the surgeon is standing on the right side of the patient as she lies on the table

A pair of scissors is passed in the subcutaneous plane all around while pulling and hooking out the bands which were tethering the nipple inward. All tight bands are cut one by one while continuing to apply traction on the stay sutures. The end point is reached when the nipple stays everted and projects itself without any pull on the traction sutures.

The release is complete once the nipple stands out in the desired position even after traction on the suture is eased.

T

The tight band pulling the nipple are hooked out and then transected one by one so as to cause eversion without traction.
When combined with excision of Fibroadenoma a peri-areolar incision may be used for the same procedure

3. An encircling purse string suture is taken through the subcutaneous tissue at the level of the desired base of the nipple. The knot is tied tight enough to not allow retraction but loose enough not to cause a vascular compromise.

 Encircling suture at base of nipple with absorbable suture, tight enough to prevent retraction but loose enough not to cause vascular compromise

4. The Incision is closed with absorbable suture such as 4-0 Vicryl or Monocryl for both the purse string as well as the closure of the skin.

5. Another purse string suture can be taken through the skin only if the bands were found to be very tight and the Surgeon fears a recurrence of inversion in spite of transection of all the bands and the previous suture in the subcutaneous plane. Here too care is taken in tying the knot as narrated in point 3.

Dressing

The Principle in dressing these wounds is not to have the slightest pressure on the newly everted nipple during the phase of healing and maturation.

There are 2 ways of doing it. First by placing an open lid upside down with 2 holes on its top through which the stay sutures come out and are tied so as to retain traction on the nipple. The vascularity of the nipple can be inspected through it if the lid is transparent or by gently lifting it and seeing underneath the lid without untying the knot. The other way is to place a thick foam with a hole in its centre in which the nipple sits in a relaxed fashion without any pressure on it. Such a foam is any case necessary inside the brassiere for 3 months till healing occurs. This is to prevent the pressure of the brassiere on the nipple causing the transected bands to reunite and result in recurrence.

Foam with a hole to avoid even slightest pressure on the operated nipple, this continues for 6 weeks till mature healing occurs.
Cross sutures passed through holes in a plastic lid and tied to maintain traction. The lid prevents any pressure of dressing or Bra on the everted nipple

The traction sutures are removed between the second and third week

Results

Satisfactory eversion maintained after 3 yrs.

If done carefully and with attention to detail the results are gratifying.

The possible complications are partial or complete necrosis of the nipple due to devascularisation and recurrence of inversion. Both would result from the way the purse string suture is applied. A tight suture can lead to de-devascularisation and a loose one may lead to a relapse.

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