Outline

Numerous techniques have been described for the correction of inverted nipples; their diversity supports the lack of a consistently reliable method. Dermoglandular flaps, open suture, and suction techniques have all been described to combat the “corrected” nipple's propensity to collapse. We present a minimally invasive parenchymal release and percutaneous suture technique that provides sustainable long-term correction of inverted nipples. Thirty-one patients with 58 inverted nipples were treated. The technique, performed under local anesthesia, employs lysis of the foreshortened subareolar fibro-ductal tissue to achieve resting eversion of the nipple using an 18-gauge needle. Through the same needle-access site, a purse-string suture is then placed, exiting the areolar skin and re-entering through the same stitch point every 3 to 5 mm around the circumference of the new nipple-base. An absorbable suture closes the access site over the knot, and 2 crossed absorbable mattress sutures are placed beneath the nipple to complete the correction. Of 27 patients with bilateral and 4 with unilateral, nipple inversion, durable correction was achieved in 1 procedure in 45 of 58 nipples (78%). There were 13 recurrences, of which 11 (19%) were successfully treated under local anesthesia with a second purse-string suture, and 2 (3%) required a third procedure under local anesthesia. There were no late reinversions. There were no cases of infection, nipple ischemia, or other complications. Occasional recurrences are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through “needle-only” access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.

Inverted nipples are common sources of self-consciousness and concern for many women. Presenting unilaterally or bilaterally, and with varying degrees of severity, it has been estimated that up to 10% of women are affected by inverted nipples.1–3 Most often due to a “tethering” effect that results from congenitally foreshortened ductal elements,4 correction of the inverted nipple involves releasing the fibrous bands and short lactiferous ducts as well as suspension of the nipple to maintain the repair. Dermal and dermo-glandular flaps, endoscopic release, internal suture, continuous traction, artificial dermis, and a variety of suction techniques have all been described to correct the inverted nipple.5–11 The diversity of procedures denotes the lack of a single technique that reliably results in durable, sustainable correction for this common problem. As a result of many of the open-incisional and flap techniques,5,6,8,12–15 areolar scarring or nipple shape may be unsightly or objectionable. Minimal-incision and traction techniques often use additional indwelling or external appliances such as wires, springs, rings, splints, or aspirators that may require weeks or months of maintenance to achieve variable results.9,16–19

In this study, we present and evaluate a minimal-incision fibro-ductal and parenchymal release technique, further supported by percutaneous suture, which provides sustainable long-term correction of inverted nipples.

Thirty-one patients’ 58 inverted nipples were treated from July 2002 through June 2007, with follow-up ranging from 8 to 69 months (mean 22 months). Twenty-seven patients had bilateral nipple inversion and 4 had unilateral inversion. All patients selected had congenital deformities, with no cases of posttraumatic, postinfectious, or postsurgical inversions. All patients had normal preoperative breast examinations and no family or personal history of breast cancer. Nipple inversion severity was classified according to Scholten's 20 and Han and Hong's 21 classification: a grade I inverted nipple (mild) is easily corrected manually, and maintains its projection without continued traction; a grade II inverted nipple (moderate) can be everted manually with greater difficulty than grade I, and has a tendency to more rapid retraction; and a grade III inverted nipple (severe) is deeply inverted, extremely difficult to manually evert, and retracts immediately. The data were reviewed retrospectively.

The procedures were performed under local anesthesia only (24 patients), except when performed during concomitant surgical procedures requiring general anesthesia (7 patients). The proposed base-circumference of the nipple is marked, and after infiltration of local anesthetic solution, a temporary traction suture is placed to evert the nipple. A standard 18-gauge needle (B-D Fill 1 1/2 18GTW, Becton Dickenson and Co., Franklin Lakes, NJ) is inserted at the 6 o'clock position, using the tip to lyse the foreshortened subareolar fibro-ductal tissue as necessary to achieve resting projection of the nipple without suture traction (Fig. 1). Through the same needle-access site, a monofilament purse-string suture (4-0 clear nylon or 4-0 polydioxanone) is inserted, exiting the areolar skin and re-entering through the same stitch point every 3 to 5 mm around the circumference of the nipple-base (Fig. 2). The purse-string suture is tied under moderate tension, and the nipple-areolar access site over the knot is closed with a 6-0 plain gut suture (Fig. 3). Two crossed 5-0 plain gut mattress sutures are then placed beneath the nipple to complete the correction. Antibiotic ointment is applied liberally, followed by a very loosely applied cotton-free gauze dressing. No splints or other appliances are used. Patients are instructed to wear a T-shirt or camisole with no compressive brassiere for 2 weeks, after which there are no restrictions.

In 31 women with 58 nipples corrected (27 bilateral and 4 unilateral), 18 inverted nipples were classified grade I (mild) (Fig. 4); 30, grade II (moderate) (Fig. 5); and 10, grade III (severe) (Fig. 6).

Durable correction was achieved with 1 procedure in 45 of 58 nipples (78%). There were 13 recurrences, occurring between 3 days and 17 weeks. Of these, 11 (19%) were successfully treated under local anesthesia with a second procedure, and 2 (3%) required a third procedure under local anesthesia.

There were no recurrences in grade I inverted nipples (0/18), 8 recurrences in grade II inverted nipples (8/30, 27%, all corrected after a second procedure), and 5 recurrences in grade III inverted nipples (5/10, 50%, 3 corrected after a second procedure, and 2 corrected after a third). There were no late reinversions. There were no cases of infection, ischemia, or necrosis.

Inverted nipples have both functional as well as psychologic sequellae, the latter of being the impetus for most women seeking correction; the embarrassment, self-consciousness, and insecurity that women with inverted nipples feel is often substantial.

Nipple inflammation, mastitis, and malformed appearance due to inversion has historically been addressed with a wide variety of surgical and nonsurgical procedures.3,5–10,16–24 First described by Kehrer 24 in 1879, methods of correction have employed variations and combinations of several different themes and techniques: maintenance of the integrity of the ductal tissue with flap construction, augmentation, or support of the nipple, division of lactiferous ducts and fibrous elements, with or without internal or external support, and gradual distraction of the nipple with direct mechanical or negative pressure-assisted (suction) methods.

Skoog, Spina, Schwager et al, and Wolfort et al 12–15 have all described various dermal flaps and dermoglandular flaps that aim to preserve the main lactiferous ducts. These procedures require multiple areolar incisions that may result in significant scarring and deformity of the nipple-areolar complex, and ultimately an objectionable cosmetic result. Additionally, given that the tightly tethered and foreshortened main ductal elements are not corrected, variable long-term durable projection and recurrence is common. In our experience, the goal of women seeking the correction of inverted nipples is to achieve pleasing esthetic results, and the disfigurement and distortion associated with these techniques inspired our exploration of a less-invasive approach.

Minimal or “microincision” procedures have been described for the correction of inverted nipples,25,26 and served as the theoretical basis of the technique evaluated in our study. After local anesthetic infiltration and traction-eversion of the nipple, the 18-gauge needle tip is sufficient for the release of ductal and fibrous elements as necessary to allow for tension-free, resting projection of the nipple. Placement of the tiny incision site at the perpendicular transition between the projecting nipple and the areola camouflages the primary access point.

A monofilament suture is always used for the purse-string correction, as it slides easily and ultimate tension can be well-controlled. The choice between a permanent suture (clear nylon) and dissolvable suture (polydioxanone) is made based upon the severity of inversion. Moderate and severe grade II and III nipple inversions are corrected with a permanent purse-string suture, and mild grade I inversions are corrected with an absorbable purse-string suture. We have not experienced any early or late recurrences with this suture choice in the grade I inversion group.

Recurrences occurred in 13 of 58 nipples corrected (22%), and all recurrences were in the grade II and grade III groups. The higher the severity classification, the higher the recurrence rate: 0 in group I, 27% in group II, and 50% in group III. Recurrences are extremely simple to correct, and patients are prepared preoperatively for the possibility of additional procedures required to achieve long-term correction. During the primary correction, the release of the underlying tethered fibro-ductal pathology also leaves the newly projected nipple perfused only by the subdermal and subareolar vascular plexus, hence, judicious “cinching” of the purse-string suture is required. The application of enough tension to maintain projection, while avoiding constriction of the blood supply, is the delicate balance that must be achieved. In striving to avoid ischemia, we feel that a number of recurrences are acceptable, particularly early in the learning-curve of this technique. Treatment of recurrences is similarly performed under local anesthesia. A minimal-access location at or adjacent to the initial site is used, and after scar release, a second purse-string suture is placed using the same technique. If the original suture is visualized, it is removed; otherwise it is left in place. With the second procedure, increased tension can be applied, as the nipple has undergone a flap “delay” having been previously isolated on its subareolar vascular plexus.

The decision to choose any procedure that completely divides the lactiferous ducts is one to be given careful thought and consideration by both patient and surgeon. Although there have been reports of lactation and breast-feeding following duct-dividing procedures,27 presumably due to ductal recanalization, the assumption must be made that the ability to breast-feed will be extremely small following complete division of the lactiferous ducts. Although it may be predicted that certain women with inverted nipples, particularly grade III inversions, have limited ability, or inability, to breast-feed, this cannot be confirmed until infant suckling has been attempted. Women considering duct-dividing surgery must be thoroughly counseled regarding the preclusion of the ability to breast-feed.

This minimally invasive technique for inverted nipple correction represents a practical and safe method for the treatment of inverted nipples of all stages. Occasional early recurrences, based on the need to cinch the purse-string snugly while maintaining perfusion of the newly everted nipple, are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through “needle-only” access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.

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Key Words: inverted nipple; correction of nipple inversion; minimally invasive nipple correction; lactiferous duct division