The breast is unique to mammals. It differentiates mammals from other species. It serves to provide nourishment from mother to her offspring. The nipple is typically elevated, or everted, above the surface of the breast and contains 15 to 20 milk ducts, which allows for the passage of milk from the breast gland. The nipple is surrounded by the areola, a sheet of fibromuscular tissue and skin. For reasons we don’t understand, the nipple can become inverted, meaning that it projects into the breast. This usually develops during puberty as the breast grows. Common findings include either shortened ducts, deep fibrous tissue that prevents the nipple from everting, or both. Aside from preventing a baby from successfully breastfeeding, there are no physical consequences to having inverted nipples. However, inverted nipples are not typically depicted as “beautiful” and as such, many woman who have inverted nipples feel inadequate and very self-conscious. This can cause problems with intimacy and self-confidence. Even many women with inverted nipples, who have stable, healthy relationships, come to the office for correction because they “have always” felt (and continue to feel) unattractive.
In 1999, a grading system was described by Han and Hong. It is still used today to describe the severity of inverted nipples. In addition to being able to classify a patient’s condition, it helps to predict the success of the variety of different treatments. There are three grades.
In Grade I, the problem is mild. The nipple can easily be everted with gentle pinching and can usually maintain an everted position for a short time while the areola contracts. Surgical correction of this grade can usually be accomplished with just a buried suture at the base of the nipple. Sensation and the ability to breastfeed should be maintained.
Grade II inverted nipples can also be manually everted, but it takes a lot more effort. Also, it does not stay everted and quickly becomes inverted when released. Usually the ducts are not too short but being pulled downward by the fibrous tissue. The ducts can be released by dividing the deep fibrous tissue. Adding the buried suture maintains the everted position and completes the procedure. Usually sensation and the ability to breastfeed are maintained, though not guaranteed.
Intra-operative view of intact ducts after
removal of fibrous tissue
Grade III is the most severe. The nipple cannot be everted manually. There is a lot of fibrous tissue that keeps the nipple inverted, and the ducts might be physically shortened. This is the most difficult grade to successfully treat. There have been many types of procedures designed to correct these inverted nipples. They all have certain things in common. They divide the fibrous tissue, keep the nipple everted after surgery with a traction suture and add tissue into the nipple. Adding tissue helps to add bulk, which is lacking once the nipple is everted. The tissue usually comes from small “flaps” created from the adjacent areola. In addition to adding bulk, the flaps can serve as a sling to keep the nipple everted. The drawback in these techniques is that there is a lot of cutting beneath and within the nipple. This can divide the ducts, nerves and blood vessels. This can result in the inability to breast feed, numbness and, in some cases, can cause a problem with circulation and healing. Finally, in spite of all of these efforts, there is always a chance of relapse.
Dr. Schuster’s choice of correction of Grade III inverted nipples is to perform the surgery with the help of a magnifying small joint arthroscope. This technique was first reports by Chen, et al, in 2007. By using the arthroscope, the surgery can be performed through a very small incision placed at the base of the nipple. The scope magnifies the area so that the fibrous tissue can be divided while leaving the ducts, nerves and vessels alone. Then a small strip of skin is taken from a well-concealed area in the groin, and placed into the nipple to provide the needed bulk. A buried suture is added at the bottom and a suspension suture is worn for a week. Although it is a technically more demanding surgery, and takes a bit longer to perform, Dr. Schuster believes it has the highest success rate and the best chance to preserve sensation and the possibility to breastfeed. The surgery is performed on an outpatient basis under IV sedation. It is not painful after surgery. A slightly bulky bandage is worn for a week. Light protection is needed for six weeks after surgery. Exercise can be resumed three weeks after surgery.
To learn more about how Dr. Schuster treats inverted nipples, please schedule a consultation.