Inverted nipple; contribution to the surgical treatment

A New Technique in Correction of Nipple Inversion Using Dermal C Flaps

BACKGROUND

Nipple inversion, which is defined as a nipple located on a plane deeper than the areola, presents both functional and cosmetic problems. Surgical repair of severe cases involves suture or flap techniques. In the present study, an alternative repair technique using two cross dermal areolar flaps to correct challenging inverted nipples is presented. Releasing the inverted nipple is performed by severing the underlying tight fibrous tissue bands and canaliculi.

METHODS

This is a retrospective case series. Fifteen patients who had been operated between January 2010 and January 2016 were included in the study. Seven of these had bilateral inverted nipples. Patient age at operation ranged from 26 to 47 years (mean age, 32.5 years). All nipples were congenital, with no previous operations. The follow-up period ranged between 8 and 16 months (mean of 13 months).

RESULTS

There were no complications associated with surgery, including infection, hematoma, permanent sensory disturbance, or nipple necrosis. Unilateral recurrence occurred in one patient on the 26th postoperative day. This patient was reoperated on successfully using the same method. Adequate projection was achieved in all patients. All patients were satisfied with their results.

CONCLUSIONS

The authors conclude that their procedure is a reliable, simple, safe, and effective method for correction of inverted nipples. The alignment of the scar with the junction of the nipple and the areola leads to a more aesthetic appearance with no apparent scarring. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

LEVEL OF EVIDENCE IV

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Sensation-Sparing Correction of Inverted Nipples Using the 'Drawbridge' Flap Approach

INTRODUCTION

An inverted nipple can cause significant functional and psychologic disturbance to women. The holy grail of any surgical technique to correct this is to restore adequate nipple projection and at the same time, try to preserve lactation and nipple sensation. We describe our experience using an inferior dermal nipple-areolar interposition flap to correct the inverted nipple alongside with selective release of the lactiferous ducts of the nipple.

MATERIALS AND METHODS

We have employed this technique successfully in 97 cases of inverted nipples in 60 patients with follow-up periods of up to 2 years. Twenty-three of them had unilateral inversion, and 37 of them had bilateral nipple inversion.

RESULTS

The appearance of the nipple was good to excellent. Seventy to 80% of the initial postoperative nipple projection at the end of 1 year was maintained. Postoperative complications included stitch abscess in one patient (n = 1) and an epidermal cyst in another (n = 1). Nipple sensation was preserved in 100% of cases. There was no recurrence of inversion in any of the nipples.

DISCUSSION

By identifying the root cause of inverted nipples in each individual case, and selectively targeting them, we minimize surgical morbidity with a simple technique that avoids any form of traction or compression of the nipple and minimizes the risk of altered nipple sensation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Trans-nipple double Z-plasty for benign periareolar disease with inverted nipple

BACKGROUND

Various surgical procedures have been reported for correction of inverted nipples. The authors herein report a new procedure, "the trans-nipple double Z-plasty," for correction of inverted nipples combined with periareolar disease requiring excision.

METHODS

From July 2010 to June 2012, 11 unilateral inverted nipples with other benign periareolar diseases were treated with this technique. A midline incision and 5-mm Z-incisions were designed on the nipple-areola complex toward the direction of the combined breast disease. After removal of combined benign disease through the trans-nipple double Z-plasty incision, the defect was filled with surrounding breast tissue, and the inverted nipple was corrected.

RESULTS

One case of partial necrosis improved with conservative treatment. No recurrence was reported during the follow-up period. Five patients each assessed the cosmetic result as excellent and good.

CONCLUSION

The trans-nipple double Z-plasty is an easy and useful technique for simultaneous management of periareolar disease with an inverted nipple.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple invagination: the umbrella effect

The authors present their technique for correction of invaginated nipple, a procedure used for the past 20 years. Most often, this condition is a consequence of a subareolar muscle diastasis associated with short fibrous septa as well as short and fibrotic ducts. The correction technique specifically divides the fibrous tracts and corrects the diastasis of the subareolar muscle. The procedure was performed for healthy patients as well as for patients with mastitis sequel treatment and surgical reduction or augmentation mammaplasty.

A method for correcting an inverted nipple with an artificial dermis

Various methods have been reported to correct an inverted nipple. Although a satisfactory outcome has been reported with most techniques, each method carries a drawback inherent in the technique itself, including complicated operative technique, sensory disturbance of the nipple, marked scarring of the nipple areola and other donor regions, destruction of breast function, and incomplete correction. This report describes a simple method for correcting an inverted nipple. It incorporates a new concept of using artificial dermis for tissue augmentation and is performed without sacrificing any donor site and complex design. It was applied to four nipples in two nulliparous cases. For all four corrected inverted nipples, good results were obtained, and there have been no complications. There were no deformities of the nipples or the areolas after this procedure, and the surgical scars were inconspicuous.

The inverted nipple: to cut the ducts or not?

Much dilemma exists as whether to divide the lactiferous ducts or not when correcting an inverted nipple. We report a series of 26 cases (44 nipples), which have undergone correction with or without duct division. Eversion was maintained in 59% of nipples. Analysis of the failure groups revealed similar rates of failure for umbilicated nipples whether the ducts were divided (27%) or not (25%). Invaginated nipples showed an increased tendency to reinvert postoperatively if the ducts were not divided (80%) than if they were (42%) (not significant). Permanent loss of nipple sensation was noted in 20% of cases when the lactiferous ducts were divided. Postoperatively two women were able to breast feed despite complete division of their lactiferous ducts. Women with umbilicated nipples are usually able to breast feed. We believe that correction of the umbilicated nipple can usually be successfully performed, and function maintained without dividing the ducts. Correction of the invaginated nipple requires duct division. The underlying pathogenesis and varying methods of correction are reviewed.

Inverted nipple: the new method of correction

A new technique for correcting inverted nipples is described. It consists of the sectioning of the only genetic factor--the resistance of the collagen fibers--by undermining, under the control of a palper. The trophicity of the nipple is assured by a circular "umbrella" musculocutaneous flap containing the superficial vascular system. A subdermal cutaneous notch "blocks" the nipple and prevents any recurrence.

Nipple reconstruction with muscle flap

The authors present a new technique for nipple reconstruction using muscle flaps obtained from muscles situated deep in the retromammary costal region. In the case illustrated, the muscle used was the rectus abdominal muscle, previously transposed for reconstruction in a patient mastectomized more than three years ago. The resulting nipple salience as well as the areolar area were covered with a skin graft obtained from the medial thigh donor site.

Correction of the inverted nipple

A simple procedure for correction of inverted nipples is described. The key to the method is the preparation of 2 deepithelized dermal flaps after supplementing the volume of tissue beneath the nipple, and preventing recurrence of the deformity with slings.

Treatment of the postoperative inverted nipple with or without asymmetry of the areola

Postoperative inversion of the nipple is a possible complication in reduction mammoplasty, especially when a tendency toward inversion exists prior to surgery. A technique for correction is presented, leaving no more scars than the peri-areolar scar corresponding to the nipple transposition. Dermal flaps are used to prevent recurrence. Any asymmetry in the location of the areolas or excessively high position can be corrected simultaneously.

Genetic studies in a family with inverted nipples (mammillae invertita)

A Jewish Sephardi family is reported in which 16 members are affected (15 females and 1 male) with inverted nipples. The one affected male and his brother also have gynecomastia. Under the assumption that this trait is transmitted as an autosomal dominant, linkage studies were done but were not revealing. Further family and investigative studies are needed in this disorder to understand better its pathogenesis and precise mode of genetic transmission.