Breast nipple inversion
It is widely believed that the inversion of the breast nipple is just an aesthetic problem, since the breast does not look very harmonious.
If we think about it, we will find out that the inversion of the breast nipple is an highly important problem that should be treated, since many women are not able to breastfeed their babies after giving birth.
According to plastic surgery principles, the correction of breast nipple (or nipples) retraction can provide a solution for both the aesthetic harmony and the restoration of the mammary gland function.
How does a normal breast look like?
A normal female breast consists of a conical projection of the mammary gland on the top of which raises the nipple-areolar complex. The areola is of circular or oval shape, with a diameter of about 3 to 5 cm, of dark or brown color and in the center of the areola projects the nipple.
The breast nipple has a diameter of about 1 to 1,5 cm and is of the same color with the areola, is found in its center and projects about 0,5 to 1,5 cm in front of the areola.
What does the inversion of the breast nipple mean?
When one or both breast nipples present an inversion, this means that the nipple is totally flat or is immerges deep inside the breast parenchyma. Normally, the nipple should project in front of the areola about 0,5 to 1,5 cm.
In most cases of inversion, the nipple position is fixed facing inwards and does not react to any irritation. However there exist incidents that the nipple is moving and raising beyond the areola after its irritation, as normally happens to nipples.
How common is the phenomenon of the inversion of the breast nipples to the general population?
The inversion of breast nipples is a quite frequent phenomenon that concerns about 2% of the general population. It may concern both men and women and may be spotted only to one or to both breasts.
What are the main causes of breast nipples inversion appearance?
The most common cause is congenital (i.e. the retraction appears from birth).
Other causes of appearance are:
- After breastfeeding due to repeated pregnancies,
- After inflammations, eg mastitis,
- After inflammatory diseases such as tuberculosis,
- After injuries or breast surgeries,
- After sudden and exceeding weight loss, where the breast is completely emptied and the nipple support disappears.
6 It is always worth mentioning that if the appearance of retraction of breast nipple is sudden and usually one-sided, this may be breast malignancy with tumor growth behind the nipple that pulls it inwards.
What happens in terms of pathology-anatomy when we have a inversion of the breast nipple?
Nowadays we know that 15-20% of the inversion of the nipple incidents appears from birth. The most frequent cause (pathologically/anatomically) is the shortness of the breast lactiferous ducts. This means that the lactiferous ducts flowing into the nipple are short, thereby holding the nipple stuck and not letting it raise forward.
Other causes of the inversion of the breast nipple are the atrophy of the connective tissue that lies beneath the nipple and supports it, as well as the hypertrophy of the areola muscle sphincter, or a combination of the causes mentioned above.
The cause of the inversion in injury or inflammation cases is the formation of a cicatricial tissue whereas the retraction by a malignant disease is due to its attraction by the neoplastic tissue.
Are there any classification stages of the inversion of the breast nipples?
Depending on the fixation and flattening degree of the nipple and the full or not projection weakness in front of the breast after its pulling or irritation, the inversion of the nipple is classified into three stages:
1st STAGE: The nipples present a flattening or retraction, but with gentle pressure around the areola, or project outwardly and effortlessly after stimulation. The breastfeeding is usually possible.
2nd STAGE: A greater pressure is required in order to pull out the nipple. When the pressure or irritation stops the nipple is automatically flattened and is deeply immersed in the breast parenchyma. The patient, though, is able to breastfeed with great difficulty using a special breast pump.
3rd STAGE: This is the most serious stage where the nipple does not at all project from the breast even exercising high pressure. The nipple is always retracted and hygiene issues or infections are frequently observed. The mother is not able at all to breastfeed her baby.
Is a woman with inversion of breast nipple able to breastfeed?
According to the degree of the retraction, the severity of the problem changes, as well as the possibilities of breastfeeding.
Breastfeeding after stimulation is relatively easy when the inversion of breast nipple is at the first stage.
Breastfeeding is possible using a special breast pump, when the retraction of breast nipple is at the second stage, but it is often a painful procedure for the mother.
The breastfeeding is definitely impossible when the inversion of breast nipple is at the third stage, since there are no nipple projection margins.
What is the surgical treatment of the breast nipple retraction?
Depending on the cause of the problem we should always choose the most adequate treatment technique.
- The most frequent case of breast nipple inversion is the shortness of the breast lactiferous ducts behind the nipple, or the atrophy of the areolar connective tissue. There are two techniques depending on the degree of retraction. The technique of either maintaining or intersecting the lactiferous ducts.
- In case the inversion of breast nipple is due to an injury or surgical treatment we perform a reconstructive surgical treatment with local flaps usually combined with fat transplantation.
- In case the retraction of breast nipple is due to a malignancy, an oncological treatment should be performed.
How is the surgical treatment of breast nipple retraction performed, which is due to shortness of the breast lactiferous ducts or to atrophy of the areolar connective tissue?
For the inversion of 1st and 2nd stage we prefer a Plastic Surgery technique of preserving the breast lactiferous ducts. We remove very carefully a part of the lactiferous glands from the connective tissue that fixes them and then we support the areolar connective tissue with local flaps.
The retraction of the 3rd stage means that the breastfeeding is impossible, since the shortness of the breast lactiferous ducts is greater. For this reason we prefer a technique that intersects the lactiferous ducts and then we support the areolar connective tissue with local flaps, in order to prevent the forwarded nipple falling again backwards.
What type of anesthesia is applied? Is it a painful surgical treatment?
It is a routine surgery with the application of local anesthesia. In general terms this surgery can be performed in a private clinic and is considered to be a painless treatment both at preoperative and postoperative stage.
What is the surgical procedure? What should the patient do after the breast nipple retraction treatment?
The surgery usually lasts 30-40 minutes and after that the patient is able to go back immediately to her ordinary life.
After the surgery it is placed a special suture on the nipples, which attracts and holds the nipples at their new position, supported by a small cotton splint.
What we want to avoid after surgery is the backwardly pressure of the nipples by the bra. This special suture ensures that the nipples are free without any pressure.
The suture remains for about 2 or 3 weeks and it can be simply removed when we are sure that the nipple projects naturally from the breast.
Can a woman breastfeed after the surgery? Is the result permanent or may relapse depending on the extent of the problem?
At 1st and 2nd stage breast nipple retraction, where the lactiferous ducts are maintained, the technique allows the breast to breastfeed after the surgery, since the lactiferous ducts are maintained. Nonetheless, the nipple can be relapsed at an approximate rate of 25-40%.
At 3rd stage breast nipple retraction, since the lactiferous ducts are intersected, the breast is not able to breast feed after the surgery. As mentioned above, the breast with 3rd stage retraction is not able to breastfeed at all.
The relapse rates are about 5-15%.
How long should the aftercare last?
Generally speaking, a time period of 3 to 4 weeks is required. During this period the patient is able to normally return to his/her daily activities, such as work, exercising, holiday etc., since the nipple area is totally painless and protected with simple cotton pads.