Inverted Nipple

An inverted nipple is a situation in which the nipple is curled inwards instead of projecting outwards as it should be in normal anatomy. It can affect both men and women, and it can be present at birth (congenital) or acquired during life. In contrast to the usual anatomic posture, where the inverted nipple projects beyond the line of the areolar breast, the protrusion of the inverted nipple falls beneath the areolar plane. The appearance can be distressing emotionally, as well as a concern during breastfeeding in nursing mothers. As many as 12 to 19 percent of females are born with one or more inverted nipples, which are often asymptomatic until they are nursing. The appearance might be unattractive and concerning from an aesthetic standpoint. It's important to distinguish between a benign inverted nipple and primary breast cancer.

Inverted Nipple Epidemiology

Up to ten percent of the population has a congenital nipple inversion. Both men and women are affected. Bilateral diseases account for 87 percent of cases, while family diseases account for 50 percent.

Inverted Nipple Pathophysiology

Around the third trimester, the nipple forms in utero, with a mammary pocket forming on the mammary bud's epidermis. This pit canalizes during the ninth month, and the underlying mesoderm continues to spread to raise it above the level of the areola, resulting in the creation of a nipple. An inverted nipple can occur from defective developmental patterns in the mesoderm that fail to lift the nipple above the areolar level.

Inverted Nipple Etiology

Saggy breasts, traumatic fat necrosis, infections such as acute mastitis, duct ectasia, tuberculosis, abrupt weight loss, following surgeries performed on the breast and in cancer, and Paget's disease of the breast are all examples of inverted nipples.

The invasion of the lactiferous ducts by tumor tissues causes nipple inversion in malignancies. These must be precisely recognized with a thorough physical examination and oncologic evaluation of a patient, as nipple-plasty or other surgical treatment is contraindicated in these cases and could delay or complicate an essential breast cancer diagnosis. An inverted nipple can be treated surgically for both congenital and benign reasons.

Inverted Nipple Symptoms

As the patient reaches puberty, a psychiatrist or general practitioner would most likely identify congenital nipple inversion during a wellbeing examination. During puberty, many inverted nipples that exist in pre-pubescent patients will be correct on their own. They normally do not create any problems at that time, and they are usually watched until puberty or adolescence to see if they resolve. They will often persist if they do not disappear with puberty, and correction may be necessary for adulthood for breastfeeding, psychological, or cosmetic concerns. When faced with lactational issues, many patients seek correction/treatment. Digital intervention is commonly used to grade the inversion.

After puberty or breast maturation, pathological/acquired nipple inversion is more concerning for cancer or other problems. This is usually linked with a breast bulge, nipple discharge (serious/bloody), or nipple ulceration. In both male and female patients with any breast carcinoma, it is critical to get a full personal and family history, as well as any confusing trauma history to the breast or chest, because scarring and fat necrosis can resemble malignancy. It is unlikely that the latter will result in nipple discharge.

Psychological issues such as significant psychosexual discomfort can be caused by an inverted nipple. Furthermore, this disorder can cause esthetic and functional issues, as well as localized irritation and infection, preventing optimal breastfeeding.

The nipple and areola can appear in a variety of sizes, colors, and shapes. The nipple's average height and girth are both about 2 cm, while the areolas' average diameter is about 4 cm.  Nipples come in five different shapes: rectangular, omega, circular, round, and slanting.

Inverted Nipple Diagnosis

A clinical diagnostic is an inverted nipple. When inverted nipples are linked with discharge, ectasia, or cancer, studies such as mammography, ultrasonography, or ductoscopic examination can be performed. Treatable reasons, such as underlying lumps or infections, may be discovered.

Both types of inverted nipples can be congenital or acquired. If they were inverted occasionally, they were categorized as umbilicated, and if they were inverted continuously, they were described as invaginated.  Two doctors described the modern surgical classification system. According to the level of fibrosis, the simplicity of manipulation, and the level of damage to the lactiferous ducts, they divided them into three groups.

• Grade 1 inverted nipples shy nipples.  They show soft-tissue adequacy and have low or no fibrosis. Even with the retraction, the lactiferous ducts are normal. These nipples are easy to manipulate and retain projection for a long period, allowing for easy breastfeeding, though initiation may be challenging.
• Grade 2 inverted nipples - They have a substantial amount of fibrosis. Smooth muscle fibers can be detected wrapping the fibrous matrix on tissue examination. Retraction of the milk ducts. The nipples can be stretched out, but they quickly retract. It is acceptable to breastfeed, however, the baby may have trouble gripping onto the nipple. The decision to lyse the fibrous layers that surround the lactiferous ducts is made on a case-by-case basis. The majority of cases do not necessitate surgical intervention.
• Grade 3 inverted nipples - There is a lot of fibrosis and a lot of soft tissue insufficiency. Lactiferous ducts are small, restricted, and retracted to a large degree. The terminal ductal segments are fibrosed and atrophied histopathologically. These nipples can't be taken out; thus, they need to be surgically removed. It is practically impossible to breastfeed an infant. Rashes, painful nipples, and recurring mastitis are common issues for these patients.

Inverted Nipple Treatment

The grade of inversion has a big impact on management. There has been a diversity of surgical and non-surgical treatments used to address nipple inversion over time, with both successful and unsuccessful outcomes. Non-invasive/conservative treatments were used to treat grade 1 inverted nipples successfully, and grade 2 inverted nipples partially. Grade 3 and recurrent grade 2 inversions are the most common reasons for invasive/ surgical operations. As a result, no uniform method has been used.

The conservative treatments primarily entail the use of equipment that provides graded/continuous suction on the nipple-areolar complex in order to lengthen the nipple and keep it protracted.

Hoffman proposed a historic technique that comprised placing thumbs on opposite sides of the nipple over the areola and applying hard deflationary pressure on the breast to evert the nipple while progressively shifting away from it. This was thought to protract the nipple if performed all around and multiple times, however a study by Alexander et al. found that not only is this not useful in nursing, but it may also disturb the lactiferous ducts, therefore it was discontinued.

Nipple Retractor and Suturing Method

Yukun et al. used a nipple retractor built from the hollowed end of a single-use needle to treat all classes of nipple inversion for a decade. Eight holes were drilled for stitches crossing the base, and the retractor's height was determined by the size of the nipple-areola complex and breast capacity. The hollow retractor was positioned on the areola with the nipple and four ends of the stitches in the middle, and two stitches were crossed below the base of the nipple to lift the nipple. Stitches were then threaded through the retractor base's premade holes and secured with knots and appropriate tension. The retractor was worn for 4-6 months before being taken out. Grades 1 and 2 nipple inversions were managed more successfully than grade 3, however, the avoidance of lactiferous duct injury and the continuation of breastfeeding were highlighted as substantial benefits.

Suction Devices and Piercing

Suction devices, such as shells, cups, nipple retractors, and extractors, have been sold for use undergarments. They stimulate and fully extend the nipple by pulling it into a tiny cup. However, no research has yet shown their efficacy or long-term advantages. Piercing, according to Scholten, is a form of correction that retains breast function. This is accomplished by piercing the nipple's base and inserting a stainless-steel barbell similar to those used for decorative body piercing. The corrected location was preserved for one year after the piercing was removed three months later.

Surgical Treatment

Inversions of grades 2 and 3 are usually treated surgically. The many surgical treatments are based on the core premise of freeing fibrous bands and galactophorous ducts, increasing mass underneath the nipple, and filling up the dead space formed within to give the nipple stability and prevent reinversion. The ideal technique is a straightforward and reliable operation that does not involve several incisions or bulky bandages, has minimal scarring, and has a low rate of recurrence or sensory abnormalities. Lactiferous duct preservation and lactiferous duct destructive operations are two types of procedures. Most treatments can be completed with only local anesthetic and superficial and extensive infiltration of the nipple and areolar complex. The formation of dermal and dermo-glandular folds, endoscopic relief, internal stitch, and the interposition of alloplastic and autoplastic components were the most commonly used surgical procedures.

Morris Ritz et al. proposed a straightforward procedure involving two dermo-glandular flaps. A skin clip is used to raise the inverted nipple. A 3mm wide peri-nipple doughnut of skin is de-epithelialized. Connected to the nipple base are two longitudinal dermo-fibrous flaps. To free the nipple, the ducts and fibrous tissue are pulled out and the nipple is lifted to its maximum length. Two holes are created in the deep tissue below the nipple with a blunt dissector, and the flaps are stitched reasonably taut at the nipple base with Monocryl sutures. Interrupted half-buried stitches are used to seal the skin. Grade 3 nipples inversion sidewalls are not sealed and are left to recover through tissue regeneration. For the first four days, a doughnut dressing with antibiotic ointment is applied, with the new nipple attached to the dressing using silk sutures. There were no serious postoperative complications with this method, and it resulted in a satisfactory repair with a little, well-tolerated scarring around the new nipple base. The simplicity of revision adjustment in the event of failure is a benefit of this strategy.

Three Dermo-fibrous Flap Technique

According to some doctors, the two flap surgeries can cause a progressive up/down tilting. As a result, Huang suggested a technique that used three dermo-fibrous flaps to give mass to the repair, provide a strong floor, and keep the circular nipple architecture. After freeing the fibrosis and retracting ducts, three diamond-shaped flaps were created at three different positions and then turned down into the tunnels, creating a conjoined space under the nipple. The only surgical consequence in six research patients was sloughing off the partial skin over the helmet, which healed without mishap due to epithelialization.

Dissecting Microscope

Sowa et al. discovered that using a dissecting microscope was helpful when attempting to fix grade 3 inversions. On the nipple-areola complex, centerline and zigzag-shaped micro-incisions were performed, accompanied by counter-traction with stitches on the divided areola. The transparent elastic channels hidden in the white fibrous connective tissue were identified using a surgical dissecting microscope. The ducts were retained following proper nipple protrusion by careful dissection with minimally invasive surgical scissors. The base of the nipple was constricted by two areolar dermal flaps on opposite sides. They also used a traction device with two syringes to apply an anteriorly focused force to keep the nipple in the over-corrected configuration. Because a dissecting microscope allowed for accurate dissection without trauma and injudicious destruction of lactiferous ducts. nipple sensitivity and ductal functioning were retained.

Postoperative Deformity Correction and Rehabilitation

Lee et al. recommended using internal suturing to close the soft-tissue defect that can occur following correction. A high peri-areolar nipple flap was raised after an inferior peri-areolar incision. To assist the dissection of the fibrous tissue and ducts, a traction suture was placed to the inverted nipple. The deformity was obliterated after release by suturing the interior walls of the nipple together in two layers, superior and inferior. This was a duct-damaging method with high patient satisfaction and no persistent inversion, but it has concerns for breastfeeding.

For significantly inverted nipples or recurrent nipple inversion following primary treatment, rib cartilage has been used to obliterate the deformity. After the lactiferous ducts and fibrous tissue have been released, nylon sutures are used to construct a base. A cartilage transplant from the back of the ear is cut into two disks, stitched back together as a laminated graft, and then inserted into the pocket. A horizontal mattress stitching is used to stabilize it at the base. This produces a projected nipple, but it has an unnatural feel about it. This is a duct-damaging method, and nursing success is quite rare. 

Gauze dressings with a topical antibacterial cream are used as postoperative treatment. Patients should avoid digital manipulation until they are completely healed.

Breastfeeding with Inverted Nipple

Instead of facing out, inverted nipples curl inward. Breastfeeding is still possible for most females with inverted nipples. If your infant is having trouble getting onto the breast, get assistance from the doctor, midwife, or lactation consultant.

To determine whether you have flattened or inverted nipples, do the following:

• Just behind the nipple, place your thumb and fingers on the margins of the areola (the dark region around the nipple).
• Gently squeeze the nipple.
• Instead of sticking out, the nipple will flatten or regress into the breast if it is flat or inverted.

Inverted nipples are sometimes prepared for breastfeeding using special methods and breast covers. However, how well they operate is debatable. After your kid is born, your inverted nipples may normally become more prominent. If your nipples stay inverted, the doctor or a lactation consultant can typically help you and your baby start nursing. He or she may advise utilizing a nipple shield in some circumstances.

If you realize that the nipples have shifted from erect to inverted, irrespective of whether you plan to breastfeed, contact your doctor.

Differential Diagnosis

Differential diagnosis is especially necessary in cases of nipple inversion that have developed over time. Nipple inversion may be accompanied by clinical symptoms such as erosion, inflammation, redness, dermatitis, bloody nipple discharge, or a detectable subareolar lump. The key differential diagnoses for acquired etiology are breast cancer, Paget's disease of the breast, erosive adenomatosis of the nipple, florid papillomatosis, subareolar ductal papillomatosis, and breast dermatitis. Other benign causes include post-surgery alterations, traumatic fat necrosis, fibrocystic disease, and Mondor's disease. Syringomatous adenoma of the nipple, nipple leiomyoma, and Borrelia-associated lymphocytoma cutis are all atypical causes.

Treatment Plan

For the management of nipple inversions, Olivaz-Maneyo and Berniz devised an approach.  The approach takes into account the patient's nursing preferences as well as the degree of nipple inversion. Because duct-damaging treatments might cause permanent damage and lead to a complete inability to breastfeed in the damaged breast, lactation wishes should be carefully considered.

Inverted Nipple Prognosis

In most cases, congenital nipple inversion is a harmless disorder. The prognosis is determined by the severity of the inversion and the therapeutic approach selected. Grade 1 inversions have an excellent prognosis when treated conservatively using non-surgical approaches. Long-term repair is usually ensured by the development of successful lactation. With cautious procedures, grade 2 inversions have shown ambiguous findings. After extensive discussions with the patient about planned lactation goals, surgical repair can be performed in cases of recurrence or no recovery.

Postoperative Complications

In most cases, inverted nipple repair is a very safe technique. Swelling and sensitivity are most common in the early postoperative period, but they usually go away on their own. The most frequent surgical consequences are bleeding and wound infection, while both are uncommon. The most serious complication is the recurrence of nipple inversion, with the highest risk of recurrence occurring 6 to 12 months after surgery.

Patient Education

In addition to allowing breastfeeding, breasts and nipples are an integral aspect of the description of femininity. Nipple inversion can have a serious influence on a patient's confidence and self-perception in addition to being a functionally deterrent. For various causes, this can affect young teenagers, teenagers, and adults. Children will rapidly notice that the nipple differs from those of their classmates, and that they could also be bullied as a result. Significant consequences on intimacy can arise as adolescents mature and become sexually active people. Some patients are aware of the disease but are unconcerned about it. As a result, determining the underlying motivations for a patient seeking nipple repair is critical. Is this the patient's wish, or is it an issue that should be tried to address? Is the patient under the external influence to endure treatment that they otherwise would not have been taught?

Conclusion

Nipple inversion is a disorder that has both cosmetic and psychological consequences for the patient, and it is best treated by a multidisciplinary team. The treating doctor must keep in mind the primary goal of the repair, whether it is to restore function or to improve the patient's personal look. Proper patient education on the condition, as well as the therapeutic alternatives available, aids them in making an informed decision about their care. The differentiation between innocuous, congenital, nipple inversion, and cancer is the most crucial. To ensure that cancer is not ignored, the surgeon should have a low threshold for obtaining a biopsy or other action.