Surgical correction of the inverted nipple with a tendon graft: hammock procedure

Our procedure, in which the inverted nipple was suspended using autogenous tendon grafts, was easy to perform, and it was not necessary to cut the lactiferous ducts. There was no deformity of the nipple or areola after this procedure, and the surgical scars were inconspicuous. Three patients who were followed up for over 1 year after surgery were presented in this paper. In eight patients (13 corrected inverted nipples), good results were obtained and there have been no complications to date.     

A direct surgical approach to correct the inverted nipple

Inverted nipples are cosmetically unpleasing to the patient and can become inflamed due to mechanical difficulty with cleaning the nipple-areola complex. A surgical technique for the permanent repair of inverted nipples is described. The rationale for the surgical approach is that the major pathophysiologic basis for nipple inversion is shortened lactiferous ducts. Briefly outlined, under local anesthesia, the nipple is everted with a skin hook and held in gentle traction while a small incision is made on each side at the nipple-areola junction. Breast ducts are then divided by sharp dissection, and a drain is inserted through the tunnel under the nipple. The drain is removed in 7 to 10 days. The patient must be informed before the procedure that breast-feeding will not be possible afterward because breast ducts will be permanently divided. Advantages to the procedure are (1) no scars on the areola, (2) no stricture from sutures, (3) adequate blood and nerve supply to the nipple, and (4) decreased risk of hematoma.     

Purse-string suture for nipple projection

A simple and useful technique for nipple projection is reported. A buried, subcutaneous, purse-string suture is placed through prick holes and, when tied, gives a nipple mound, without the need of skin incisions, flaps, or undermining. This procedure can be applied to inverted, missing, and/or ill-defined nipples.     

An alternative operation for inverted nipple.

An operation to correct inverted nipples is described. Its main advantage is that reinversion of the nipple is prevented, because two "dermal" flaps not only increase the density of tissue underneath the nipple but also act as slings.     

Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples.

OBJECTIVE--To determine the value of recommending breast shells or Hoffman''s exercises, or both, to pregnant women with inverted or non-protractile nipples who intend to breast feed. DESIGN--Randomised controlled trial with a two treatment by two level factorial design. SETTING--Antenatal clinics in a district general hospital and the community. SUBJECTS--96 nulliparous women recruited between 25 and 35 completed weeks in a singleton pregnancy with at least one inverted or non-protractile nipple. MAIN OUTCOME MEASURES--Anatomical change of nipples, judged blindly before first breast feeding, and success of breast feeding reported by postal questionnaire six weeks postnatally. RESULTS--Sustained improvement in nipple anatomy was more common in the untreated groups but the differences were not significant (52% (25/48) shells v 60% (29/48) no shells; difference -8% (95% confidence interval -28% to 11%) and 54% (26/48) exercises v 58% (28/48) no exercises; -4% (-24% to 16%)). 24 (50%) women not recommended shells and 14 (29%) recommended shells (21%; 40% to 2%) were breast feeding six weeks after delivery (p = 0.05), reflecting more women recommended shells both deciding to bottle feed before delivery and discontinuing breast feeding. The same number of women in exercise and no exercise groups were successfully breast feeding (0%; -20% to 20%). 13% of women approached about the trial (and planning to breast feed) did not attempt breast feeding. CONCLUSIONS--Recommending nipple preparation with breast shells may reduce the chances of successful breast feeding. While there is no clear evidence that the treatments offered are effective antenatal nipple examination should be abandoned.     

Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.     

The inverted nipple: its grading and surgical correction

Inverted nipples have been treated by various methods by many authors, but the relationship between the grade of the deformity and the appropriate surgical procedure is not clearly described. One hundred seven inverted nipples in 60 patients were treated from 1993 to 1997. They were divided into three groups by the authors' system of grading. The grade was made by preoperative evaluation of severity of inversion and was confirmed by the surgical findings. In grade I, the nipple is easily pulled out manually and maintains its projection quite well. Grade I nipples are believed to have minimal fibrosis; thus, manual traction and a single, buried purse-string suture are enough for the correction. The majority of inverted nipples belong to grade II, i.e., the nipples can be pulled out but cannot maintain projection and tend to go back again. These nipples are thought to have moderate fibrosis beneath the nipple. Blunt dissections for surgical release were carried out until the inversion did not recur after releasing the traction. The lactiferous ducts could be identified and preserved, permitting proper release of fibrotic bands in the grade II group. The purse-string suture was used. In grade III, to which the least number of inverted-nipple cases belong, the nipple can hardly be pulled out manually. Severe fibrosis made it impossible to reach optimal release of the fibrotic band with the preservation of the ducts. The fibrotic bands are widely dissected, and the lactiferous ducts are cut, especially in the central portion. Two or three deepithelialized dermal flaps may be used to make up for soft-tissue deficiency; a purse-string suture is also used. This grading system will be useful for patient classification and analysis, systematic planning, and application of the proper surgical procedures.     

Correction of inverted nipple with periductal fibrous flaps.

I devised a method to correct the inverted nipple considering the preservation of the lactiferous ducts, sensory fibers to the nipple, and the contracting function of the areolar muscle. Excision of the excess skin at the base of the nipple was done in three diamonds fashion, and they were located at 2, 6, and 10 o'clock positions not to jeopardize the sensory fibers to the nipple. To release the fastened nipple, the periductal fibrous tissue was thoroughly dissected and made into three flaps pedicled inferiorly. These three flaps were sutured to the dermis of the periareolar skin to pull up the nipple base by means of traction in three directions. The purse-string suture, the dermal stitch on the shorter diagonals of the diamond-shaped defects, anchors the skin-muscle bridges caught at the base of the ductal column, makes the nipple base narrower, obtains stable anchoring, helps the areolar muscle contraction to resume, and prevents the recurrence of the inversion. The use of the periductal tissue as flaps to bring in areolar skin for easier anchoring and for more prominent eversion of the nipple has not been described in the literature.     

Improving safety and aesthetic results in inverted T scar breast reduction

Breast reduction using an inverted T scar skin design and a variety of glandular pedicle types is widely practiced and is the standard by which more recent limited scar techniques are judged. The inverted T procedures are attractive because they are predictable and versatile and permit great control over both the extent of reduction and the breast-shaping process. Despite these advantages, common criticisms of inverted T scar techniques include breast shape abnormalities, areolar malposition, hypertrophic scars, and poor long-term projection. Preoperative markings influence both safety and aesthetics. A method of skin marking that is based on a displacement method to determine vertical limb splay angle is described. This design concept must be modified to address certain variants, such as macromastia presenting with normal nipple position or large-diameter areolae, moderately severe macromastia, and macromastia involving radiated breasts. Safety in breast reduction is improved by paying attention to patient positioning issues, using techniques that minimize blood loss, raising flaps of appropriate thickness in the correct plane, and performing resection by observing the principles that reduce the risk of compromise of nipple and areolar circulation. Aesthetic results are improved by analyzing vertical breast meridian lengths during final breast shaping, modifying areolar shape as necessary, and carefully tailoring the medial inframammary crease. The latter is also important for minimizing the potential for scar hypertrophy. The principles presented have been refined during the course of a 12-year experience with several hundred breast reduction procedures. They contribute to improved results in inverted T scar breast reduction when practiced consistently.     

Umbilical reconstruction with an inverted C-V flap

We have created a method for umbilical reconstruction with satisfactory results. The C-V flap developed for nipple reconstruction was used in an inverted fashion. The inverted C-V flap can produce a satisfactory reconstruction of umbilical structures, especially the ring.     

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.     

Nipple-areola reconstruction with auricular tissues.

Various methods of reconstructing the nipple-areolar complex with auricular tissues are presented. A basic one-stage reconstructive technique is described which seems suitable for the use of various tissues. An alternative method of correcting the inverted nipple is reported.     

Reconstruction of the nipple: a new technique

We propose a simple one-stage procedure for nipple reconstruction. The fundamental basis, the technique itself, and the results obtained demonstrate that a single-flap reconstruction achieves a nipple that will keep its shape 15 months later.     

Scrape cytology in the diagnosis of Paget's disease of the breast

Eczema of the nipple is an important symptom presenting to the general surgeon in the out-patient department. the diagnosis of Paget's disease of the nipple has traditionally been made by incision biopsy necessitating at least a local anaesthetic. We present 14 patients with nipple skin change, in whom the technique of scrape cytology was used to identify patients with Paget's disease. In our series eight cases of Paget's disease were successfully identified by scrape cytology with no false negatives or positives. We suggest that this is a quick, easy, non-invasive method of screening eczema of the nipple in the out-patient clinic.     

Subcutaneous mastectomy. The excess skin problem.

Subcantaneous mastectomy through a lateral approach, with preservation of the nipple and areola on a dermal pedicle, removing the excess skin at the time of aubautaneous mastectomy, is a safe procedure which results in esthetically acceptable breasts. The surgical approach greatly facilitates the removal of the entire glandular portion of the breast. The need for a second surgical procedure is eliminated. Lateral biopsy scars can be reinforced by the dermal sling support, thereby decreasing the chances of exposure of the implant. The implant is also successfully and easily held in position by the use of the dermal-fat sling support. The nipple and areola survive quite well on the dermal pedicle, with preservation of contractility and sensation, as well as of blood supply.     

Nipple reconstruction with the double-opposing-tab flap

The double-opposing-tab flap, a new method of nipple reconstruction used in 50 patients to date, is described. This technique uses two dermal-fat flaps, each similar to those described by Hartrampf, but with tab extensions inspired by the skate flap of Little. The donor sites of the two flaps are closed like Burrough's triangles, bringing the flaps into opposition so that they support each other's projection. The tabs cover all the exposed fat on the nipple so that no skin graft is required on the nipple proper. The result is a nicely shaped nipple that can be designed directly over a scar, maintains a projection averaging 3.8 mm at 10 months, and is technically easy to construct.     

Investigation into the possible cause of subjective decreased sensory perception in the nipple-areola complex of women with macromastia

Patients with macromastia often comment on a lack of sensation in their nipple-areola complex. A study was designed to investigate the cause of this decreased sensation. Two hypotheses were proposed. First, the decreased sensation could result from neuropraxia of the sensory nerve fibers secondary to traction caused by the heavy breast parenchyma. The second hypothesis proposed that tissue expansion of the nipple and areola by the voluminous breast parenchyma caused a decrease in nerve fibers per surface area and hence decreased sensory perception. Sixty-one patients were assessed in the study. All patients underwent surgery in which histological biopsy of either the areola alone (31 reduction mammaplasty patients) or the nipple and areola (30 mastectomy patients) was possible. Before surgery, each nipple-areola complex was tested with Weinstein Enhanced Sensory Test monofilaments as a quantitative test of tactile sensation. Breast cup size, ptosis, and weight of tissue excised were recorded to allow general assessment of the breast size. The nipple and areola biopsy specimens were assessed using immunohistochemistry (S-100 polyclonal antibody, Dako Z311) to measure nerve fiber count per unit area. Statistical analysis was undertaken to find any association among sensitivity, breast cup size, ptosis, weight of tissue resected, and nerve fiber density in the nipple and areola biopsy specimens. Sensitivity at the areola decreased with increasing breast cup size (r = 0.47, p < 0.001) and ptosis (r = 0.42, p = 0.002 for increasing distance between inframammary crease and nipple; r = 0.49, p < 0.001 for increasing manubrium to nipple distance). There was a weak correlation between nerve fiber density at the areola and breast cup size (r = -0.22, p = 0.1). Sensitivity at the nipple was higher than at the areola. Nerve fiber density count at the nipple was higher than at the areola, but there was no statistically significant correlation between nipple sensitivity and breast cup size, ptosis, or weight of tissue resected. The results suggest that the areola and nipple are different in their neuroanatomy. The areola is a thin, pliable structure that is predisposed to stretch as the breast enlarges and therefore experience a decrease in nerve fiber density. The nipple is a compact structure that is less likely to stretch with breast enlargement. In the nipple, neither sensory perception nor nerve fiber density varied with size or breast ptosis. The perceived lack of sensation in the nipple-areola complex is multifactorial. This study shows that neither traction injury to the sensory nerves nor decreased nerve density alone can explain the subjective numbness reported by patients with macromastia. Psychological factors, such as dissatisfaction with body form or interpretation of lack of sensation in the areola as also affecting the nipple, may influence the patient's assessment of the nipple-areola sensitivity.     

Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

Nipple or areolar reduction with simultaneous breast augmentation

Patients requesting nipple or areolar reduction often desire simultaneous breast augmentation. A technique is described for implant placement by means of a nipple base incision with either nipple reduction or intraareolar reduction. Nipple reduction is accomplished by removing a ring of skin from the base of the nipple, while areolar reduction is performed by removing a donut-shaped area of skin whose inner diameter is at the nipple base. The elasticity of the areolar skin allows for access for saline implant placement. The resulting scar is well concealed. Results from 15 patients demonstrate that the technique is safe, practical, and appears to pose no increased risk of sensory changes to the nipple.     

Nipple reconstruction: the S flap

A one-stage procedure to reconstruct the nipple-areola complex is presented, with special attention given to nipple volume and projection using local dermis-fat flaps. The preliminary results have been very encouraging.