A simple method for the correction of the inverted nipple

A procedure is described in which a direct approach to the underlying pathology of the inverted nipple is undertaken. The inverted nipple is raised as desired by freeing it from the surrounding tissue by vertical and horizontal undermining and then is stabilized by purse-string suture. It can be performed as an office procedure under local anesthesia. This procedure is simple, reliable, not time-consuming, leaves no visible scars, and requires no special or bulky dressing.     

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.     

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.     

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.     

Assessment of long-term nipple projection: a comparison of three techniques

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.     

Repeat reduction mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.     

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.     

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.     

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.     

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.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

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.     

揪提手法与梯级提升牵引器矫治乳头内陷患者的效果对比分析

目的:分析和比较揪提手法与梯级提升牵引器矫治乳头内陷的临床效果。方法:选择2013年1月-2018年1月于我院进行治疗的44例乳头内陷患者为研究对象,按照随机数字表法将其均分为实验组与对照组,每组各22例患者。对照组患者实施揪提手法治疗,实验组患者使用梯级提升牵引器进行治疗,两组干预时间均为2个月。治疗结束后,对比两组患者治疗有效率,治疗开始时、治疗1个月时及治疗2个月时视觉模拟量表评分(VAS),术后3个月时复发率及治疗期间并发症发生率。结果:(1)对照组治疗有效率为59.09%(26/44),实验组治疗有效率为86.36%(38/44),较对照组显著升高(P0.05);(2)治疗第一天,实验组患者VAS评分明显高于对照组(P0.05),但两组患者治疗1个月及2个月时VAS评分对比差异不具有统计学意义(P0.05);(3)术后6个月随访示实验组复发率显著低于对照组(P0.05);(4)实验组患者治疗期间不良反应发生率明显低于对照组(P0.05)。结论:阶梯提升牵引器矫治乳头内陷的效果明显常规优于揪提手法,虽然治疗之初患者较为疼痛,但患者远期预后显著好于常规揪提手法。     

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.     

Supernumerary Teat Removal Can Be Avoided in Dairy Sheep

The aim of this work was to determine whether the removal of supernumerary teats from dairy sheep when they are born is a useful procedure in the farming routine. Ewes were divided into 3 groups according to the number of teats at milking: ewes who were born with 2 teats; ewes who were born with 4 teats and had the 2 supernumerary nipples cut just after birth; and ewes who were born with 4 teats and did not have nipple amputation performed. Removal of supernumerary teats at lambing produced a significant reduction in milk production during the 2 first milking periods (p < .01). There were no differences between ewes with 2 or 4 teats, which suggests that this procedure is not necessary on dairy sheep farms. Because the presence of supernumerary teats is highly heritable, the elimination of this trait could be accomplished through selection methods.     

Reconstruction with bilateral pedicled TRAM flap for paraffinoma breast

Although autogenous tissue can be used to replace unsatisfactory prosthetic breast reconstructions in mastectomy patients, because of the magnitude, complexity, and many potential complications associated with the procedure, combined with a long-term recovery, the use of an implant to replace the mastectomy defect is still the most common method for paraffinoma breast treatment. Between July of 1996 and June of 2003, 21 paraffinoma breast patients underwent bilateral pedicle transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. There were 10 primary cases that had never been treated before this visit, including a case of unilateral associated breast cancer. There were also 11 secondary cases that had prostheses implanted after removal of materials injected in other clinics. The diagnoses included unacceptable breast contour in 11 patients, breast hardening in 11 patients, palpable nodules in five patients, nipple malposition in four patients, prominent scarring in three patients, breast skin necrosis in one patient, and nipple necrosis in one patient. A 100 percent flap survival rate with no clinical fat necrosis was achieved. There were 11 of 21 abdominal hypertrophic scars, six of 21 prechest (anterior surface of the thorax) hypertrophic scars, and no abdominal hernia; the symmetry satisfaction rate was 100 percent among primary cases and nine of 11 in secondary cases. The breast softness satisfaction rate in primary cases was also 100 percent and nine of 11 for secondary cases. Excellent cosmetic results were achieved in all patients (42 breasts in total). The unfavorable results of the secondary cases (patients with previous treatments) indicate that it is impossible to completely remove all of the injected foreign body by resection. This also means that scar appearance can only be minimized if resection of the entire paraffinoma is performed through a periareolar incision. The excellent results of the primary cases show that immediate autogenous tissue reconstruction should be the first alternative and is the best option for treating foreign-body granuloma breast, given that autogenous tissue is available. Similarly, the results of the secondary cases also demonstrate that autogenous tissue reconstruction could be considered in reversing some unfavorable results of past treatments.     

Integrated breast mound reduction and nipple reconstruction with the wraparound flap.

A new method for nipple reconstruction is described that combines revision of an autologous tissue breast mound with creation of a projecting nipple. The method is applicable only to reconstructed breast mounds that must be reduced or lifted to achieve symmetry with the opposite breast. In this technique, the mound is reduced as if it were a normal breast, using an inverted-T or vertical mammaplasty pattern. In this way, breast projection can be increased and, if necessary, the inframammary fold can be elevated. A rectangular flap is created from skin and subcutaneous tissue that would normally be discarded during the breast reduction, and this flap is wrapped around on itself to form a projecting nipple. This new technique avoids the flattening of the breast mound usually seen after nipple reconstruction because it does not take tissue away from the completed breast mound to make the nipple. In appropriate patients who require reduction in size of their reconstructed breast mound, the wraparound flap nipple reconstruction is worth considering.     

Breast sensitivity after vertical mammaplasty

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejour's technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes-Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two-point discrimination tests with a Disk-Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch-to-nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch-to-nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple-areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I.In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejour's technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple-areola complex.