Minimally-Invasive Correction of Inverted Nipples: A Safe and Simple Technique for Reliable, Sustainable Projection
Adam R. Kolker, MD, Philip J. Torina, MD.
Mount Sinai School of Medicine, New York, NY, USA.
Background: Numerous techniques have been described for the correction of inverted nipples; their diversity supports the lack of a consistently reliable method. Dermoglandular flaps, open suture, and suction techniques have all been described to combat the “corrected” nipple’s propensity to collapse. We present a new minimally-invasive parenchymal release and percutaneous suture technique that provides sustainable long-term correction of inverted nipples.
Methods: Thirty-one patients with 58 inverted nipples were treated, with follow-up ranging from 8 to 69 months (mean 22 months). The procedures were performed under local anesthesia (24 patients), or under general anesthesia during concomitant breast surgery (7 patients). The proposed base-circumference of the nipple is marked, and a traction suture is temporarily placed to evert the nipple. An 18-gauge needle is inserted at the 6 o'clock position, using the tip to lyse the foreshortened subareolar fibro-ductal tissue as necessary to achieve resting eversion of the nipple without suture traction. Through the same needle-access site, a purse-string suture is inserted (4-0 clear nylon or 4-0 polydioxanone), exiting the areolar skin and re-entering through the same stitch point every 3 to 5mm around the circumference of the nipple-base. A 6-0 plain gut suture closes the access site over the knot. Two crossed 5-0 plain gut mattress sutures are placed beneath the nipple to complete the correction (Figure). The degree of inversion was staged to three groups: Stage I - mild inversion that everts with stimulation, Stage II - moderate inversion that everts with manual traction, Stage III - severe inversion that does not evert by manipulation. Data were reviewed retrospectively.
Results: Of 27 patients with bilateral and 4 with unilateral inversion, durable correction was achieved in one procedure in 45/58 nipples (76%). There were 13 recurrences, occurring between 3 days and 17 weeks. Of these, 11 (19%) were successfully treated under local anesthesia with a second purse-string suture, and 2 (3%) required a third procedure under local anesthesia. There were no recurrences in Stage I (0/18 nipples), 8 recurrences in Stage II (8/30 nipples, 27%, all corrected after a second procedure), and 5 recurrences in Stage III (5/10 nipples, 50%, 3 corrected after a second procedure, and 2 requiring a third). There were no late re-inversions. There were no cases of infection, nipple ischemia, or other complications.
Conclusions: This technique represents a practical method for the correction of inverted nipples of all stages. Occasional early recurrences, based on the need to cinch the purse-string snugly while maintaining perfusion of the newly everted nipple, are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through “needle-only” access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.