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3 authors, including:
Anindya Lahiri
Sandwell and West Birmingham Hospitals NHS Trust
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KEYWORDS
Inverted nipple;
Surgical correction;
Dermoglandular flap
Introduction
Inversion of the nipple refers to a condition when either
a portion of, or the entirety of the nipple lies below
the plane of the areola. The true incidence in todays
1748-6815/$ - see front matter 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2011.05.002
Please cite this article in press as: McG Taylor D, et al., Correction of the severely inverted nipple: Areola based dermoglandular rhomboid
advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002
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also give rise to feelings of underdevelopment or inadequacy and thus have important psychosexual implications.4
The first published literature referring to this abnormality was by Sir Astly Cooper in 1840 and the long evolution of its surgical correction started with Kerher in 1879. It
is however, only in recent years that our understanding of
the histological pathogenesis behind this malformation has
been recognised.1,5 Clinically, the inverted nipple was
initially classified by Schwager, as being umbilicated
(intermittently inverted) or invaginated (permanently
inverted).1 More recently, Han and Hong divided inversion
into three grades depending upon severity,5 with the worst
affected group being deeply inverted and rarely, if at all,
everted for any significant period of time.
A variety of methods have evolved to address this deformity. These can be conservative; predominantly using
external devices to maintain eversion,6 or surgical; which
concentrate on techniques to either, tighten the nipple base
or provide additional support under the nipple. In the later
group this has been achieved through the use of local flaps,
autoplastic and alloplastic material. Whether or not division
of the lactiferous ducts is necessary for complete release of
the inverted nipple is disputed. However, there remains no
consensus on one universally superior technique.
It is our belief that the severely inverted nipple (invaginated/grade II-III) is a different entity, both functionally
and histologically from the milder umbilicated form and
must therefore be treated as such. For these cases, we
propose three important components that need to be
addressed: 1. Complete release of the tethering fibrous
bands and lactiferous ducts to allow full nipple eversion, 2.
Supplementation of tissue under the nipple to fill the dead
space created and reduce scar tissue deposition, 3. Support
of the nipple with a suspension platform to prevent reinversion.
A technique incorporating these components has been
developed and used by the senior author and the results of
a long term follow-up are presented.
Patients
Since 1992, this technique has only been used for correction
of the more severely inverted nipples. All patients were
classified at the initial clinical assessment to be deeply
invaginated and of severity grades IIeIII.5
Please cite this article in press as: McG Taylor D, et al., Correction of the severely inverted nipple: Areola based dermoglandular rhomboid
advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002
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Figure 3 a: Schematic representation of the dermal rhomboid flaps and conical incision of the tethering lactiferous ducts
and fibrous bands with the resultant defect. b: Closure of
glandular defect and double breasting of dermoglandular flaps.
Results
Figure 2 a: De-epithelialised and reflected dermoglandular
areolar flap. b: Angled division of the fibrous bands and
lactiferous ducts.
Please cite this article in press as: McG Taylor D, et al., Correction of the severely inverted nipple: Areola based dermoglandular rhomboid
advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002
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Figure 4 a: Areolar skin closure. b: Immediate post-operative result compared to the contralateral unaffected nipple.
Discussion
Over the years the causation of the congenitally inverted
nipple has been investigated in a number of studies;
Schwager suggests that an inverted nipple results from
a failure of the underlying mesenchyme to proliferate
and push the nipple out of its developmentally depressed
Surgical techniques
A large number of surgical techniques have been described
in the literature for correction of inverted nipples, suggesting that no single method gives uniform satisfaction in
all grades of inversion. The techniques usually belong to
one or more of the following groups; 1. Narrowing the base
of the nipple. 2. Supplementing bulk under the nipple. 3.
Preserving or dividing the lactiferous ductal system.
The first surgical technique described to correct the
inverted nipple was in 1879 by Kehrer in his mammilliplasty operation,9 involving excision of two semilunar
areas of skin to narrow the base of the nipple. Basch (1893)
Please cite this article in press as: McG Taylor D, et al., Correction of the severely inverted nipple: Areola based dermoglandular rhomboid
advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002
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All patients were advised that they were very unlikely to
be able to breast feed following surgery. It was of interest
to ourselves that on long term review, all three patients
which subsequently had children were able to produce milk
and breast feed from the corrected side. The explanation
for this can only be postulated. Complete release of the
nipple is achieved by division of the centrally tethering
structures (including ducts as appropriate). It is possible
some lactiferous ducts may remain in the most lateral
aspects of the preserved nipple bipedicle. It has also been
suggested by Crestinu, that recanalisation of the ducts is
possible some years after surgical division.4
However, for the purposes of our technique, it is still
advisable to inform the patient that subsequent breast
feeding may be affected.
Conclusion
In our opinion, this technique provides a consistent and reliable method for the correction of the more severely inverted
nipple. We have found, on review of patients up to 16yr postoperatively, that the projection and prevention of re-inversion of the nipple in this very difficult group of patients can still
be maintained with a good aesthetic outcome.
Conflict of interest
None.
Funding
Our technique
None.
A number of important differences distinguish our technique from others previously described.
The key principle behind the design of this technique is
that it uses true forward advancement of tissue in two
separate vectors perpendicular to one another.
The forward advancement of the nipple is achieved
through the division of the tethering fibrous bands and
lactiferous ducts, done specifically in an inverted conical
shaped incision. This allows complete release of the nipple
and advancement, whilst retaining a block of tissue
underneath it. The resultant dead space is subsequently
created well below the level of the areola.
The flap design uses two rhomboid-shaped dermoglandular flaps based laterally towards the areola margin at
180 to each other. This does not involve invasion to the
nipple proper. The position ensures a rich areola blood
supply33 incorporating a dermal and a glandular component. The true medial advancement of the flaps provides
a number of advantages; 1. There is no folding or kinking of
the flap which could compromise its blood supply. 2. Double
breasting of the rhomboid-shaped flaps provides a broad
and stable platform on which the everted nipple (including
the incised subnipple tissue) is well supported. 3. The
resultant dead space created under the nipple is closed in
a V to Y advancement, and 4. The intervening barrier
created by the dermoglandular flap platform between the
nipple and gland reduces scarring and aids in preventing
retraction of the nipple over time.
References
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advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002
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Please cite this article in press as: McG Taylor D, et al., Correction of the severely inverted nipple: Areola based dermoglandular rhomboid
advancement, Journal of Plastic, Reconstructive & Aesthetic Surgery (2011), doi:10.1016/j.bjps.2011.05.002