Inverted Nipples

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What Are Inverted Nipples?

It is an abnormal syndrome that is characterized by a nipple that retracts into the breast rather than pointing outwards. In some people, the nipple tends to protrude temporarily on stimulation. In others, there is no inversion with or without the presence of an external stimulus. Both women and men can suffer from this problem.

The condition is occasionally also known as “Invaginated Nipple”.

Inverted Nipples Grades

This disorder is categorized into three grades or varieties, based on factors like:

  • The ease of protraction of the nipple
  • The degree of fibrosis existing in the breast
  • The damage that fibrosis (excess fibrous connective tissue) causes on the milk ducts

Depending on these factors, Inverted nipple can be classified into

Grade 1

In this grade, the nipples that can be easily protracted (pulled out) by pressing the region around the aureola with finger. These types of inverted nipples rarely retract and keep their projections. However, these nipples may occasionally project even without finger pressure or manipulation. In this form, milk ducts are not generally compromised and it is possible to breast-feed. Fibrosis is believed to be minimal or absent in this case and the nipples do not exhibit any soft-tissue deficiency. The mammary gland ducts are usually normal and do not exhibit any sign of retraction. Grade 1 nipples are also known as “shy nipples”.

Grade 2

A Grade 2 nipple can also be pulled out, though not as easily as a Grade 1 nipple. It retracts after releasing the pressure. It is possible to breast-feed with this type of a nipple though it may be a very difficult process. However, some women find breastfeeding impossible with Grade 2 nipples. These types of nipples have a mild degree of fibrosis. There is moderate retraction of the lactiferous ducts. However, they do not need to be cut for releasing fibrosis. A histological examination of these nipples usually displays rich Collagenous Stromata along with lots of smooth muscle bundles. Most women with inverted nipples suffer from Grade 2 of this problem.

Grade 3

In this grade, the nipple is found to be acutely inverted and retracted. It can rarely be pulled out with physical pressure and needs surgical assistance to be protracted. Grade 3 women often have narrowed down milk ducts and find it impossible to breast-feed their infants. They may also suffer from rashes, infections or difficulties with nipple hygiene. In such women, lactiferous ducts are found to be short and seriously retracted. There is severe fibrosis involved. There is noticeable insufficiency in the amount of soft tissue in the nipple.

Inverted Nipples Causes

Nipples as well as the small circular region around them (known as the “areola”) may differ in color, shape and size. In normal cases, nipples are flat, bulging and slightly puffy. Nipples can undergo a change due to a variety of reasons. The most common causes of the condition include:

Congenital problems

In many cases, individuals are seen to be born with this condition. 10-20% of all women are supposed to be born with this problem. The most common type of nipple variations in women born with the problem are caused by a wide areola muscle sphincter or short ducts.

Weight Loss

The condition may also occur after an episode of sudden and noticeable loss of weight.

Breast disorders

Cancerous conditions affecting the breast, such as Inflammatory Breast Cancer (IBC), Paget’s disease and breast carcinoma, may also result in this problem. Inflammatory or infectious condition of the breast, such as mastitis, mammary duct ectasia or breast abscess can also give rise to this condition.

Breastfeeding

Some nipples get inverted after breastfeeding due to accumulation of scar tissues in the milk ducts. Breastfeeding is one of the three main causes of nipple inversion after birth, the other reasons being constricted milk ducts and absence of adequate skin at the base of the nipple.

Genetic variation

A change of nipple shape may also occur due to genetic disorders like Chromosome 2q Deletion, Fryns- Aftimos syndrome, Kennerknecht-Sorgo-Oberhoffer syndrome or Weaver syndrome. A congenital disease of glycosylation type 1 L & 1A can also result in this problem.

Trauma

Trauma or injury caused to the nipples by disorders, such as fat necrosis, may also lead to this condition.

Gynecomastia

This condition is characterized by extreme growth of the breasts in males. It generally arises as a result of hormonal imbalance or due to the use of some types of drugs (including certain Antihypertensives).

Holoprosencephaly

This is a congenital abnormality that results from the failure of the prosencephalon to split up into hemispheres at the time of embryonic development. It is marked by more than one midline facial defects, which includes Cyclopia (developmental abnormality characterized by the presence of only one eye) in acute cases.

Monocytosis

It is usually a sign of Monocytic Leukemia and is marked by an increase in the amount of monocytes in the bloodstream.

Some other causes of inverted nipples include:

  • Tuberculosis
  • Pregnancy
  • Recurrent infections
  • Post-surgical effects on breast
  • Drooping or sagging of the breasts

Inverted Nipples Symptoms

The condition, as the name indicates, is primarily characterized by an inversion of the nipples. The nipple is indentured into the areola but often tends to pop out during pregnancy or with breast stimulation. It may also give rise to retracted nipples in which the nipple projects above the surface but starts to draw back inwards and does not show up even when stimulated.

There may also be other problems, such as nipple discharge. Clear or discolored discharge (red, green or brown) releases out of the breasts and causes embarrassment. The discharge can also be milky in color, as in Galactorrhea. The discharge may occur from one or both nipples. In some people, discharge may occur only when pressure is applied over the breast. Discharge occurring without any application of pressure is known as Spontaneous Discharge.

In many sufferers, changes may occur in the skin region surrounding the nipples. There may be redness, cracking or tenderness of the skin surface over the nipple. Rashes, dimples or puckers may also arise over the skin surface of the nipple or the darker skin region around the nipple (Areola).

Other changes that can occur in breast include:

  • Tenderness in breast
  • Increased warmth in breast
  • Breast inflammation or irregular lump over breast

Inverted Nipples Diagnosis

The initial diagnosis of this condition involves performing a physical examination and considering the medical history of the patient. In case of a nipple discharge, health care providers may also conduct other diagnostic tests to detect the possible causes. These include:

  • Thyroid function tests
  • Prolactin level tests
  • CT scans
  • MRI scans, to detect Pituitary tumor

Some other tests that can be conducted involve:

  • Ultrasound of the breast
  • Mammography
  • Skin biopsy (if Paget’s disease is suspected)
  • Ductogram or Ductography, an x-ray examination which involves injecting Contrast dye into the affected milk duct

In some people, a biopsy of the breast may also be carried out. A Breast biopsy is necessary if

  • A lump or mass is detected
  • If the mammogram is found to be abnormal
  • If the discharge occurs spontaneously, without exertion of any pressure on the breast

Inverted Nipples Treatment

The treatment of Inverted Nipples actually depends on the cause of the condition. Surgical repair is the standard mode of cure for many cases of nipple inversion. Nipple discharge, caused by conditions extraneous to the breast, is generally cured by:

  • Changing drugs that are possibly causing the discharge
  • Curing underlying disorders, such as Breast infections, Pituitary tumors and Hypothyroidism
  • Removal of some or all of the ducts of the breast, which can be done after a period of surveillance or even immediately
  • Biopsy and occasionally subsequent removal of any unusual findings detected on a mammogram or breast ultrasound

Steroid creams, antibiotic creams and antifungal creams are often used for treatment of any changes occurring in the skin region around the nipple.

Most women suffering from breast discharge and having a normal physical exam, mammogram or breast ultrasound may be followed up by periodic mammogram and physical exam over a period of 1 to 2 years. In some cases, a Ductogram (a special type of breast duct imaging) is performed before any other surgery.

Inverted Nipple Repair

In many cases, it is essential to perform a surgical repair of the inverted nipples. Operative techniques, that are used to rectify inverted nipples, can be classified into two types. One that leaves the milk ducts intact and another that does not leave them intact. In both cases, repair aims at reshaping the nipple and also the areola. Treatment of both can ensure that the nipple projects out of the breast.

Surgical repair improves the physical appearance of the breasts as well as maintains the sensitiveness of the nipples. The method that leaves the milk ducts intact may also help the affected woman preserve her ability to breastfeed.

Inverted Nipple Repair Cost

On an average, Inverted Nipple Repair costs anything from $2000 to $4000 in the United States. Through Medical Tourism, the surgery can be performed in the range of $1500 to $2500 in Australia. The same operation can be also conducted at a much cheaper rate in countries like India and Philippines. The price chart of various countries can be looked up over the internet.

Inverted Nipple Surgery

It is an outpatient method of treatment that is used to repair an inversion of nipples, typically resulting from a deficiency of ducts inside the nipple or a malformation of ducts that pull the nipple inward. Usually regarded as plastic surgery, this operation involves releasing the tissue inside the retracted nipple and letting it heal in an outward posture. This surgical technique is regarded as a simple procedure. However, it is not always a lasting solution for this problem.

Inverted Nipples and Hoffman Technique

The Hoffman Technique is basically a nipple stretching exercise. When performed for several times a day, it helps relax the adhesions at the basal area of the nipple. Even though the method is highly promoted for curing this condition, a study conducted in 1992 suggested something disturbing. According to it, the Hoffman technique and breast shells actually disrupt successful breastfeeding.

Inverted Nipples and Breastfeeding

Women with inverted nipples may suffer from temporary or permanent protraction (coming out) of their nipples during pregnancy, or due to breastfeeding. Majority of women with this condition are able to breastfeed their infants without complication. However, first-time mothers may experience a higher than usual pain and soreness in their breast during nursing. If affected women use proper breastfeeding technique and their infants latch on well to the areola and not the nipple, nursing may not be an issue. Using a breast pump or a similar suction device immediately before a feeding can also help draw out inverted nipples. In some women, use of a nipple shield may also help facilitate breastfeeding. Frequent stimulation in the form of foreplay (such as sucking on the nipple) may also help protract the nipple.

Inverted Nipples and Suction Cups

In some people, mild cases of Nipple Inversion can be cured with an at-home suction cups. This device uses suction power to gradually draw out the nipple. Compared to surgery, this is a simple technique that produces excellent results and allows sufferers to recover rapidly. It is considered to be an inverted nipple correction without surgery. Unfortunately, this is not a full-proof cure. This is due to the fact that in spite of suction treatment most affected people need inverted nipple surgery for correction of one or both nipples.

Inverted Nipple Prognosis

Patients find it relatively easy to recover after an inverted nipple surgery. While the time for recovery actually differs from one patient to another, most people are able to go back to work one or two days after operation. Many patients are able to return to a normal life within two weeks.

Soreness and partial loss of sensations at the surgical spot are the main issues arising in the initial days after surgery. Mild to moderate inflammation generally persist for two to three days after the process but usually disappears within three weeks.

References:

http://www.nipplerepair.com/inverted-nipples.cfm

http://health.nytimes.com/health/guides/disease/nipple-problems/overview.html

http://www.breastfeedingbasics.com/articles/flat-or-inverted-nipples

http://www.mayoclinic.com/health/medical/IM02408

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