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Correction of the severely inverted nipple:


Areola-based dermoglandular rhomboid
advancement
Article in Journal of Plastic Reconstructive & Aesthetic Surgery June 2011
DOI: 10.1016/j.bjps.2011.05.002 Source: PubMed

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) xx, e1ee6

Correction of the severely inverted nipple: Areola


based dermoglandular rhomboid advancement*
D. McG Taylor*, A. Lahiri, J.K.G. Laitung
Department of Plastic Surgery, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK
Received 11 October 2010; accepted 11 May 2011

KEYWORDS
Inverted nipple;
Surgical correction;
Dermoglandular flap

Summary Inverted nipple is a relatively common aesthetic problem presenting to a plastic


surgeon. Along with the functional problems; recurrent inflammation/infection and an
inability to nurse, most patients seek intervention because of the abnormal appearance.
Many different surgical techniques have been described, suggesting that no one technique is
universally successful. Most techniques employ, either individually or in combination, methods
to tighten the nipple base or the use of areolar dermal flaps to support the nipple.
We propose two modifications to the dermal flap technique. Firstly, the rhomboid dermal
flaps are designed solely on the areola, the bases directed peripherally, improving vasularity
and allowing true medial advancement. Secondly, the lactiferous ducts and tethering fibrous
bands are released in a conical fashion allowing closure with a vertical VeY advancement. This
gives better projection and support to the nipple proper with medial recruitment of glandular
tissue closing the dead space created.
This technique has been used successfully by the senior author in 20 patients over a 16 year
period, with a high rate of preserved nipple evertion and patient satisfaction. The technique is
simple, reliable and provides sustained results over long term follow-up for the correction of
the more severely inverted nipple.
2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

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

Presented: BAPRAS Summer meeting, July 2008.


* Corresponding author. Tel.: 44 7969695608.
E-mail address: dmcgtaylor@hotmail.com (D. McG Taylor).

population is likely unknown, though published reports vary


between 2 and 10% of females being affected on one or
both sides.1e3 Aetiology is most commonly congenital,1
though acquired causes; ductal mastitis, macromastia,
breast surgery and carcinoma must be excluded. For the
individual the consequences are significant, presenting with
functional difficulties in maintaining hygiene, recurrent
inflammation or infection and in the more invaginated
nipples an inability to nurse. Aesthetically, the appearance
of the nipple influences activities and clothing often with
the addition of a profound psychological component. It may

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 and methods


Operative technique
The procedure is routinely performed under local anaesthesia using 1% lignocaine with 1:200,000 adrenaline,
ensuring both superficial and deep infiltration of the nipple
areola complex.
After eversion of the nipple using a skin hook, a 3/0 silk
stitch is placed in the nipple proper to maintain eversion
and facilitate manipulation. With the nipple everted to its
desired position, two opposing rhomboid flaps are designed
in the twelve and six oclock positions. Their apex is placed
at the nipple base with the flap extending towards the
areolar margin. The base width is approximately one eighth
of the areola margin. This can therefore be adjusted
according to the size and proportions of the nipple areola
complex (Figure 1a and b).
Each flap is then de-epithelialised and raised such that
the tip is dermal in thickness, extending to dermoglandular
at the base (Figure 2a).

D. McG Taylor et al.

Figure 1 a: Nipple inversion seen with relaxation on the


everting silk suture. b: Rhomboid flap design with the manually
everted nipple.

The fibrous connective tissue and lactiferous ducts


under the nipple are then divided in an inverted conical
shaped incision using an eleven blade and haemostasis
achieved. This allows complete release of the nipple as the
constraining tethering structures drop down to produce an
area of dead space (Figure 2b).
A single 3/0 PDS stitch is then placed in the deep glandular tissue to close the base of the V defect created.
Using the same stitch the tips of the two flaps are sutured
together so they lay double breasted under the nipple. The
medial translation of the two flaps completes the closure of
the dead space under the nipple in a V to Y vertical
advancement and also provides a strong platform for
support of the everted nipple (Figure 3).
The skin is closed with horizontal mattress stitches using
a 5/0 vicryl resulting in two short linear wounds on the
areola (Figure 4a and b).
A simple opsite dressing is applied with a fenestration
centrally so as not to compress the nipple.
No special requirements are made post-operatively.

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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Correction of the severely inverted nipple

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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.

another surgeon for the same condition without a successful outcome.


All patients attended for routine follow-up at approximately three months post-operatively and if no problems
were encountered they were discharged.

Results
Figure 2 a: De-epithelialised and reflected dermoglandular
areolar flap. b: Angled division of the fibrous bands and
lactiferous ducts.

A total of 20 patients with 35 inverted nipples, with an


age range from 16 to 48 years (mean age 35 years) were
treated over this period.
15 of the 20 cases were bilateral and only one case was
not congenital in aetiology. This was a result of recurrent
mastitis. Two patients had previously been operated on by

For the purpose of this study, patients were invited to


either attend a review clinic or participate in a telephone
questionnaire.
Seven patients attended for outpatient review and 11
participated in a telephone interview. In total 32 nipples
were assessed. The post-operative review ranged from one
to 16 years, with a relatively even distribution over the
years.
Regarding short term complications; there were no cases
of nipple necrosis, either partial or complete or haematoma

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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D. McG Taylor et al.

Figure 4 a: Areolar skin closure. b: Immediate post-operative result compared to the contralateral unaffected nipple.

formation. Three cases developed superficial infection


treated with oral antibiotics only.
Fifteen nipples had maintained complete eversion
(nipple position proud of the areola) with minimal change
over time (longest follow-up 16 years). 13 nipples which
had previously been noted to be corrected were reported
to show variable results, ranging from flat (nipple at areola
level) to fully everted depending on situation. Five nipples,
in three patients, did not gain much benefit from the
procedure and in all cases this was evident early postoperatively (3 month follow-up). All patients were offered
further corrective surgery. One patient, with a unilateral
recurrence, underwent correction with a repeat of the
same procedure and has maintained a good long term result
(at 16yr).
All patients were happy with the visual appearance of
the resultant scars and there were no cases of hypertrophy
or keloid. On specific questioning, no patients reported
a reduction to nipple sensation following surgery.
Three patients had children following surgery (at 4, 10
and 16 years) and all 3 unexpectedly, were able to breast
feed from the corrected nipples.
14 of the18 patients recommended the surgery and
would have the same procedure done again giving an
overall satisfaction score greater or equal to seven out of
ten (Figure 5a and b).

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

Figure 5 a: Pre-operative photo right inverted nipple. b: 5


year post-operative result.

position.1 In his studies he found there to be no qualitative


histological difference in the subareolar tissue, however,
the thickness of dense connective tissue beneath the
normal nipple was 50e100% greater than under the
congenitally inverted nipples. Postulated by both Broadbent7 and Teimourian8 and more recently, histologically
shown by Han and Hong,5 are the differences in the subareolar composition of the inverted nipple. These vary
comparably to the clinical severity. The more severely
inverted nipple shows short atrophic terminal lactiferous
ducts with marked fibrosis, predominantly centrally under
the nipple preventing its eversion. These conclusions have
now become more universally accepted in the modern
literature and form the basis for designs on surgical
correction.

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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Correction of the severely inverted nipple


added the concept of a subcutaneous myotomy of the
circular muscle of the areola10 and Sellheim (1917)11 later
combined these two procedures. Modifications thereof
were popular for a number of years.1,12
While Axford (1889)13 was the first surgeon to describe
a purse-string suture (along with some excision of skin), the
technique was repopularised by Lamont14 in 1973 and
Schwager1 in 1974. Modifications on this technique have
been suggested since.4,15
Schwager demonstrated that a major cause for nipple
inversion is paucity of dense connective tissue underneath
it. Along with a concern that the purse-string method may
embarrass the blood supply to the nipple, a new group of
techniques emerged. These were aimed at supplementing
soft tissue bulk underneath the nipple. Over the years
a number of different methods have been employed,
including; tendon grafts, auricular cartilage and alloplastic
material such as synthetic supports to nipple piercing.16e19
However, most commonly these techniques utilise flaps of
areolar or glandular tissue.
Eslay (1976) first described the use of de-epithelised
areolar dermal flaps, stitched together in a tunnel deep to
the nipple.20 He aimed to not only increase the density of
tissue underneath the nipple, but for it also to act as a sling
to support the nipple in the elevated position. Other variations based on this theme have come to form the basis of
correction of the more severely inverted nipple in the
modern literature.5,7,21e31 There is continuing debate
regarding the need to divide the short lactiferous ducts in
order to gain adequate eversion to the nipple.32

e5
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.

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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

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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