Correction of Inverted Nipples with Fat Grafting: A Novel Technique for a Challenging Problem.

Abstract

Nipple inversion occurs because of pathologically shortened or fibrotic lactiferous ducts and periductal tissue. It is a common breast deformity with significant functional and aesthetic implications, including mastitis, psychological distress, and breastfeeding complications.1 Minimally invasive treatments can suffice for grade I inversion, but surgical release is often required for more severe cases. There is no consensus on the most effective technique and recurrence rates are reported in up to 41% of cases.2 We describe a novel technique that combines and expands upon previously described procedures. After harvesting and processing fat using the Coleman technique, a 2-0 polyglactin suture is passed through the base of the papilla and pulled taut to evert the nipple manually. A combination of vertical and horizontal rigotomy movements are then performed with an 18-gauge needle to release fibrotic bands until the papilla can maintain eversion without tension. Coleman needles are used to inject fat using multiple passes along the base of the nipple-areola complex with care taken to inject only into the subcutaneous plane. The nipple is supported by placing suspension sutures at the base of the papilla, which are then secured to a nipple shield (Medela; McHenry, IL), an external traction device (Fig. 1). Appropriate tension on these sutures is essential to avoid tissue ischemia. [See Video 1 (online), which shows temporary suspension suture placement at the papule base and needle rigotomy. See Video 2 (online), which shows the fat grafting portion of the procedure.] Nipple shields are left in place for 2 weeks, after which time patients transition to a Niplette (Phillips Avent; Amsterdam, Netherlands) external traction device for 4 weeks. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"A temporary tension suture is placed at the papule base and needle rigotomy is performed.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_zw47vhe6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"Once all fibrotic bands are released, the autologous fat is injected in the subcutaneous plane beneath the nipple-areola complex.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_pzhpcpkc"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Suspension sutures are placed at the papule base in the fat-grafted nipple and secured to the nipple shield device with gentle external traction for 2 weeks.In our experience with three patients, the average volume of fat grafted was 8.7 ml. All papules maintained cylindrical shape, symmetry, and projection at 10.6 months mean follow-up (Fig. 2). All patients reported reduced nipple sensitivity postoperatively with partial return of sensation over time. One patient experienced persistent inability to breastfeed. No patients required reoperation.Fig. 2.: Preoperative (left) and postoperative (right) views. Note that despite attempts at self-correction with nipple piercings, significant retraction and inversion are still evident in the right breast preoperatively.Strategies to release fibrotic tissue using needle rigotomy are well-described, but are associated with recurrence rates up to 22% without application of external traction devices.3 The novel step in our technique is autologous fat grafting after rigotomy, obliterating the dead space created. The grafted fat provides internal support while the nipple shield provides external support. Autologous fat grafting also encourages tissue and scar remodeling, which is attributed to soluble trophic factors present in adipose-derived stem cells.4,5 There is evidence that grafted fat promotes local increases in capillary density and blood flow, favoring wound healing and tissue regeneration over pathologic contracture.5 To our knowledge, fat grafting to fill the native subpapillary space has not been described, and we injected significantly larger volumes of fat (mean 8.7 cc) than previously reported to account for anticipated resorption. Limitations to this technique include alterations to sensation and lactation, which must be disclosed to patients. This is a straightforward technique that yields satisfactory results over time and we advocate its use in patients with class II or III nipple inversion. DISCLOSURE The authors have no conflict of interest or financial interest to declare in relation to the content of this article.