Inverted Nipple Research Articles

Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed Onset of Lactation, and Excess Neonatal Weight Loss

Even mothers who strongly want to breast feed their infants could have difficulty getting started. This prospective community-based study was an attempt to identify risk factors other than sociocultural barriers that arerelated to poor lactation outcomes. Risk factors were sought for suboptimal infant breastfeeding behavior (SIBB), delayed lactation, and excessive neonatal weight loss. Participants gave birth to a healthy single infant at term and were willing to try breast feeding exclusively for at least 30 days. Trained lactation consultants provided guidance in such areas as correct positioning, demand feeding, and avoidance of supplements, and also evaluated infant breastfeeding behavior using the Infant Breast-feeding Assessment Tool. Weight loss exceeding 10% of birth weight on day 3 was considered excessive. The mean maternal age was 30.6 years and 56% of mothers were primiparous. Nearly 80% of subjects were non-Hispanic whites. The average educational level was high. These mothers expressed strongly positive attitudes toward breast feeding. SIBB was found in 49% of infants at baseline, 22% on day 3 and 14% on day 7. It correlated significantly with primiparity on days 0 and 3, with cesarean section (day 0 in multiparas), and with flat or inverted nipples. Other significant correlates of SIBB included using nonbreast milk fluids in the first 2 days of life, use of a pacifier, stage II labor lasting longer than 1 hour, and a maternal body mass index (BMI) greater than 27 kg/m 2 . Lactation was delayed in 22% of women, more frequently in primiparas, after cesarean section, and women having a prolonged second stage of labor, a high material BMI, flat or inverted nipples, or (in primiparas) a birth weight greater than 3600 g. Excessive weight loss was observed in 12% of neonates. It correlated with primiparity, a long labor, the use of labor medication (by multiparas), and infant status at birth. Excessive weight loss was 7.1-fold more likely if lactation was delayed and 2.6-fold more likely if SIBB was present on the first day of life.

Correction of inverted nipple: an alternative method using two triangular areolar dermal flaps.

Inverted nipple, which is defined as a nipple located on a plane lower than the areola, presents both functional and cosmetic problems. It is a source of repeated irritation and inflammation, and interferes with nursing. In addition, its abnormal appearance may cause psychological distress. Inverted nipples are congenital or acquired, and are classified as the umbilicated and invaginated types or divided into 3 groups (grades 1, 2, and 3). With consideration of its underlying pathophysiologic components and severity, various surgical procedures have been proposed. For correcting the inverted nipple, the authors introduce an alternative, simple method using 2 triangular areolar dermal flaps. Compared with other methods using triangular areolar dermal flaps, each triangle is approximately 1 mm shorter than the diameter of the nipple, and the deepithelialized areolar dermal flaps are lodged at the slit in the bundle of the lactiferous ducts in the grade 2 inverted nipple. From August 2000 to December 2001, 11 patients (16 nipples) were treated. Five patients had bilateral inverted nipples. Patient age at operation ranged from 18 to 31 years (mean age, 27 years). All nipples were congenital and they had no previous operation. Thirteen nipples were grade 2 and 3 were grade 3 according to the classification of inverted nipple by Han and Hong. The mean follow-up period was 8.7 months (range, 3-12 months). Follow-up examinations revealed no evidence of recurrence of inversion. There was no complication associated with surgery, such as infection, hematoma, permanent sensory disturbance, or nipple necrosis. The resulting scars were minimal. All patients were satisfied with their results. The authors conclude that their procedure is reliable, preserves the lactiferous ducts in grade 2 inverted nipple, requires no special postoperative care, and leaves minimal scars and no recurrence of inversion. This technique can be applied to any type of inverted nipple as a primary surgical procedure.

Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss.

Some mothers have difficulty initiating lactation even when highly motivated to breastfeed. The purpose of this study was to determine the incidence of and risk factors for suboptimal infant breastfeeding behavior (SIBB), delayed onset of lactation, and excess neonatal weight loss among mother-infant pairs in a population with high educational levels and motivation to breastfeed. All mothers residing in Davis, California, who gave birth to a healthy, single, term infant at 1 of 5 area hospitals during the 10-month recruitment period in 1999 were invited to participate if they were willing to attempt to breastfeed exclusively for at least 1 month. Lactation guidance was provided and data were collected in the hospital (day 0) and on days 3, 5, 7, and 14. Infant breastfeeding behavior was evaluated by trained lactation consultants using the Infant Breastfeeding Assessment Tool. Onset of lactation was defined based on maternal report of changes in breast fullness. Infant weight loss was considered excessive if it was >or=10% of birth weight by day 3. Of the 328 eligible mothers, 280 (85%) participated in the study. The prevalence of SIBB was 49% on day 0, 22% on day 3, and 14% on day 7. SIBB was significantly associated with primiparity (days 0 and 3), cesarean section (in multiparas, day 0), flat or inverted nipples, infant status at birth (days 0 and 3), use of nonbreast milk fluids in the first 48 hours (days 3 and 7), pacifier use (day 3), stage II labor >1 hour (day 7), maternal body mass index >27 kg/m(2) (day 7) and birth weight <3600 g (day 7). Delayed onset of lactation (>72 hours) occurred in 22% of women and was associated with primiparity, cesarean section, stage II labor >1 hour, maternal body mass index >27 kg/m(2), flat or inverted nipples, and birth weight >3600 g (in primiparas). Excess weight loss occurred in 12% of infants and was associated with primiparity, long duration of labor, use of labor medications (in multiparas), and infant status at birth. The risk of excess infant weight loss was 7.1 times greater if the mother had delayed onset of lactation, and 2.6 times greater if the infant had SIBB on day 0. Early lactation success is strongly influenced by parity, but may also be affected by potentially modifiable factors such as delivery mode, duration of labor, labor medications, use of nonbreast milk fluids and/or pacifiers, and maternal overweight. All breastfeeding mother-infant pairs should be evaluated at 72 to 96 hours' postpartum.

A new method for correction of inverted nipple with three periductal dermofibrous flaps.

The inverted nipple may be congenital or caused by repeated inflammation and breast surgery. The reported prevalence of congenital inverted nipple ranges from 1.77% [1] to 3.26%, and most of them are bilateral and umbilicated [2]. The inversion has been linked to many aesthetic, functional, and psychological problems. Many methods have been proposed to correct this deformity since the first surgical correction by Kehrer in 1879. I propose a new method with three periductal dermofibrous flaps to add bulk to the nipple base and to form a hammock to prevent recurrence. The design also shortens the circumference of the root of the nipple without compromise of the neurovascular supply. We have corrected 46 nipples of 25 patients with this method successfully since 1996. This method can be applied to all types of inverted nipple without significant complications.

Syndrome d'hypoglycosylation des glycoprotéines sériques

Carbohydrate-deficient glycoprotein syndrome (CDGS) is a newly delineated group of inherited multisystemic disorders associated with abnormal glycosylation of a number of serum glycoproteins. Several types have been described on the basis of clinical presentation and biochemical changes of the glycosylation of serum transferrin and attributed to different enzymatic defects; their clinical presentations are fully different and a clinical heterogeneity is observed within a same type of CDGS. Patients with CDGS type la usually present with neurologic (hypotonia, strabismus and cerebellar hypoplasia) and cutaneous (inverted nipples, abnormal distribution of adipose tissue) abnormalities, together with multivisceral involvement (digestive, hepatic, cardiac, renal). However, neurologic and cutaneous symptoms may be absent, so that CDGS must be looked for in case of unexplained organ failure such as isolated liver insufficiency, cardiomyopathy, pericarditis, tubulopathy, nephrotic syndrome, vascular accident or retinitis pigmentosa. Patients with CDGS type Ib present with liver disease, enteropathy and hypoglycemia without neurologic involvement. These patients are successfully treated with oral mannose administration emphasizing the importance of making the diagnosis. Patients with CDGS type Ic present with mild psychomotor retardation and seizures. Patients with CDGS type II have psychomotor retardation association with severe gastrointestinal disorder, dysmorphic features and abnormal electroretinogram. Other types (III, IV) are less clearly defined and the clinical presentation includes convulsive encephalopathy. Biological abnormalities such as mild hepatic cytolysis, hematologic and hormonal abnormalities are consistently observed in CDGS type I, as well as renal hyperechogeneity, leading one to look for this syndrome when they are associated. Until now, only four enzymatic deficiencies have been identified (types Ia, Ib, Ic, II).

The prevalence of congenital inverted nipple.

To investigate the prevalence and type of congenital inverted nipple, and realizing that the condition is a disease for which treatment is necessary, 1,625 unmarried women aged between 19 and 26 were physically examined and responded to questions about inverted nipple. Fifty-three of 1,625 subjects (3.26%) presented with this malformation, and it was found in 3.05% of the 3,250 nipples examined. In 46 of the 53 (86.79%), the condition was bilateral, and in 7 (13.21%), it was unilateral. In such cases, inversion was found on the right side in two subjects and on the left side in five. Of the total number of congenital inverted nipples, 96.23% were umbilicated and 3.77% were invaginated. Nine of the 53 subjects with inverted nipple considered that the condition should be corrected. Prior to counseling and possible surgery, the medical practitioner must carefully consider all available information, and the data contained in this report may thus be useful.

A new surgical procedure for the very severe inverted nipple.

Severe cases of inverted nipple usually cannot be corrected by a simple procedure, especially if the nipple cannot be pulled out above the areolar level by manipulation. We describe a new method for these cases and we classify the inverted nipple into 3 grades following the choice of their required operative procedure. Our classification for inverted nipple is as follows. Grade I: The inversion is corrected simply by manipulation; the nipple protrusion is long-lasting. Grade II: The inversion can be corrected by manipulation, but recurrence of the inversion is frequent. Grade III: The inversion cannot be corrected without a surgical procedure. Cases of Grades I and II can be corrected by conventional simple surgical procedures. But some cases of Grade II and almost all of Grade III cannot be corrected by conventional methods, in spite of the high frequency of relapse. Cutting of the lactiferous duct, such as the Pitanguy and Broadbent methods, can correct the very severely inverted nipple. But if we want to maintain the lactiferous function after correction, we had better not cut the lactiferous ducts. Our new procedure for correcting very severe cases can keep the lactiferous function after correction without any relapse. In order to avoid the recurrence of nipple retraction and to maintain the lactiferous function, the new surgical procedure that we performed makes an incision deeply and vertically on the nipple to free the lactiferous ducts from the contracted tissues surrounding them. After extension or resection of the restricting tissues, the nipple is raised easily. This procedure will preserve the feeding function and prevent the recurrence of nipple inversion. For very severe cases, using a dermal flap inserted into the base of the nipple may be necessary due to its role of interposing tissue to prevent reverting to inversion.

Retroareolar breast carcinoma: clinical, imaging, and histopathologic features.

To evaluate the clinical, imaging, and histopathologic features of breast carcinoma in the retroareolar tissues and to determine whether there are any characteristics common to this location. Thirty-five patients (age range, 38-77 years) with 37 retroareolar carcinomas were identified retrospectively. Retroareolar carcinoma was defined as that within 2 cm of the nipple-areolar complex. Mammographically occult tumors were identified by using histopathologic records (n = 4) or clinical examination findings (n = 6). Twenty-nine (78%) tumors had clinical findings, including palpable mass (n = 29), associated nipple inversion or retraction (n = 4), and associated nipple discharge (n = 2). Twenty-seven (73%) tumors had mammographic findings of mass (n = 16), mass with calcifications (n = 5), and microcalcifications (n = 6; four of these microcalcifications were associated with a mammographically occult palpable mass). Ultrasound was performed in 17 tumors, all of which were hypoechoic. The stage of 31 carcinomas was known: one was stage 0, 17 were stage I, and 13 were stage II. Histopathologic analysis revealed 35 ductal carcinomas and two invasive lobular carcinomas. Retroareolar carcinoma usually manifests as a palpable mass. Mammography is less sensitive in this area than in other areas of the breast. Ultrasound can be a valuable adjunct in the assessment of retroareolar malignancy.

Correction of recurrent nipple inversion with cartilage graft.

Of the many techniques advocated to correct nipples, all demonstrate a failure rate with a recurrence of the inversion. We report a technique to correct the recurrent nipple inversion in a simple and permanent fashion. This technique consists of releasing all scar tissue and any lactiferous ducts deep to the nipple and inserting a cartilage graft (rib or auricular) under the nipple. This cartilage graft serves to fill in any soft tissue defect and prevent recurrent contraction and nipple inversion. Although generally used for correction of recurrent nipple inversion, we have also used this technique successfully as an initial modality in patients with inverted nipples. We have found this technique to be simple, nondeforming, cosmetically acceptable, and permanent in the treatment of both inverted and recurrent inverted nipples.

Mammography in the evaluation of nipple inversion.

The purpose of this study was to correlate the clinical and mammographic appearances of the nipple, determine the effects of breast compression on nipple position, and describe the mammographic findings in women with nipple inversion. We examined 312 consecutive women who were referred for mammography using routine craniocaudal and mediolateral oblique views, which resulted in 595 breasts imaged Nipple position (normal or inverted) was assessed visually, both with and without breast compression, and correlated with the findings at mammography. Of the 312 women, 29 (9%) had visually inverted nipples without breast compression; similarly, of the 595 breasts, 36 (6%) had visually inverted nipples without breast compression. Clinical nipple inversion was chronic in 33 (92%) of 36 breasts and acute in the remaining three breasts (8%) Nipple inversion occurred at birth in one (3%) of 36 breasts, during puberty in 21 (58%), and during adulthood in 14 (39%). Reported causative factors were pregnancy in one (3%) of 36 breasts, nursing in one (3%), prior benign biopsy in one (3%), and prior cancer in one (3%). In the other 32 breasts (89%), causative factors were not known. Both visually and mammographically, 29 (81%) of 36 clinically inverted nipples remained inverted with breast compression, but seven (19%) became normal in position. Of the 312 women, 23 (7%) had inverted nipples on mammography; likewise, of the 595 breasts, 29 nipples (5%) were inverted on mammography. Mammographic findings in the 33 breasts with chronically inverted nipples were normal in 29 (88%), probably benign masses in two (6%), multiple cysts in one (3%), and axillary lymphadenopathy in one (3%). Mammographic findings in the three breasts with acutely inverted nipples were normal in two (67%) and revealed a suspicious mass in one (33%). Mammography often failed to reveal nipple inversion; nearly one in five clinically inverted nipples became normal in position as a result of breast compression. In the vast majority of women with nipple inversion, the process was long-standing and without causative factors. Also, these women typically lacked mammographic findings suggestive of malignancy. Of the 14 patients with nipple inversion that had occurred during adulthood, two women (14%) had an underlying malignancy.

Breastfeeding Update 2: Clinical Lactation Management

Breastfeeding Update 2: Clinical Lactation Management

Mammographic patterns of inflammatory breast carcinoma: a retrospective study of 92 cases

Objective: To quantitaté initial mammographic signs and to describe post-therapeutic patterns of inflammatory breast cancer. Material and methods: Two radiologists retrospectively analyzed the initial clinical and mammographic findings of 92 patients with inflammatory breast carcinoma. The post-therapeutic mammogram ( n = 75) was considered abnormal when focal opacity and/or malignant-type microcalcifications were still visible. Results: Redness of the skin, ‘peau d'orange’ and increased temperature were the most common findings. A palpable mass was noted in 97% with axillary lymph node involvement in 83% of cases. All initial mammograms were abnormal. Isolated inflammatory signs were observed in 14% and malignant signs in 86% of patients (opacity = 77%, and/or malignant-type microcalcifications = 47%). Skin thickening was seen in 93.5%, nipple inversion in 56.5%, increased breast density in 93.5%, stromal coarsening in 85% and hypervascularisation in 32.5% of mammograms. On post-therapeutic mammograms, 35 patients (46.5%) were suspected of having residual disease. During follow-up, 19 patients (25.3%) relapsed locally: 75% had abnormal post-therapeutic mammograms. Conclusion: The presence of isolated inflammatory signs on the mammogram is sufficient to suspect inflammatory breast carcinoma and biopsy must be performed in doubtful cases. Radical surgery is indicated when persistent malignant signs are still visible on mammogram after conservative treatment.

Clinical use of silicone nipple shields.

Use of nipple shields is controversial. However, when weaning is imminent, they may enable breast-refusing infants to transfer back to the breast. A chart review of 248 clients seen during a 13-month period in a private lactation clinic revealed 32 women who received thin, silicone nipple shields. Among this group, the most common presenting problems were breast refusal (69 percent) and difficulty with latch (25 percent). Bottles had been introduced in 75 percent of these cases. Thirty-eight percent of the mothers using nipple shields weaned their infants during the initial crisis period; 56 percent continued to breastfeed for at least six weeks postpartum. Two ill infants continued to receive human milk by bottle for four and 12 months respectively. Parity appeared to correspond inversely with success of the shield intervention. The presence of flat or inverted nipples appeared to contribute to the phenomenon described as "nipple confusion."

Subareolar breast cancer: Long-term results with conservative surgery and radiation therapy

It has been suggested that patients presenting with breast cancers within 2 cm of the nipple areolar complex represent a relative contraindication to conservative management due to either a compromised cosmetic result associated with sacrifice of the nipple areolar complex, reluctance to include the entire nipple areolar complex in the conedown field, or increased risk of multicentricity. We have reviewed our experience of conservatively treated patients with specific reference to the subset of patients presenting with tumors within 2 cm of the nipple areolar complex. Between January 1970 and December 1989, 1014 patients with early stage breast cancer were treated at Yale-New Haven Hospital by excisional biopsy with or without axillary lymph node dissection. Of the 1014 charts reviewed, a total of 98 patients fulfilled the criteria of having a central/ subareolar breast cancer. Reexcision was performed on only 16 patients. Following conservative surgery, patients were treated with radiation therapy to the intact breast to a total median dose of 48 Gy with conedown to a total of 64 Gy. adjuvant systemic therapy and regional nodal irradiation were administered as clinically indicated. As of December 1993, the median follow-up for the 98 patients in this study was 9.03 years. The majority of patients had presented with either a palpable mass or a mammographically detected lesion. Three patients presented with Paget's disease, five with nipple discharge, and seven with nipple inversion. Ten of the 98 patients had the nipple areolar complex sacrificed at the time of surgery, while the remaining 88 patients had the entire nipple areolar complex included in the conedown field. Four of these 88 patients had the nipple partially blocked during the electron conedown. There were no significant complications associated with including the entire nipple areolar complex within the conedown field to a median dose of 64 Gy. Six of the 98 patients experienced a local recurrence, three experienced a regional recurrence, and nine experienced distant metastasis. The actuarial 10-year survival (0.79 +/- 0.06), distant disease-free survival (0.88 +/- 0.04) and breast recurrence-free survival (0.84 +/- 0.07) were not significantly different from those patients who presented with cancers in other parts of the breast. Patients presenting with subareolar breast cancers within 2 cm of the nipple areolar complex are suitable candidates for conservative surgery and radiation therapy. In the majority of patients in this study, the nipple areolar complex did not need to be sacrificed and could be safely included in the electron conedown field with acceptable complications and cosmesis. A subareolar breast cancer does not represent a relative contraindication to conservative management in patients with early stage breast cancer.

Inflammatory breast carcinoma: mammographic findings.

To identify and quantitate mammographic characteristics of inflammatory carcinoma (IC). A retrospective analysis was made of the clinical and mammographic findings in 22 women (aged 31-66 years [mean, 51 years]) with IC, who were seen between 1980 and 1990 at the authors' institution. A palpable mass was present in 17 of the 22 women (77%); skin thickening, axillary adenopathy, nipple inversion, and erythema were common findings. At mammography, the findings in one woman with dense breasts were negative. A primary tumor, evident on the basis of a mass and/or malignant-type calcifications, was seen in all other cases. Skin thickening was present in 15 women, stromal coarsening in 11, diffusely increased breast density in nine, and axillary adenopathy in five. IC has a mammographic pattern of inflammatory changes: skin thickening and stromal coarsening and/or diffusely increased breast density, associated with evidence of a primary tumor mass and/or calcifications. In this series, inflammatory changes without an associated mass and/or malignant-type calcifications were not seen in women with IC.

Surgical Correction of the Inverted Nipple with a Tendon Graft

Our procedure, in which the inverted nipple was suspended using autogenous tendon grafts, was easy to perform, and it was not necessary to cut the lactiferous ducts. There was no deformity of the nipple or areola after this procedure, and the surgical scars were inconspicuous. Three patients who were followed up for over 1 year after surgery were presented in this paper. In eight patients (13 corrected inverted nipples), good results were obtained and there have been no complications to date.

A Direct Surgical Approach to Correct the Inverted Nipple

Inverted nipples are cosmetically unpleasing to the patient and can become inflamed due to mechanical difficulty with cleaning the nipple-areola complex. A surgical technique for the permanent repair of inverted nipples is described. The rationale for the surgical approach is that the major pathophysiologic basis for nipple inversion is shortened lactiferous ducts. Briefly outlined, under local anesthesia, the nipple is everted with a skin hook and held in gentle traction while a small incision is made on each side at the nipple-areola junction. Breast ducts are then divided by sharp dissection, and a drain is inserted through the tunnel under the nipple. The drain is removed in 7 to 10 days. The patient must be informed before the procedure that breast-feeding will not be possible afterward because breast ducts will be permanently divided. Advantages to the procedure are (1) no scars on the areola, (2) no stricture from sutures, (3) adequate blood and nerve supply to the nipple, and (4) decreased risk of hematoma.

Ductal carcinoma‐in‐situ of the breast: Fine‐needle aspiration cytology of 12 cases

Aspiration specimens from 12 patients with histologically documented ductal carcinoma-in-situ (DCIS) of the breast (seven patients) or DCIS with minute foci of stromal invasion (five) were evaluated. Five patients presented with palpable masses, 1.5-4.0 cm, and four patients presented with localized thickening, associated with nipple erosion and discharge in two of them. One patient had nipple inversion, and one patient had bilateral nipple discharge. In one patient, no apparent abnormality of the breast was present. Mammography was either suspicious for or strongly suggestive of carcinoma in 10 patients and negative in two. Aspirates from all patients were composed of fragments of atypical ductal epithelium and numerous single epithelial cells. In nine cases, the smears were hypercellular and similar to aspirates of typical invasive ductal carcinoma. Calcifications were present in six cases. In four of these, associated tumor necrosis was evident. Cytologic features separating DCIS patients from those showing minimal stromal invasion or common types of invasive ductal carcinoma (IDC) were not identified. We conclude that fine-needle aspiration cytology of DCIS is identical to that of IDC. If preoperative radiotherapy or chemotherapy is considered in the management of invasive breast carcinoma, cutting-needle biopsy for confirmation of tumor invasion is necessary.

Correction of the Inverted Nipple

Correction of the Inverted Nipple

Combination of the square flap method and the dermal sling to correct flat or inverted nipples.

A technique for the correction of flat or inverted nipples is presented. The procedure is a combination of the square flap method, which better shapes the corrected nipple, and the dermal sling, which provides good support for the repaired nipple.