Inverted Nipple - The Small Problem, that Can Cause Big Complications

Inverted Nipple Meaning

Inverted nipple which is sometimes also known as nipple retraction is a condition, where the nipple is pulled inwards, instead of pointing outwards. It is rather a common problem, that is seen in almost 10 % of women and sometimes in men too. Either one or both the breast may be affected.

Can Inverted Nipple be Fixed?

This inverted nipple may be a reversible (temporary) condition – which can be corrected by manual maneuvers, or an irreversible (permanent) condition, which cannot be corrected by any procedures excluding surgery.

Many women (and men) having inverted nipples, remain ignorant about the health conditions concerning their inverted nipple – sometimes which has serious consequences later on. It is with keeping these people in view, a sincere attempt has been made to explain the causes for Inverted nipple and associated complications, surrounding this rather innocent-looking condition.

Concern for Inverted Nipples

In many women, Inverted Nipples may be due to a congenital cause i.e. it is present since birth. If a woman has been born with an inverted nipple, then it does not automatically point to a disease, but when an inverted nipple develops later on in life, in women who were normal previously then this is much more suspicious.

Although the most significant complaint, that women believe, which is associated with an inverted nipple is - the inability to breastfeed a baby, there can be other problems too. Many women can breastfeed their baby, despite having an inverted nipple and this makes them believe that there is no reason for worry; but that may not be always true.

Symptoms of Inverted Nipple

When the inverted nipple is not associated with any underlying pathology, there is usually no sign and symptoms. But when an associated illness is present, then some of the features mentioned below may appear.

These symptoms make it imperative that a person suffering from an inverted nipple should consult a doctor – a surgeon to be precise (Surgical specialist).

There is no need to get alarmed, for fixing an appointment with a surgeon. Getting an opinion and getting surgery are two different matters. Coming back to the symptoms of an inverted nipple, which deserve medical attention are:

1) A secretion coming out of the breast of a woman who is not pregnant. Even in a pregnant woman, a discharge that is bloody demands attention.

2) If the nipple is excessively tender, with the involvement of surrounding breast tissue, an expert opinion should be taken.

3) Changes in the skin over the nipple, areola, and breast, in form of cracks, tear, or redness - is also a cause of concern.

4) Most importantly, a firm mass or lump felt under the areola, or any other region of the breast makes a consultation with a Breast surgeon mandatory.

Causes for Inverted Nipple

Many diseases can cause an inverted nipple, as a symptom.  Here an attempt would be made to describe only the most important ones in short –

1) Local Trauma

• Any kind of local trauma, over the nipple-areolar complex, can cause scarring. The resulting fibrosis causes nipple inversion.
• Sometimes even breastfeeding can cause scarring and fibrosis and is the reason many women complain of the inverted nipple after breastfeeding their baby. Sometimes surgery and fat necrosis also cause inversion of the nipple, due to the same reason.

2) Mammary Duct Ectasia

• In Mammary Duct Ectasia, there is a generalized dilatation of the ductal system of the breasts, and ducts are filled with secretions. The main symptoms are pain, nipple retraction, and discharge -- which may be of brown/green/white color. Sometimes a frank red bloody discharge may also be seen.

3) Mastitis

• In layman’s terms, Mastitis means the inflammation of the breast. This is commonly seen, when a woman is breastfeeding her baby and almost 10% of breastfeeding women can suffer from this condition.
• Bacteria like staphylococcus and streptococcus, enter the breast either through the bloodstream or lactiferous ducts.
• Pain is the initial symptom, which at first is dull but soon becomes continuous and throbbing. The breast is swollen, reddish in color, tender, and hot to touch.
• This condition may be associated with a generalized symptom like fever, in addition to the localized breast symptoms. An abscess may form as a complication.

4) Paget’s Disease of the Breast

• Paget’s Disease of the Breast is a malignant condition (cancer in layman’s terms), in which the nipple is gradually destroyed and growth or lump may develop within the breast, close to the nipple area.
• This is often seen in women nearing menopause.
• The beginning of this problem, resembles eczema of the nipple, as the nipple and areola become red and covered with scales. Thereafter the scales get detached and the nipple is destroyed. A bloody or straw-colored discharge may come from the affected area.  

5) Breast Carcinoma (Inverted Nipple in Breast Cancer)

• This is a type of cancer, which rises from epithelial cells of the breast. There are many different varieties present. Without going into technical details, we would just like to state only the features, which are highly suspicious of this condition and requires an urgent referral to a breast surgeon.
• A lump in the breast which is hard like stone & has an irregular surface, with or without dimpling, and has retraction or puckering of the skin above & is associated with inverted nipple needs urgent medical attention, to rule out Breast cancer.

Investigations for Inverted Nipple

As has been mentioned previously, an inverted nipple may or may not be associated with other diseases of the Breast, with the Inverted Nipple Breast Cancer association demanding special focus and exclusion during investigations.

 Before declaring, that everything is fine; it would always be prudent to carry out the relevant investigations, to rule out the danger of life-threatening causes of inverted nipple. The most important investigations which help a doctor to come to a definite diagnosis are -

1) Ultrasound

Ultrasound is one of the most basic investigations for the diseases of the breast. The main role is to differentiate a solid (example- fibroadenoma) swelling from cystic swelling (breast cyst).

• Breast ultrasounds are of limited usefulness in the detection and diagnosis of breast cancer but indirectly helps in guiding biopsy needles precisely to the suspicious area of the breast while collecting breast tissues for further examination.

2) Mammography

In layman’s terms, mammography is an x-ray picture of the breast. It can be used as a screening procedure, to check breast cancer in women, who otherwise have no other sign or symptom of the disease. This is known as screening mammography and serves as a key element for the early diagnosis of breast cancer.

• Mammography is also useful when a distinct lump is present, to further strengthen the diagnosis. Specific patterns in mammography results indicate specific breast tumors, and a precise diagnosis obtained in such a manner helps the treating doctor, formulate the next plan of action.

3)FNAC

• Fine needle aspiration cytology (FNAC) is a specialized form of biopsy, done to evaluate a breast lump. In this procedure, a very small sized needle attached to a syringe is passed through the breast into the lump. By pulling the plunger of the syringe, the negative suction pressure is produced and material from the tumor is collected.
• The material collected from the tumor is smeared in a glass slide, which is analyzed by the pathologist under the microscope, after adequate preparation.  The results given by the pathologist, helps the treating doctor to decide on the next course of action.

Inverted Nipple Correction

• Inverted nipple, when is not associated with other health diseases or any other difficulty while breastfeeding, does not necessitate treatment (except maybe for cosmetic correction).
• If there are more dangerous pathologies present in the breast, compared only to the comparatively simple innocent external manifestation of an inverted nipple, then the more serious health problem should be treated before, turning the focus to the inverted nipple.
• Here we would just focus on the cosmetic correction of inverted nipple, that is not associated with or caused by any other more serious breast problems.

Non-Surgical Treatment for inverted Nipple

1) Hoffman Technique

• Hoffman Technique or procedure can be done by the women themselves. The thumbs are placed on either side of the nipple at the base of the nipple and they are firmly pushed inside towards the inner aspect (or base) of the breast.
• While maintaining this inner pressure, the thumbs are pulled apart from each other. After that, the thumbs are moved around the nipple. This maneuver is repeated multiple times.
• The disadvantage with this procedure is that the improvement which occurs with this procedure is temporary and the condition soon goes back to its original state and some women, may not get at all any benefit from this technique.

2) Nipple Piercing

• Nipple Piercing is a controversial procedure, with most people being skeptical about the final result. In this the nipples are drawn out first, followed by nipple piercing and passing of a stainless-steel ring or a barbell through the nipple.
• In the case of barbells, screw-in balls are used in both ends, to prevent the nipple from retracting back inside the breast. It does not work in all cases & and after taking out the ring/barbell in many cases, the nipple may go back to its original position.
  • Piercing also hampers the ability to breastfeed in many women. Finally, the aesthetic appeal of this kind of therapy may be quite unpredictable or frankly displeasing.

3) Suction Devices

• Many devices are available in the market, which uses a small cup attached to a plunger, pulling which creates a negative suction pressure. These devices are applied over the areola, encircling the inverted nipple and negative suction pressure is created by pulling the plunger.
• This brings out the nipple, which protrudes into the cup. Repeated maneuvers like this can bring the inverted nipple into a protruding position, but this procedure may not work always. 

4) Other Mechanical Devices

• If a woman already has an inverted nipple, from a time before she got pregnant, and the need to breastfeed arises, later on, she can try some specialized mechanical devices. An important Breastfeeding with inverted nipple tips here would be about the use of a nipple shield.
• A nipple shield can help the baby to suck more easily, breast shield can also apply pressure on the nipple making it more protruding. Manual nipple stimulation by hand can also help in some cases.

Inverted Nipple Repair surgery

The best thing about the surgical treatment for the inverted nipple is, unlike the previously mentioned techniques, this gives a permanent result. This can be again of two types.

A)  The inverted nipple repair surgery which can give a cosmetic improvement, without hampering a woman’s ability to breastfeed.

B) Inverted nipple repair surgery where the ability to breastfeed is lost forever.

The decision for choosing the surgery is done after a thorough consultation between the doctor and the patient, where the patient’s expectation of benefit is evaluated against the price, she is ready to pay for it.  The available techniques are -

1) Partial Preservation of Milk Ducts

This surgery is known as the parachute flap technique & is usually done under local anesthesia. Usually, nipple sensation is not altered in this surgery and the woman in question would be able to breastfeed after the procedure, as the integrity of some milk ducts is maintained.

2) All Milk Ducts are Severed

This procedure is more common and believed by some to be more effective. The surgery is usually done under local anesthesia, but for patient comfort, general anesthesia may also be administered. Here all the milk ducts are cut, which allows nipples to protrude more freely. Nipple sensation is not usually altered but the ability to breastfeed is lost forever.

Inverted Nipple – The Conclusion

An inverted nipple is an innocent-looking condition, but it can hide sinister pathology inside. This can even be dangerous breast cancer (Breast Cancer with Inverted Nipple) for which a woman can lose her breast or sometimes her life also.

A thorough examination by an experienced medical practitioner along with necessary investigations will bring forward the right diagnosis. In case of associated breast diseases, treatment should be advised as soon as possible.

However, if there are no other dangerous diseases associated & the lady concerned does not suffer any difficulty in breastfeeding or has any problem in her conjugal relationship with her husband, then treatment is a matter of personal choice, for improvement in aesthetic appearance only.

(Disclaimer – This article is just for raising awareness in society, regarding the problem of inverted nipples. This is certainly not meant for use as a substitute for face to face consultation & examination of patients by a registered medical practitioner, for those who need it and should be never used for such a purpose.)