Inverted Papilla: Treatment with Closed Microincision

Goals/Purpose: The inverted nipple may have functional and esthetics implications. HAN and HONG recently proposed a classification to guide diagnosis and surgical planning. They divided it into three groups (I, II, III) according to the severity of the invertion and the fibrosis , planning the surgical correction according to this degree. The purpose of this paper is to demonstrate a method that proved effective in the authors' experience in the treatment of inverted nipple, especially those of grade II and III. This is accomplished through a microincision, using a 16 G needle, which ends in two options, resembling a microbisturi. The technique seeks to address the basic physiological findings, responsible for the inverted nipple, in releasing the retractable fibroductal tissue and promote internal growth of tissue, which fills the tissue deficiency, adding volume, designed to bear the nipple. No internal or external suture is left, as well as dermal flaps are unnecessary or soft tissue to stabilize the nipple after its correction.

Methods/Technique: The nipple is pulled with Adson forceps next a 2-0 monofilament wire loop is passed in the nipple-areola transition, anchoring the fibroductal tissue and pulling it externally with a needle holder. Then, the needle is inserted in position 3 or 9 hours clockwise and the dense retractable fibroductal tissue and is fully released in a circumferential motion. The end of the procedure will be when the nipple is fully designed, without  traction. Right now, bidigital palpation reveals absence of tissue, internally. The handle with wire monofilament is left in place, secured by a micropore tape, in order to pull the nipple, gently upward for four days and down for four days as outpatients. No internal or external suture is left and any dermal or cutaneous flap is transposed.

Results/Complications: This method was applied in eight women (one bilateral and seven unilateral cases) n = 9. The group was divided according to classification and HAN and HONG (n = 5 grade II, grade III n = 4). The patients were followed for a period ranging from 8-19 months. The results were considered satisfactory, considering the good nipple projection obtained in all cases treated. Patients were encouraged to massage the areola-nipple plaque twice a day for four months, through the bidigital manipulation . The purpose was to soften the temporary tenderness in the operative site, due to the neoformation of connective tissue. The first patient became pregnant eight months after undergoing bilateral treatment. Although breastfeeding has not been satisfactory, milk secretion was made possible by digital pressure on breast tissue.  In order to broaden the evaluation of the technique, the sensitivity of the nipple-areola complex was preliminarily evaluated through an analog scale. Each patient was asked to quantify on a scale of 1 to 10, the response to stimuli, pre-operatively, the next day, after one week and one month after the procedure.It was used as an analysis tool, the soft touch and  two points discrimination , comparing these findings with the preoperative levels. We observed an early recovery of the nipple-areola complex sensitivity. Although the number of patients was not significant, to be analyzed under statistical bases, no permanent sensory damage was reported.

Conclusion: we found in this study, a simple, quick and easy in the treatment of inverted nipple, through a procedure for a closed micro-incision, which must be considered in the therapeutic armamentarium of those who commonly treat this condition.