Etiology of nipple invagination
The skin and subcutaneous tissues are sunken, the nipple smooth muscle is dysplastic, the ducts are shortened, and some tissues are fibrotic contractures. Among them, ductal shortening and tissue fibrosis contracture are the main causes of severe nipple invagination. It is congenital or hereditary; unilateral nipple invagination is less common.
Symptoms of nipple invagination
Nipple invagination is often bilateral and the degree of depression varies from side to side. In mild cases, the nipple loses its projection and is partially sunken into the areola; in severe cases, the nipple loses its appearance and is completely sunken under the areola plane, showing a crater-like deformity. Dirt or oil can accumulate in the sunken nipple, causing itching, eczema or inflammation. In severe cases, it can interfere with the infant’s ability to suckle milk. There are three clinical types of nipple invagination: Type I, where the nipple is partially invaginated and the nipple neck exists, and the invaginated nipple can be easily squeezed out by hand, and the size of the nipple after squeezing out is similar to normal; Type II, where the nipple is completely invaginated in the areola, but the nipple can be squeezed out by hand, and the nipple is smaller than normal, mostly without the nipple neck; Type III, where the nipple is completely buried under the areola and cannot be squeezed out.
Examinations to check nipple invagination
1.Molybdenum X-ray examination: axial films can detect lumps, fibrosis and calcified lesions in the breast.
2, MRI examination: fat resisted scanning can show an invaginated nipple.
Diagnosis of nipple invagination
Nipple invagination is divided into primary and secondary nipple invagination according to the cause of its production.
Primary nipple invagination is due to congenital dysplasia of the milk ducts and their surrounding smooth muscles and lack of supporting tissue under the nipple, resulting in inconspicuous nipple projection or nipple invagination. In some cases, nipple invagination is caused by dysplasia of the breast ducts themselves, where the dysplastic ducts fail to ductalize and form short, constricted strips. Nipple invagination due to congenital development alone is relatively rare and is often aggravated by repeated infections based on congenital factors. Poorly patent ducts and localized skin depression of the nipple can cause infection, resulting in degenerative necrosis of the local tissue and scar contracture, resulting in nipple invagination.
Secondary nipple invagination is caused by the pulling of the nipple by pathological tissues in the breast, and the most common cause is breast cancer.
Treatment
Treatment of Inverted Nipples
Summary of treatment for nipple invagination.
The treatment of nipple invagination is mainly surgical, and those with less invagination can also try to correct it by continuous low negative pressure suction. The crescent-shaped areola flap correction method for patients with nipple invagination is suitable for patients with severe congenital nipple invagination and long-standing acquired nipple scar contracture. Patients with mild nipple invagination should be treated conservatively first, and surgery can be considered for those who are not effective.
Treatment of nipple invagination.
The main treatment for nipple invagination is surgery, but those with mild invagination can also try to correct it by continuous low negative pressure suction. At present, there are many clinical methods to correct nipple invagination, although their surgical steps are different, but the purpose is basically the same, that is, the surgical method to lift the internal contracture of the nipple, filling the deep void after the nipple reset, reconstruction of the nipple root of the narrow. The surgeon should choose the surgical method reasonably according to the etiology, course and local condition of the nipple of the patient with nipple invagination in order to achieve the best surgical result.
Areolar skin diamond excision method
This method is suitable for patients with mild nipple invagination.
(1) Design: centered on the top of the nipple, four symmetrical radial rhombic skin excision areas are designed on the nipple and areola. The nipple end of the rhombus does not exceed the apical edge of the nipple and the areola end does not exceed the edge of the areola, and the width of the rhombus is determined according to the circumference of the nipple so that the sum of the lengths of skin retained between the corresponding points is equal to the circumference of the top of the nipple.
(2) Anesthesia for patients with nipple invagination: local infiltration anesthesia.
(3) Incision: Excision of skin and subcutaneous tissue within the diamond-shaped incision as designed.
(4) Release: traction on the nipple with sutures, separation under the nipple without damaging the normal breast ducts, and cutting off the overly tight smooth muscle fibers and fibrous connective tissue to completely release the nipple.
(5) Suture: A subcutaneous purse-string suture is made around the root of the nipple followed by a transverse suture in the rhomboid area to form the nipple root. Do not put too much tension on the sutures to avoid affecting the blood circulation of the nipple and causing nipple necrosis.
Crescent-shaped areola flap correction method for patients with nipple invagination
This method is suitable for patients with more severe congenital nipple invagination and longer acquired scar contracture in the nipple area.
(1) Design: A crescent-shaped areola flap is designed in the inner lower quadrant of the areola, approximately (0.5-1.0) cm × (1.5-2.0) cm, the size of which depends on the degree of nipple indentation and nipple size, so that the skin of the resurfaced nipple is loose and without retraction force. Freeing the flap in this orientation is less likely to damage the sensation of the nipple.
(2) Anesthesia for patients with nipple invagination: local infiltration anesthesia.
(3) The nipple is pulled out of the body surface with one traction stitch above and below each nipple with silk sutures.
(4) The skin is incised according to the design and the areola flap is freed subcutaneously. The lower edge of the nipple is incised, and the contracted fibrous bundle between the milk ducts is separated and severed to correct the invagination deformity. If necessary, some of the ducts can be cut.
(5) A (0.5-1.0) cm x (1.5-2.0) cm sized rotational flap of breast tissue is designed below the inner nipple and filled into the deep space of the repositioned nipple. A purse-string suture is made in the nipple neck to secure the rotated flap of nipple tissue.
(6) A crescent-shaped areolar flap is sutured into the incision at the lower edge of the nipple to make part of the nipple neck.
Nipple dissection method
In patients with nipple entropion, this method minimizes damage to the normal breast ducts, reduces surgical blindness, and protects lactation function. It is suitable for patients with more severe congenital nipple invagination and smaller nipples.
(1) Anesthesia: local infiltration anesthesia.
(2) One traction suture at each of the nipple 6 and 12 points to lift the nipple. The nipple is dissected in two between 3 and 9 points of the nipple, and the incision is extended at the root of the nipple appropriately toward the areola, usually not exceeding the edge of the areola.
(3) The fibrous tracts and underdeveloped ducts that cause nipple invagination are cut under direct vision so that the nipple loses retraction.
(4) Pulling the nipple so that the nipple and breast tissue are turned out.
(5) The incision is closed in layers, with the first layer sutured to the surface of the glandular tissue to fill the base of the nipple. The second layer draws the two halves of the muscle fiber bundle together near the base of the nipple, causing the nipple to flare out. The third layer unites the two nipple halves and finally closes the incision with interrupted sutures.
Precautions for nipple invagination treatment
1, for patients with mild nipple invagination should first conservative treatment, after repeated pulling and attracting for more than six months is still ineffective to consider surgery.
Before surgery, patients who have not been married should be informed that they may not be able to breastfeed in the future, which may be due to surgical damage to the breast ducts or due to the patient’s own breast duct dysplasia.
3. The nipple invagination is difficult to clean and bacteria are prone to parasitic reproduction, and chronic inflammation exists in many cases before surgery. The patient must be adequately flushed and disinfected before surgery, and those with inflammation must wait for the inflammation to be controlled before surgery.
The key to successful surgery for patients with nipple invagination is to thoroughly loosen the overly tight smooth muscle fibers and connective tissue, and if necessary, to cut off the poorly developed breast ducts to avoid recurrence of nipple invagination after surgery. For those who have recurrence of nipple invagination, negative pressure suction can be used first, and if the nipple is still invaginated after six months, re-operation can be considered.
5, nipple invagination surgery need to pay attention to the protection of the subdermal vascular network when loosening the free, purse suture ligation do not too tight, in order to avoid post-operative nipple necrosis. When the nipple is found to have poor blood flow, the purse string should be relaxed in time. Once the nipple is found to be necrotic, the necrotic tissue must be removed and the wound healed for six months after elective plastic surgery.
For patients with secondary nipple invagination, attention should be paid to analyze the causes of secondary nipple invagination, the most common cause is breast cancer.
Health care for nipple invagination
Health care: If nipple invagination is congenital, it is recommended that when the breast begins to develop, the nipple be lengthened by insisting on manual nipple traction every day. Generally, this method can effectively correct mild to moderate nipple invagination. For severe nipple invagination, it can also provide some relief. For nipple invagination due to secondary causes, it is necessary to actively treat the primary cause, remove the cause of nipple invagination as early as possible, and create conditions for surgical treatment.
Diet: Nipple invagination can be treated by sucking out breast milk regularly with a breast pump and bottle feeding.
Prevention of nipple invagination
For one thing, any female in the immediate family, such as mothers and aunts, who have ingrown nipples should be the focus of prevention. After the birth of a baby girl with a genetic predisposition, the mother can gently lift the small nipple outward, once or twice a day. Note that the action must be gentle and it is best to ask an experienced person to operate. In this way, you can see that the baby’s nipples are green bean-shaped or small round pieces higher than the skin, the chance of future nipple inversion is greatly reduced.
Second, pay attention to clothing. The intimate underwear should be cotton products, and frequent changes, sunlight. If your nipples are red and cracked, your underwear should be steamed and disinfected, and girls should not use bras too early.
Third, to prevent squeezing. Underwear, bras appropriate, not too tight, for girls with larger breasts, more attention should be paid to the breast loose. For girls who have the habit of lying down, they should be corrected in time to prevent the nipples from being squeezed, so as not to aggravate the degree of nipple invagination.
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Secondary nipple invagination should be treated for the cause, such as treatment of inflammation of the breast, trauma, tumor, etc. Primary nipple invagination is treated with non-surgical or surgical treatment as appropriate. True nipple invagination, on the other hand, requires surgical correction.
Complications of nipple invagination
1, local infection nipple inversion makes local cleaning difficult, easy to accumulate dirt and secondary infection, causing chronic inflammation, local exudate often accumulate, can have bad odor, can lead to local skin erosion.
2, breastfeeding difficulties nipple inversion so that breastfeeding can not be carried out, milk stagnation. Even the secondary infection causes acute mastitis.
3. Invagination affects the beauty and requires plastic surgery.