Q: Dr. Eppley, I have severe Grade 3 nipple inversion since birth and had a procedure earlier this year with high hopes. It was a release and then attached to a plastic device onto which the nipple was sewn. It did not work and I am extremely disappointed. What are my options at this point?
A: Inverted nipples present in differing severities which have been classified by grades and reflect the degree the nipple is inverted and ho scarred in it is. (milk duct fibrosis) Fundamentally, grade 1 nipple inversions may only occasionally retract and are easily pulled ouot if they do. (no soft tissue deficiency) Grade 2 nipple inversions can be pulled out but retract quickly when released. (very little soft tissue deficiency but with some scar) Grade 3 nipple inversions are very hard to pull and may not even be able to done. There is considerable retraction and scarring and a true soft tissue deficiency exists underneath. While the technique of release and sustained retraction by suturing to an external plastic device is the standard treatment, it is not one I have ever liked and there is risk of nipple necrosis with such sustained retraction. I find that release of the nipple and the placement of an interpositional dermal-fat graft to be a more effective solution. The key is that scar tissue and the natural shortage of nipple length will pull the nipple right back into hole from whence it came. This is an issue of a tissue defect, not just a release. Constant traction on the nipple by an external device allows the filling of the defect with scar tissue which is highly prone to scar retraction and recurrent nipple inversion as it heals. A revascularized dermal-fat graft provides a better resistance to scar contracture.
Dr. Barry Eppley
Q: Hi, I need your help. Three months ago I had a gynecomastia operation done and now I have a problem. The problem is that my nipples are folded in now and going inside. My skin is also very dry around nipples and my nipples have become cracked. This looks like a serious problem. How can I fix my nipples?
A: Gynecomastia reduction procedures can be done two fundamental ways; liposuction or open excision (removal) of excess breast tissue. Sometimes the two techniques are done together to get the best result. With the open excision technique, breast tissue is removed through an incision on the underside of the nipple. (technically the areola) Removal of this breast tissue is largely an art form. How much to remove and how to shape what is left behind is more of matter of experience than an exact science.
One of the known complications of open gynecomastia removal is over-resection, removing too much breast tissue. This make look alright in the very beginning (or not) but as the swelling subsides and scarring sets in, the nipple gets pulled into the over-resected space where breast tissue once was. This is called nipple inversion or a retracted nipple. It most commonly appears underneath the nipple since this is closest to the incision but it can appear outside the diameter of the areola if the over-resection goes beyond just that area.
Correction of the inverted nipple after gynecomastia reduction requires replacement of the missing tissue to support the projection of the nipple. This is best done by a fat graft or a dermal-fat graft using the patient’s own tissues. This requires a donor site and a scar elsewhere on the body to do it.
Dr. Barry Eppley