Inverted Nipple Correction

Transcript between Mr Adrian Richards and Mr Stephen McCulley on Inverted Nipples
AR	My name is Adrian Richards.  Welcome to the Plastic Surgery Podcast.  Providing information for patients from patients.
	I’m a Consultant Plastic and Cosmetic Surgeon and during the podcasts I will be talking to Specialists in particular fields to get the latest updates on treatments.
	During the second part of these podcasts I will be talking to patients who have undergone these treatments to get their opinions and views on how the treatments work.
	So, I’m here with Stephen McCulley and we are going to quickly talk about, often something people come and talk to me about and that is nipple abnormalities and there is not much written about it and people often find it difficult to get any information about it and particularly don’t realise there are relatively simple procedures to correct nipple inversion so can you tell me a little about nipple inversion, how it affects people and your views on how it is best treated.
SM	Well first thing to say it is relatively common and it’s a lot more common than people think and most of it is developmental so that…
AR	So what do you mean by that Steve, so what causes it?
SM	When you talk about abnormalities in the body people often ask is con-genital i.e. Is it in your genes or is it developmental which us  doctors, a posh way of saying it’s just the way its grown to be honest.  So essentially it is the way that the breast has grown and how the breast ducts grown.  The cause of an inverted nipple is that the ducts are a little bit short and it pulls the nipple in and that will vary in how marked it is so for some patients it goes in a little bit but will come out if they put a bit of weight on or during their periods.
AR	I always say there is three grades, so grade one goes comes out and stays out for a period,  grade two comes out and goes straight back in stays out and grade three stays in all the time.
SM	The problems are that is causing anxiety to the patient.
AR	In clothes, particularly if one is in swimwear and things
SM	There are a number of issues, but the cosmetic concern purely of the way it looks in terms of the impact on the breast and we all are aware of the relative importance of the breast in terms of it’s aesthetics and that will vary from woman to woman but it certainly does markedly impact about confidence and self esteem image issues for certain patients and I think that is a common cause for people pursuing correction of it.
AR	Is it worth just mentioning now Steve about there is sudden inversion in a slightly older lady does raise some alarm bells. It can do can’t it?
SM	Well that’s important because inversions of the nipple that develops later on does not necessarily mean it but it can constitute or can be a sign that there is a disease or a cancer going on in the breast.
AR	That would tend to shorten the ducts…
SM	And that can pull the breast in.
AR	So I suppose someone who is young and in their teens and as they breast develops and has a developmental nipple inversion there is unlikely to be anything sinister other than short ducts.
SM	It is a very important thing to bring out because nipple inversion that is present and develops at a younger age over time does not have these concerns but yes an inverted nipple that develops later on still often isn’t but is something that would be check out.
AR	Tell me about the operation, does an operation for grade one differ from a grade three – how do you do it?
SM	I think people also pursue it if there are concerns about their ability to breast feed although sometimes actually getting pregnant may sort out mild versions of it.  There are different philosophies to the operation end essentially it comes down to whether you cut the ducts or do not cut the ducts.
AR	It’s performed under local anaesthetic normally isn’t it.   Just as a sort of simple day case operation.
SM	There are lots of lots of different types of operations for nipple inversion and when ever there lots of different ways of doing something it does usually mean none of them are perfect and none of them  work consistently and recurrence regardless of the technique is still quite high in nipple inversion.
AR	It is one of these operations that is done badly by quite a few people isn’t it?
SM	Yeah I think the results are highly variable so yes but in terms of how you do it there are lots of different ways as I say but it roughly fits into the operations which cut the ducts which means you wont be able to breast feed.
AR	And nipple sensation?
SM	It can run the risk of that but most of the operations will maintain nipple sensation it may affect it certainly temporarily but most of the operations will maintain it as such.
AR	In my practice it is very unusual for nipple sensation to be affected by the ducts.  Just tell me where the incision is, how do you approach the ducts and do you need any sort of stitching.
SM	Again it varies on the techniques but probably the definitive procedure is where an incision goes down the middle of the nipple, so the nipple is open like a book and that operation allows you to… well that is the incision I would use if I am trying to preserve the duct.  So that’s the one I tend to use more in younger patients after discussions as to where preservation of the ducts is really important to them.
AR	And once the nipple has been divided how do you secure the inversion?
SM	Well essentially you separate as many of the ducts as possible.
AR	What just tease them apart?
SM	That’s right and you lengthen them as much as you can and you take some of the tissue and invert it up in on itself to hold some of the tissue inverting up and what you essentially up end with is a scar across the nipple that splits but it heals so incredibly well you can hardly see it.  Another very, very simple group of operations are essentially putting a scar around the base of the nipple, on the end of the nipple.
AR	I tend to use a 2 or 3mm scar on the lower outer border and divide the duct through there and then a purse string.
SM	Yes a very good technique.
AR	I think that is probably the preferred technique, really minimal down time.  Have you had any people who nipples have re-inverted?
SM	Yes I have had revision of it and had to do some work but on the whole the procedure you just described is well established, it is good and the purse string and how the purse string sutures done is really important.
AR	I tend to use cross stitches.
SM	I think there are different ways of doing that but I don’t think that is quite so important as making sure you have divided the ducts properly and you have divided them slightly deep enough so you ensure you have some tissue to come up above your purse string.  That is probably the trick to making it work and it is a very simple procedure but you cannot breast feed.
AR	No. That is the downside.
SM	So if you are having that discussion with a twenty year old who has not yet had children it is an important discussion which is why I think in my practice I would still use both techniques.  I would only use the technique you have described in revision cases really.  If I am doing a revision case I would definitely do that.  If I’m doing a primary case I will discuss it with the patient as to what they want but I will inform them that if I don’t cut the ducts their risk of recurrence is higher.
AR	As too not burn any bridges.. Brilliant, well that’s nipple inversion, that probably the most common nipple abnormality but I occasionally see patients with big nipples who would like them reduced or indeed people who have irregular areolas which is the brown skin around the nipple.  Could you just talk to me briefly about that Stephen?
SM	Well large nipples … common causes are post breast feeding and they are actually quite simple to treat. I know it sounds quite daunting you can literally amputate as much or as little of the nipple as you want.
AR	And reshape everything?
SM	Well there is two ways  it depends on the size of the nipple, actually if you just cut across the nipple it heals so incredibly well.
AR	How fast would that tend to heal….it’s like a graze isn’t it?
SM	Days.
AR	It’s amazing isn’t it?
SM	Days.
AR	That would decrease vertical height how about decreasing the circumference?
SM	Then it is a question of taking out various wedges and there is different ways of doing that .  You can either take out , leave part of it on one side and drop it down or take out like a wedge of a pie and bring it round, there are different ways of doing.
AR	Usually melting away stitches are used aren’t they?
SM	Yes and that is relatively simple and relatively successful, well not relatively….very.
AR	And nipple sensation again preserved?
SM	Yes nearly always.
AR	And the last thing I would like to discuss is the Areola.  Do you get many patients who….
SM	Yes I do I have changed a little bit my philosophy on this.  If they have abnormal areola and it is apart of an abnormal breast shape and therefore you need to do something about the breast shape in terms of various breast lifts then changing the areola size is very good as part of that.  If you want to change just the areola and you tend to do that,  a lot of surgeons tend to use purse strings or peri-aerola scars around the nipple, I think they have mixed success in my opinion.  I think that this notion that we can  just purse string this down from some 8cm to 4cm and it is just going to stay there….
AR	The average width of an aerola is 4.5cm.
SM	Yes.  It often stretches out again.
AR	Yes that’s why people use the permanent purse strings isn’t it?
SM	Yes but even with those they still pull through and stretch a little but.  It is fine but  my only other point about it is when you do surgery on one areola even though it is different it tends to have a,…  this is the other influence factor if they have a very distinct areola then doing surgery on it makes more sense because once you do surgery the edge of the areola will look very, very demarcated and if you just do it one side that can look quite different compared to the other side.   So reducing areola is quite a complex thing, it is not difficult to technically do but I think the decision as to what you do is discussed at length with the patient, so it could be part of a breast lift type operation well that is good, that’s a good option if that is required.  If it is not and it is just reducing the areola on one side then the pros and cons need to be talked through.  If it reducing git on both sides well that is creating symmetry well that is fine At least you  are doing the same on both sides.
AR	Great.  Well that is really illuminating for me.  I have really enjoyed our chat.  Just remind me is this information on your website Stephen?
SM	Yes you can go onto my website my name is www.stephenmcculley.co.uk.
AR	Really appreciate that Stephen – thanks for coming in today.
Transcript between Mr Richards and Patient Dawn on Inverted Nipple Correction
AR	So I’m here with Dawn today who recently underwent Nipple Correction.
AR	So Dawn, I was just wondering if you could tell me roughly how old you are?, you’ve had children haven’t you?  Did the inverted nipple start early, how did it progress and what bought you to the operation?
Dawn	I’m 45 years old, I‘ve got two children and my problem started after feeding my last child and I was uncomfortable wearing nice clothes as I would put it or tight fitting clothes and have felt uncomfortable with my problem for the last ten years and I researched it on the Internet and found this website and took it from there.
AR	So everything was absolutely fine until you had children?
Dawn	Yes I think after…I breast fed my first daughter, who is now 14 years of age, but found the problem after that but didn’t see the problem really.  It got worse of having her… and four years after having her I tried to feed my second child and could not because the nipples were inverted.
AR	And what problems… you said with clothes and things, it was difficult to find anything nice and it was a problem because they were really quite inverted.  Just tell me how that affected you.
Dawn	I felt uncomfortable in my own body really and found I could not wear nice clothes because I thought people were looking at my breasts as opposed to looking at me so I use to cover it up by wearing padded bras and loose fitting clothes.
AR	OK and when you researched it, which we just talked about a minute ago, there is not much information on it is there?
Dawn	Definitely not, I had been looking for quite a long period of time on the Internet and there was nothing really to find about Inverted Nipples, but I found it in the last six months.
AR	Brilliant, so you came to see me and we talked about it, the three grades, and I think you were a grade three weren’t you? It didn’t really come out.
Dawn	Yes, definitely, on the right one it was definitely a grade three but on the left it was not so bad, it occasionally came out but the right one didn’t.
AR	Just to sort of clarify a grade three nipple never comes out, a grade two nipple comes out and stays out and pops back in but does come out and a grade one never comes out.  So tell me all about the procedure.  You were looking at me in the theatre lights, I didn’t realise.  So tell me all about the procedure
Dawn	Well first of all I felt very relaxed by everybody when I got to the surgery.
AR	It was early in the morning wasn’t it?
Dawn	Yes very, very early about seven o’clock in the morning.  I was made to feel very relaxed and felt very comfortable…. and the surgery process…I actually done a sneaky preview in the mirror lights and watched Mr Richards do the procedure, it did not feel uncomfortable, it was not uncomfortable at all and it didn’t take too long either.
AR	No..  and then at the end you do feel a little bit when the local anaesthetic is going in don’t you?
Dawn	That was the only thing I felt, literally the only thing I felt, an occasional pull, nothing more uncomfortable than that but the sharpness of the needle of the anaesthetic.
AR	And then after tell us about the dressings.  Were you bruised? Was it uncomfortable afterwards?
Dawn	I felt slight discomfort afterwards but only because the brushing against my clothes or bra but nothing more than that really and the padding that was given to me was really comfortable.
AR	So how long are we afterwards?
Dawn	We are two weeks and two days.
AR	And how are they looking now?
Dawn	Slightly bruised but they are perfect.
AR	So that is good.  So Dawn any questions or top tips you would like to give someone thinking about having this treatment?
Dawn	Research it on the internet but do not hesitate to have it done because the results are… well it makes you feel more comfortable in your self and your body.
AR	So have you had to go and buy more clothes?
Dawn	I’ve yet to do that but I will be definitely.
AR	Well thank you very much for talking to us today Dawn and see you very soon.
Dawn	Thank you.