What are the treatment options for an inverted breast nipple?

Treatment of Inverted Nipple

For inverted nipples, surgical correction is the definitive treatment, with the choice of technique depending on severity: minimally invasive percutaneous release with purse-string suture for most cases, or dermal flap techniques for severe grade III inversions where preservation of lactiferous ducts is desired.

Initial Assessment

Before considering treatment, rule out underlying malignancy, particularly Paget's disease of the nipple, which can present with nipple changes including inversion 1. Any new-onset nipple inversion in adults, especially if unilateral, eczematous changes, or bloody discharge are present, requires diagnostic evaluation with mammography and possible biopsy 2, 1.

Classification and Treatment Selection

Inverted nipples are graded to guide treatment approach 3, 4, 5:

• Grade I: Nipple easily everted by manipulation and maintains projection - may not require surgical intervention 5
• Grade II: Nipple can be manually everted but frequently retracts - surgical correction recommended 3, 5
• Grade III: Nipple cannot be everted without surgery - requires surgical intervention 5

Surgical Treatment Options

First-Line Approach: Minimally Invasive Technique

The percutaneous release with purse-string suture technique is the preferred initial approach for most inverted nipples, offering 78% success with a single procedure and 97% success after repeat intervention if needed 6.

Technique details 6:

• Performed under local anesthesia
• 18-gauge needle used to lyse foreshortened subareolar fibro-ductal tissue
• Purse-string suture placed percutaneously around nipple base circumference (every 3-5mm)
• Two crossed absorbable mattress sutures placed beneath nipple for additional support
• Minimal scarring with "needle-only" access points

Advantages 6:

• No nipple ischemia or infection risk
• Simple revision under local anesthesia if recurrence occurs (19% require second procedure)
• Preserves nipple sensation and blood supply

Alternative Surgical Techniques

For Grade II inversions where lactiferous duct preservation is important (e.g., women planning to breastfeed), triangular areolar dermal flaps can be used 3:

• Two triangular flaps approximately 1mm shorter than nipple diameter
• Deepithelialized dermal flaps lodged at lactiferous duct bundle slit
• Preserves duct function while preventing recurrence
• Minimal scarring with no reported recurrences at 8.7 months mean follow-up 3

For severe Grade III inversions, deep vertical incision technique with or without dermal flap interposition may be necessary 5:

• Deep vertical incision on nipple to free lactiferous ducts from contracted surrounding tissue
• Extension or resection of restricting tissues
• Dermal flap inserted at nipple base to prevent reinversion in most severe cases
• Maintains lactiferous function while preventing recurrence 5

Non-Surgical Option

Continuous elastic outside distraction is an alternative for patients who prefer non-surgical correction or as initial management 4:

• Adjustable elastic instrument worn continuously for 3-6 months
• Effective for all grades (I-III) in small case series
• No surgical complications but requires prolonged compliance
• Long-term recurrence rates not well-established 4

Special Consideration: Incidental Finding During Mastectomy

In patients undergoing nipple-sparing mastectomy who have pre-existing inverted nipples, simple baseline suturing to tighten the nipple base after complete duct transection during mastectomy achieves correction in over 70% of cases 7. This demonstrates that inverted nipple is primarily caused by tight fibrous bands or short ducts rather than lack of subareolar tissue 7.

Common Pitfalls

• Failing to exclude malignancy: New-onset adult nipple inversion requires imaging and possible biopsy before cosmetic correction 1
• Inadequate release of fibrous bands: Incomplete lysis of restricting tissue leads to recurrence 5, 6
• Excessive periareolar incisions: Can compromise nipple blood supply and nerve function 4
• Not counseling about breastfeeding: Techniques that divide lactiferous ducts preclude breastfeeding; choose duct-preserving methods when future lactation is desired 3, 5