What is the initial evaluation and treatment for a patient presenting with an inverted nipple?

Inverted Nipple: Initial Evaluation and Treatment

The initial evaluation of an inverted nipple must first distinguish between a longstanding congenital inversion (benign) versus a new-onset acquired inversion (concerning for malignancy), with new-onset cases requiring immediate imaging workup starting with diagnostic mammography and ultrasound in patients ≥40 years or ultrasound alone in patients <30 years. 1, 2

Critical First Step: Distinguish Congenital from Acquired

• Congenital inverted nipples are present since adolescence, bilateral in most cases, and affect approximately 10% of the female population 3, 4
• Acquired nipple inversion (new retraction) is a red flag for underlying malignancy including breast cancer, inflammatory conditions, or periductal fibrosis and mandates immediate imaging evaluation 1, 2
• Ask specifically: "Has your nipple always been this way, or is this a recent change?" This single question determines the entire diagnostic pathway 1

Imaging Algorithm for New-Onset (Acquired) Inverted Nipple

Women ≥40 Years

• Start with diagnostic mammography or digital breast tomosynthesis (DBT) PLUS bilateral ultrasound with special attention to the retroareolar region 1, 2
• If imaging identifies a lesion, proceed directly to image-guided core needle biopsy 2
• If imaging is negative but clinical suspicion remains high, consider MRI or surgical consultation for duct excision 2

Women 30-39 Years

• Either mammography/DBT or ultrasound can serve as initial imaging based on institutional preference 1
• Ultrasound has higher sensitivity (95.7%) than mammography (60.9%) in this age group 5
• However, mammography remains valuable for detecting suspicious microcalcifications associated with DCIS 5

Women <30 Years

• Ultrasound should be the initial and often only imaging study (rated 9/9 for appropriateness) 1, 5
• Mammography is generally not appropriate due to low cancer incidence (0.4% or lower) and radiation concerns 5
• Add mammography only if ultrasound demonstrates suspicious findings 5

Male Patients (Any Age)

• Men have exceptionally high malignancy rates (23-57%) with nipple changes and require aggressive imaging 1, 2
• For men ≥25 years: start with diagnostic mammography/DBT plus ultrasound 1
• For men <25 years: start with ultrasound, add mammography as indicated 5, 1

Management of Longstanding Congenital Inverted Nipple

Grading System

• Grade I: Nipple easily pulled out manually and maintains projection 6
• Grade II: Nipple can be pulled out but retracts spontaneously 6
• Grade III: Nipple cannot be manually everted 6

Treatment Options

Conservative (Non-Surgical) Management:

• Nipple retractors/suction devices are effective for Grade I inversions but require 3-6 months of continuous wear 7, 6
• Success rates: Grade I and II inversions show 90.7% correction rate, significantly higher than Grade III 6
• Key advantage: Preserves lactiferous ducts and breastfeeding function 6

Surgical Management:

• Reserved for Grade II-III inversions or failed conservative treatment 3, 8
• Preferred technique: Blunt dissection parallel to lactiferous ducts with selective (not routine) ductal division only as needed to achieve eversion 8
• V-Y advancement flaps provide good structural support with minimal scarring 3
• Critical pitfall: Most traditional surgical techniques sever lactiferous ducts and eliminate breastfeeding capability—avoid these in women of childbearing age who desire future lactation 4, 6

Breastfeeding Considerations

• Approximately 31.6% of women with nipple inversion report difficulty breastfeeding 4
• Nipple retractor techniques preserve all lactiferous ducts; all 32 patients in one series successfully breastfed posttreatment 6
• Surgical techniques that divide ducts eliminate breastfeeding function 4

Common Pitfalls to Avoid

• Never dismiss new-onset nipple retraction as benign—this represents malignancy until proven otherwise and requires immediate imaging 1, 2
• Do not perform imaging for longstanding bilateral congenital inversion in the absence of other concerning features (mass, skin changes, bloody discharge) 5
• Do not assume all surgical corrections are equivalent—specifically ask surgeons whether their technique preserves lactiferous ducts if breastfeeding is desired 4, 6
• Do not skip imaging in male patients—their malignancy risk with nipple changes is 2-3 times higher than women 1, 2