Inverted Nipples? You Aren't Alone.

Inverted nipples, much like widened areolas or excessive labial tissue, is one of those female anatomical findings that women rarely talk about let alone realize can be corrected if they so desire. Roughly 2-10% of the population either are born with or develop inverted nipples— many of whom feel just fine about their nipples with no desire to change them. Of that group of women, however, there is an even smaller group that experience psychological discomfort, potential functional limitations hindering breastfeeding or can even experience susceptibility to local irritation and infection. Knowing the options and potential risks associated with correction is paramount to equipping women with the tools they need in order to make the best decision for themselves. In this plastic surgery blog post we will tackle all the high points– from what exactly defines an inverted nipple, to the surgeries available, and what the biggest risk factors and draw back are to consider. 

The Basics: 

In order to have a conversation about correction of an inverted nipple, we first must establish what exactly we mean by ‘inverted’ and what anatomic features account for this finding. After all, understanding the anatomy is the key to understanding the surgical options available to patients in most plastic surgery topics. On a basic level, an inverted nipple is a nipple that either doesn’t or cannot protrude three dimensionally from the surrounding areola. This may mean it sits flat against the areola or, in some cases, actually pulls inwards to create a depression. 

So what causes an inverted nipple? The most common causes are congenital. Typically, this results from hypoplasia and the retraction of lactiferous ducts due to surrounding fibrous bands at the nipple base. Basically, the fibrotic bands and/or lactiferous ducts underneath the nipple are tight, and pull the nipple downward. Acquired inversions occur less frequently, and can be caused by periductal mastitis, prior breast surgery, breastfeeding itself, or even some types of breast cancer. It is important for your plastic surgeon to obtain a thorough history during your consultation to make sure no additional workup may also be needed. 

There have been many classification systems designed over the years to better delineate the degree of nipple inversion. I think it’s most helpful to classify the degrees of nipple inversion into three categories.  

• Grade I: The nipple can be easily everted by gentle palpation around the areola and maintains its projection without continued traction. In this grade, the lactiferous ducts remain normal.

• Grade II: Nipple eversion is still possible, though requires a bit more coaxing than in Grade I and tends to retract. Anatomically, moderate fibrosis at the base of the nipple is present, and lactiferous ducts show mild retraction.

• Grade III: The most severe form of inverted nipple classification is characterized by significant inversion and retraction such that patients are unable to manually evert the nipple and maintain it in a protracted position. This is caused by severe fibrosis below the nipple and insufficient tissue. Terminal lactiferous ducts are likely to be severely fibrotic. 

While classification systems are helpful in the overall communication of anomalies such as inverted nipples, they rarely help us to better understand the best treatment options. I propose thinking about it much simpler terms: 

• Can the nipple be everted and, if so, how hard is it to get into a projected position? 

• Once everted, does the nipple stay in its everted position or does it retract back? 

• Is there even enough tissue present to, if pulled on, create the three dimensional shape of a convex nipple? 

I find answering these questions is a much more useful guide to help determine surgical planning. 

The Surgeries:

As with all things plastic surgery, the correct surgical plan is determined both by a patient’s goals and their detailed anatomy. Irrespective of the procedure details, all inverted nipple corrections can be done under a local anesthetic only, or with the addition of an IV sedation for patients uncomfortable with the idea of being awake during a surgical procedure. The procedure will take under an hour to perform, and patients will be able to safely and comfortably return home after surgery. 

Surgery for inverted nipple correction involves addressing the key features described above– the tethering at the base of the nipple, maintaining projection of the nipple once its in a protracted position, and/or adding additional tissue to either help build nipple length or help bolster the base of the nipple. 

Tethering: 

To address tethering at the base of the nipple, a small incision is created at the junction of the nipple base and the areola through which a small pair of scissors can be placed to carefully isolate and cut any fibrotic bands present. Care must be taken to isolate out fibrotic bands from viable lactiferous ducts and/or nerves if possible. 

Maintaining Nipple Projection: 

One of the key hallmarks of inverted nipples is their inability to maintain projection. Now part of this has to do with the tethering bands underneath continually pulling them back down, but once those are cut, now what? There are a few surgical ways to approach this issue depending on the degree of nipple inversion. The most common methodology involves placing stitches around the base of the nipple to, in a sense, tighten the base and make it harder for it to slip back into its flat and/or inverted position. Many different types of sutures are used, typically dissolving, as well as many differing patterns of suture placement. Irrespective of suture or pattern, the goal is always the same– narrow the base. Alternatively, a small amount of tissue can actually be excised from the base of the nipple to produce a similar effect. 

Local Flaps:

Dermal flaps can be used to create a supportive framework beneath the nipple, help keep it in a projected position, and even add length in a severely constricted nipple. A dermal flap is simply adjacent tissue that is recruited from the surrounding areola and tucked underneath the nipple to maintain the nipple’s projection. There are various shapes of flaps that can be used– triangular, rhomboid, elliptical, diamond. Just like with the suturing techniques described above, irrespective of the shape the goals are still the same. 

Weighing The Risks: 

No surgical procedure comes without the potential for risks or trade-offs. Correcting inverted nipples is a plastic surgery procedure that risks damaging both the nerves and the lactiferous ducts which run directly below the nipple. If maintaining nipple sensation or the ability to breast feed later on down the line are of paramount importance to you, these must be discussed with your Plastic Surgeon during your consultation. These non-negotiables may help your surgeon choose the technique of surgery they will perform, establish the appropriate timeline for your surgical procedure, or make the determination that you simply aren’t a candidate for the procedure.

Lastly, all types of nipple inversion correction procedures come with the risk of recurrence. There is a natural tendency for scar tissue to tighten and retract, such that your Plastic Surgeon will often over-correct nipple position in anticipation for this occurrence. In addition, stents placed over the nipples to hold them in a protracted position are commonly used during the first few weeks after surgery to help minimize scar retraction.

If you have inverted nipples and want to know more about your candidacy for plastic surgery, Schedule your consultation today with Dr. Megan .

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Dr. Megan Dreveskracht is a Female Plastic Surgeon in Seattle, Washington who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.