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An operation for inverted nipples
A N OPERATION FOR INVERTED NIPPLES
By TORD SKOOG, M.D.
Associate Professor of Plastic Surgery, University of Upsala, Sweden THE human embryology and anatomy of deformed nipples was thoroughly studied by Basch (1893). He distinguished a cutaneous and a glandular origin in the normal development of the nipple, and the most common deformity, namely, inversion of the nipple, he considered to be caused by an arrest of the development at an early stage. These nipples were also lacking in muscular fibres, which normally grow at a later stage from the areolar muscular plaque. Thus when the areolar circular muscle thickens during pregnancy and contracts, a stricture is formed which does not allow the nipple to project above the surface of the breast. This developmental theory is now widely accepted, but it has also been suggested that retraction of the nipple is to be attributed to " that reprehensible custom--the disgrace of civilised society and the fruitful source both of injured health and deformed person in the young female--tight lacing" (Ramsbotham, 1844). Various types of depressed nipples were classified by Kehrer (I888), Basch (1893), etc. Flat and inverted nipples may render nursing difficult or impossible, and may also give rise to mastiffs and other complications during lactation. The mental distress this deformity may induce should also be mentioned. Though the condition is encountered rather frequently and has obvious functional importance, it has apparently caused a very limited surgical interest, and most obstetricians propose conservative measures, for instance, to draw the nipple out by traction with the fingers or by means of a breast-pump or by the employment of a nippleshield (Williams, I91o, etc.). In some cases this may be of benefit. There are, however, a few operative methods described in the literature. Kehrer (1888) as long ago as 1873 published his method consisting of complete excision of the areola 2 ram. adjacent to the base of the nipple, including the smooth muscle layer. The margins of the skin and the nipple were sutured together under tension, which made the groove disappear and resulted in a flat nipple. In four cases operated upon function was reported as good. After extensive research work Basch (1893) arrived at the conclusion that a stricture of the areolar muscle was an essential part of the deformity. He recommended a double subcutaneous myotomy of this muscle accompanied by frequent stretching of the nipple or suture-fixation in an improved position. He points out that the method requires the existence of at least a rudimentary nipple, although retracted. Textbooks of plastic surgerY, which have taken an interest in this subject, invariably recommend the Sellheim operation (Joseph, I93I ; Thorek, 1942; May, 1947; Berson, I948, etc.). Its principles are shown in Fig. I. By excision of small triangular pieces of skin from the freed nipple a " collar " formation of the base of the nipple is attempted in order to prevent the nipple from slipping back into its former position. Sellheim (I917) obtained satisfactory results in three cases with this procedure. I E
65
66
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
With the technique of Sellheim the first steps, in which the areola is utilised to create a new nipple, are satisfactory, but when the shortened circumference of the new areolar base is sutured to the outer skin edge representing the original
FIG. I
Sellheim's operation. margin of the areola, one will find that what was gained in the early part of the operation is to a great extent lost because of the disparity in length between the edges to be apposed. Later on, when the sutures have been removed, the result gradually deteriorates, due to stretching of the scars from the continuous peripheral pull. To overcome this disadvantage the following operation was devised.
FIG. 2 L i n e s o f incision for reconstruction in inversion o f t h e nipple.
triangular shaded areas are excised.
T h e eight
Writer's M e t h o d . - - T h e lines of incision are marked with Bonney's blue in Fig. 2, showing a circular line along the areolar margin. Based on this line are eight triangles pointing alternately centrally and peripherally. They represent the amount of skin to be excised. All the bases of these triangles should be about equal when the skin is unifermly distended, and the effect of the centripetal muscular contraction must then be considered. Depending on the size of the existing nipple, a wider or a smaller area of the areola is included in the circular incision round the nipple. When there is only a groove present the diameter of this incision should be at least 6 cm.
AN
OPERATION
FOR
INVERTED
NIPPLES
67
The operation will be facilitated if, as a preliminary step, the skin is stretched and superficial incisions are made according to the pattern. Then the circular incision is made well down in the subcutaneous layer, and the areola with its smooth muscle layer is dissected free while the nipple is held under constant pull with a traction suture. To get the nipple well out of its inverted or depressed position it will generally be found necessary to extend the dissection in between the outer galactophorous ducts, cutting fibrous bands without injury to the ducts or major vessels. When the areolar skin hangs like a folded umbrella from the everted nipple, four comparatively large triangular areas of skin are excised, as indicated in Fig. 2. The remaining flaps round the edge are rather narrow-based, but these manoeuvres have in no instance caused necrosis. The blood supply of the nipple is very rich, with capillary networks round the ducts. To shorten the outer wound edge the four triangular pieces of skin pointing peripherally are excised. When the defects from the removed triangles have been closed, the outer skin margin is so narrow that it can be sutured to the base of the new nipple without tension and without disturbing the reconstruction achieved (Fig. 3, c and D). Because of tension of the operative field during the growth of the breast in pregnancy, it cannot be avoided that the base of the nipple widens. Especially in cases where the anatomical structures of the nipple are very short with a strong tendency to retract, it is difficult to obtain a permanent result. In these cases the protruding nipple is mainly formed by the folded areolar skin, and the galactophorous ducts will all open into a pocket within the nipple, as was described in ruminants by Klaatsch (1884). Accurate technique is required in the suturing, preferably using the Gillies (1945) subcuticular corner stitch in the closure at the bases of the triangular defects. Fine stainless-steel wire and nylon thread have been used with advantage. The operation has regularly been performed under local anmsthesia. Cases and Conclusions .--Six women, aged 2 3 to 3° years, have been treated according to this technique ; four of them bilaterally. They were all pregnant in the third or fourth month at the time of operation. Pregnancy was not disturbed by this surgical intervention, and in all cases there was a normal delivery at full term. One patient, however, gave birth to a stillborn child, due to trauma. In all cases healing took place by primary intention, and the sensation of the nipple remained normal. Four of the five patients with children were able to nurse them in a normal way, but in two instances there were some difficulties during the first months of lactation, when the child was not able to suck strongly and a breast-pump had to be used temporarily. Three patients had a second child after the operation, and nursing was then considered still better. Two patients had borne children before the operation which they had not been able to nurse at all. One patient only regarded the operation as of no benefit. After childbirth she had very little milk, which might be connected with an under-development of the mammary glands as well. But it should also be stressed that it is essential that the patient takes interest and devotes energy in suckling her child. The mental attitude of the patient should therefore be considered before an operation l E*
68
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
is decided upon. For that reason a poor functional result might have been anticipated in this particular case, though the operative result was as satisfactory as in the other cases.
FIG. 3 A and B, Case of underdeveloped inverted nipples. C and D, Immediate operative result. E and F, Three years after operation.
Heredity.--Other members of the family had been affected in three instances. In one the deformity was known in four succeeding generations (mother, maternal grandmother, and great-grandmother). In the second, three sisters, the mother and the maternal grandmother suffered from the deformity. In the third the mother was affected, but three sisters had nipples of normal appearance and function.
AN
OPERATION
FOR
INVERTED
NIPPLES
69
SUMMARY An operation for inverted nipples is described, and the results in six operated cases are reported. In one case the deformity was traced through four generations, and there was a familial occurrence in two other cases. REFERENCES BASCH, K. (I893). Arch. Gynaek., 44, 15. BERSON, M. I. (1948). " Atlas o f Plastic Surgery," p. 256. N e w York : G r u n e & Stratton. GILLIES, H. D. (1945). " Plastic S u r g e r y " in T u r n e r , G. G. : " M o d e r n Operative Surgery," vol. ii, p. 1635. T h i r d Edition. L o n d o n : Cassell & Co. Ltd. JosEPH, J. (1931). " Nasenplastik und Gesichtsplastik nebst M a m m a p l a s t i k , " p. 807. L e i p z i g : C. Kabitzsch. KEHRER, F. A. (1888). Published in Mtiller, P. : " H a n d b u c h d. Geburtshfilfe," vol. iii, part 2, p. 45 o. Stuttgart : F. Enke. KLAATSCH, H. (1884). MorphologischesJahrbuch, 9, 253. MAY, H. (I947). " Reconstructive and Reparative Surgery," p. 4Io. Philadelphia : F. A. Davis Co. RAMSBOTHAM, F. H. (1844). " Obstetric Medicine and Surgery," p. 535. Second Edition. L o n d o n : J. & A. Churchill. SELLHEIM, H. (1917). Zbl. Gynaek., 41, 305. THOREK, M. (1942). " Plastic Surgery of the Breast and Abdominal Wall," p. 387 . Springfield : ' C. C. T h o m a s . WILLIAMS, J. W. (191o). " Obstetrics," p. 909. Second Edition. N e w York and L o n d o n : D. Appleton~Co.
By TORD SKOOG, M.D.
Associate Professor of Plastic Surgery, University of Upsala, Sweden THE human embryology and anatomy of deformed nipples was thoroughly studied by Basch (1893). He distinguished a cutaneous and a glandular origin in the normal development of the nipple, and the most common deformity, namely, inversion of the nipple, he considered to be caused by an arrest of the development at an early stage. These nipples were also lacking in muscular fibres, which normally grow at a later stage from the areolar muscular plaque. Thus when the areolar circular muscle thickens during pregnancy and contracts, a stricture is formed which does not allow the nipple to project above the surface of the breast. This developmental theory is now widely accepted, but it has also been suggested that retraction of the nipple is to be attributed to " that reprehensible custom--the disgrace of civilised society and the fruitful source both of injured health and deformed person in the young female--tight lacing" (Ramsbotham, 1844). Various types of depressed nipples were classified by Kehrer (I888), Basch (1893), etc. Flat and inverted nipples may render nursing difficult or impossible, and may also give rise to mastiffs and other complications during lactation. The mental distress this deformity may induce should also be mentioned. Though the condition is encountered rather frequently and has obvious functional importance, it has apparently caused a very limited surgical interest, and most obstetricians propose conservative measures, for instance, to draw the nipple out by traction with the fingers or by means of a breast-pump or by the employment of a nippleshield (Williams, I91o, etc.). In some cases this may be of benefit. There are, however, a few operative methods described in the literature. Kehrer (1888) as long ago as 1873 published his method consisting of complete excision of the areola 2 ram. adjacent to the base of the nipple, including the smooth muscle layer. The margins of the skin and the nipple were sutured together under tension, which made the groove disappear and resulted in a flat nipple. In four cases operated upon function was reported as good. After extensive research work Basch (1893) arrived at the conclusion that a stricture of the areolar muscle was an essential part of the deformity. He recommended a double subcutaneous myotomy of this muscle accompanied by frequent stretching of the nipple or suture-fixation in an improved position. He points out that the method requires the existence of at least a rudimentary nipple, although retracted. Textbooks of plastic surgerY, which have taken an interest in this subject, invariably recommend the Sellheim operation (Joseph, I93I ; Thorek, 1942; May, 1947; Berson, I948, etc.). Its principles are shown in Fig. I. By excision of small triangular pieces of skin from the freed nipple a " collar " formation of the base of the nipple is attempted in order to prevent the nipple from slipping back into its former position. Sellheim (I917) obtained satisfactory results in three cases with this procedure. I E
65
66
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
With the technique of Sellheim the first steps, in which the areola is utilised to create a new nipple, are satisfactory, but when the shortened circumference of the new areolar base is sutured to the outer skin edge representing the original
FIG. I
Sellheim's operation. margin of the areola, one will find that what was gained in the early part of the operation is to a great extent lost because of the disparity in length between the edges to be apposed. Later on, when the sutures have been removed, the result gradually deteriorates, due to stretching of the scars from the continuous peripheral pull. To overcome this disadvantage the following operation was devised.
FIG. 2 L i n e s o f incision for reconstruction in inversion o f t h e nipple.
triangular shaded areas are excised.
T h e eight
Writer's M e t h o d . - - T h e lines of incision are marked with Bonney's blue in Fig. 2, showing a circular line along the areolar margin. Based on this line are eight triangles pointing alternately centrally and peripherally. They represent the amount of skin to be excised. All the bases of these triangles should be about equal when the skin is unifermly distended, and the effect of the centripetal muscular contraction must then be considered. Depending on the size of the existing nipple, a wider or a smaller area of the areola is included in the circular incision round the nipple. When there is only a groove present the diameter of this incision should be at least 6 cm.
AN
OPERATION
FOR
INVERTED
NIPPLES
67
The operation will be facilitated if, as a preliminary step, the skin is stretched and superficial incisions are made according to the pattern. Then the circular incision is made well down in the subcutaneous layer, and the areola with its smooth muscle layer is dissected free while the nipple is held under constant pull with a traction suture. To get the nipple well out of its inverted or depressed position it will generally be found necessary to extend the dissection in between the outer galactophorous ducts, cutting fibrous bands without injury to the ducts or major vessels. When the areolar skin hangs like a folded umbrella from the everted nipple, four comparatively large triangular areas of skin are excised, as indicated in Fig. 2. The remaining flaps round the edge are rather narrow-based, but these manoeuvres have in no instance caused necrosis. The blood supply of the nipple is very rich, with capillary networks round the ducts. To shorten the outer wound edge the four triangular pieces of skin pointing peripherally are excised. When the defects from the removed triangles have been closed, the outer skin margin is so narrow that it can be sutured to the base of the new nipple without tension and without disturbing the reconstruction achieved (Fig. 3, c and D). Because of tension of the operative field during the growth of the breast in pregnancy, it cannot be avoided that the base of the nipple widens. Especially in cases where the anatomical structures of the nipple are very short with a strong tendency to retract, it is difficult to obtain a permanent result. In these cases the protruding nipple is mainly formed by the folded areolar skin, and the galactophorous ducts will all open into a pocket within the nipple, as was described in ruminants by Klaatsch (1884). Accurate technique is required in the suturing, preferably using the Gillies (1945) subcuticular corner stitch in the closure at the bases of the triangular defects. Fine stainless-steel wire and nylon thread have been used with advantage. The operation has regularly been performed under local anmsthesia. Cases and Conclusions .--Six women, aged 2 3 to 3° years, have been treated according to this technique ; four of them bilaterally. They were all pregnant in the third or fourth month at the time of operation. Pregnancy was not disturbed by this surgical intervention, and in all cases there was a normal delivery at full term. One patient, however, gave birth to a stillborn child, due to trauma. In all cases healing took place by primary intention, and the sensation of the nipple remained normal. Four of the five patients with children were able to nurse them in a normal way, but in two instances there were some difficulties during the first months of lactation, when the child was not able to suck strongly and a breast-pump had to be used temporarily. Three patients had a second child after the operation, and nursing was then considered still better. Two patients had borne children before the operation which they had not been able to nurse at all. One patient only regarded the operation as of no benefit. After childbirth she had very little milk, which might be connected with an under-development of the mammary glands as well. But it should also be stressed that it is essential that the patient takes interest and devotes energy in suckling her child. The mental attitude of the patient should therefore be considered before an operation l E*
68
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
is decided upon. For that reason a poor functional result might have been anticipated in this particular case, though the operative result was as satisfactory as in the other cases.
FIG. 3 A and B, Case of underdeveloped inverted nipples. C and D, Immediate operative result. E and F, Three years after operation.
Heredity.--Other members of the family had been affected in three instances. In one the deformity was known in four succeeding generations (mother, maternal grandmother, and great-grandmother). In the second, three sisters, the mother and the maternal grandmother suffered from the deformity. In the third the mother was affected, but three sisters had nipples of normal appearance and function.
AN
OPERATION
FOR
INVERTED
NIPPLES
69
SUMMARY An operation for inverted nipples is described, and the results in six operated cases are reported. In one case the deformity was traced through four generations, and there was a familial occurrence in two other cases. REFERENCES BASCH, K. (I893). Arch. Gynaek., 44, 15. BERSON, M. I. (1948). " Atlas o f Plastic Surgery," p. 256. N e w York : G r u n e & Stratton. GILLIES, H. D. (1945). " Plastic S u r g e r y " in T u r n e r , G. G. : " M o d e r n Operative Surgery," vol. ii, p. 1635. T h i r d Edition. L o n d o n : Cassell & Co. Ltd. JosEPH, J. (1931). " Nasenplastik und Gesichtsplastik nebst M a m m a p l a s t i k , " p. 807. L e i p z i g : C. Kabitzsch. KEHRER, F. A. (1888). Published in Mtiller, P. : " H a n d b u c h d. Geburtshfilfe," vol. iii, part 2, p. 45 o. Stuttgart : F. Enke. KLAATSCH, H. (1884). MorphologischesJahrbuch, 9, 253. MAY, H. (I947). " Reconstructive and Reparative Surgery," p. 4Io. Philadelphia : F. A. Davis Co. RAMSBOTHAM, F. H. (1844). " Obstetric Medicine and Surgery," p. 535. Second Edition. L o n d o n : J. & A. Churchill. SELLHEIM, H. (1917). Zbl. Gynaek., 41, 305. THOREK, M. (1942). " Plastic Surgery of the Breast and Abdominal Wall," p. 387 . Springfield : ' C. C. T h o m a s . WILLIAMS, J. W. (191o). " Obstetrics," p. 909. Second Edition. N e w York and L o n d o n : D. Appleton~Co.