BREAST SURGERY
An Adjustable-Traction Technique for Correction of Inverted Nipples Wei Li, MM,*† Yi Wu, BM,† Ying Deng, BM,† Ping Zhang, BM,† and Guo Sheng Ren, MD, PhD* Background: Inverted nipples are a common problem in female patients. This deformity impairs the function and appearance of the breast and may cause psychological distress. Existing correctional techniques may result in nipple necrosis, recurrence, infection, and scarring. In this study, we evaluated the efficacy of a minimally invasive inverted nipple correction method involving an adjustabletraction device designed by the authors. Methods: All patients who underwent correction of inverted nipples at the authors’ hospital from April 2003 to March 2014 were retrospectively evaluated. Patients were divided into 2 groups according to the correction technique. In group A, 41 nipples in 25 patients underwent traditional (conventional) surgical correction. In group B, 74 nipples in 40 patients underwent continuous traction using our traction device for 2 to 4 months. All patients were followed up for 6 to 12 months postoperatively (group A) or after finish the course of therapy (group B). Complications and patient satisfaction were compared between the groups. Results: No infection occurred in either group. In group A, 9 patients were dissatisfied, and a severe complication occurred in 1 nipple. In group B, all inverted nipples were corrected, and nipple inversion recurred in 2 patients; repeat traction produced a good outcome. Group B had fewer complications and higher patient satisfaction than group A. Conclusions: This adjustable continuous-traction technique provided better correction of inverted nipples with fewer complications and higher patient satisfaction than did traditional surgical correction. This safe, simple, effective, minimally invasive technique is suitable for correction of various types of inverted nipples. Key Words: inverted nipple, complications, traction, minimal invasion (Ann Plast Surg 2016;76: 29–33)
I
nverted nipple is a common problem in female patients. The incidence of congenital permanently inverted nipples is about 3%1 to 10%.2 This deformity may impair the function and appearance of the breast, induce inflammation of the breast tissue, and cause psychological distress. The various inverted nipple correction techniques that are currently available3–8 can result in complications, such as nipple necrosis, recurrence, infection, and scarring. Thus, correction of inverted nipples while limiting complications is challenging for surgeons. Some earlier methods of traction for correction of inverted nipples are still performed and may be associated with complications, such as nipple necrosis, areolar ulceration, and depigmentation. Therefore, we developed an improved, minimally invasive technique that we have used for correction of inverted nipples since March 2005. We herein describe this technique and retrospectively compare its complication rate with that of a more conventional surgical technique among patients at our hospital. Received December 28, 2014, and accepted for publication, after revision April 7, 2015. From the *Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University; and †Department of Plastic Surgery, Chongqing Emergency Medical Center, Chongqing, China. Conflicts of interest and sources of funding: none declared. Reprints: Guo Sheng Ren, MD, The First Affiliated Hospital of Chongqing Medical University Chongqing, Chongqing, China. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7601–0029 DOI: 10.1097/SAP.0000000000000543
PATIENTS AND METHODS All patients in this study had congenitally inverted nipples. The patients were divided into 2 groups. Group A comprised 41 nipples in 25 patients (age range, 19–38 years). Eighteen patients were unmarried and 7 were married. Nipple inversion occurred bilaterally in 16 patients and unilaterally in 9. Group B comprised 74 nipples in 40 patients (age range, 18– 46 years). Four nipples (2 patients) developed recurrence of inversion after surgical correction at another hospital. Twenty-five patients were unmarried, and 15 were married. Nipple inversion occurred bilaterally in 34 patients and unilaterally in 6. The Han and Hong classification9 of all patients in the 2 groups is presented in Table 1.
Surgical Procedure The procedure and its risks were described to all patients. In both groups, the chest was widely prepared with povidone iodine and draped, and local anesthesia (1% lidocaine and 1:200,000 epinephrine) was administered at the base of the nipples. In group A, surgery was performed under local anesthesia. Three periductal dermofibrous flaps were created according to the technique of Huang, which is described in detail elsewhere.5 Nursing staff provided the postoperative care. In group B, surgery was performed under local anesthesia administered before placement of the traction device. A 5-mL single-use syringe was used to create the traction device. The piston was discarded and the syringe was cut, leaving 1.5 cm at the distal end. Four V-shaped grooves were made at the 3-, 6-, 9-, and 12-o'clock positions in the cut end of the syringe, and 4 holes were made at the other end (Fig. 1). Two 7-cm long, 0.3-mm diameter sterile stainless steel wires were also prepared. Nursing staff provided the posttraction care. The inverted nipple was gradually pulled out using a suture needle and forceps by passing a 21-G needle through the base of the nipple at the 3- and 9-o'clock positions.8 One of the stainless steel wires was placed into the pinhole, and the needle was then withdrawn (Fig. 2). The other stainless steel wire was placed in the same fashion at the 6and 12-o’clock positions. Traction was applied to the nipple, and the wires were pulled over the top edge of the syringe via the notches and threaded through the holes for fixation (Fig. 3). Traction with suitable tension was put on the nipple to keep the inverted nipple just protruding from the surface of breast. All patients were followed up for 6 to 12 months (mean, 10.4 months) by postoperative telephone calls or hospital visits (group A) orafter the traction device was removed (group B).
TABLE 1. Grades of Nipple Inversion in the 2 Groups Group
Group A (n = 41) Group B (n = 74)
Grade I
Grade II
Grade III
9 16
23 34
9 24
P > 0.05 compared with Group B.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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29
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Li et al
FIGURE 1. A 5-mL syringe is used to create the traction device.
Traction Care The patients were followed up on postprocedure days 1, 3, and 7 for dressing changes and observation of the nipple blood supply. The tightness of the wire was adjusted to maintain continuous traction on postprocedure day 7. The patients were allowed to bathe normally after the first week of traction and were educated on how to disinfect the nipple with povidone iodine after bathing. They were instructed to return for wire shortening by 2 to 3 mm per week until the projection of the inverted nipple was 3 mm higher than that of the healthy side in unilateral cases or until the nipple projected 1.5 cm in bilateral cases. Nipple projection will decreases by approximately 4 mm after removal of traction devices8; thus, the projection of the inverted nipple must be overcorrected. This is important to obtaining good nipple projection and preventing relapse. After device placement, traction was maintained for 2 to 4 months. The device was removed after 2 months for grade I inversion, 3 months for grade II inversion, and 4 months for grade III inversion.
Statistical Analysis The categorical data collected included the complication rate and patient satisfaction. These data were assessed with the χ2 statistic using
FIGURE 3. The traction device is placed and fixed.
SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL). Statistical significance was set at P < 0.05.
RESULTS From April 2003 to March 2005, 41 inverted nipples in 25 patients underwent correction using the traditional surgical technique (group A). From March 2005 to March 2014, 74 inverted nipples in 40 patients (group B) underwent correction using the authors’ continuous traction device. The traction duration was 2 to 4 months. During the 6- to 12-month postoperative period, patient satisfaction was evaluated and classified as “satisfied” or “dissatisfied” according to whether the inverted nipple had recurred, whether sensitivity was maintained, and whether scarring had occurred. Complications and patient satisfaction in the 2 groups are presented in Tables 2 and 3. No infection occurred in either group. In group A, 9 patients were dissatisfied, and a severe complication occurred in 1 nipple. In group B, all inverted nipples were corrected with good projection (Figs. 4–11). Two nipples (2 patients demanded removal of the traction device before the scheduled completion of treatment) in group B developed recurrence; traction was reapplied, and good outcomes were obtained. One patient with a grade
TABLE 2. Comparison of Complication Rates Between the 2 Groups Group
Group A (n = 41) Group B (n = 74)
FIGURE 2. A wire is passed through the base of the nipple using a needle. 30
www.annalsplasticsurgery.com
Obvious Scar
Nipple Necrosis
Wire Dislocation
Recurrence
Insensitivity
6*
1
0
5
6*
0
0
1
2
0
*P < 0.05 compared with Group B.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Correction of Inverted Nipples
TABLE 3. Patient Satisfaction Group
Satisfied
Dissatisfied
16 38
9* 2
Group A (n = 25) Group B (n = 40) *P < 0.05 compared with Group B.
III inverted nipple was treated for wire dislocation by changing the site of the wire. Group A had significantly higher incidences of obvious scarring and lack of nipple sensitivity and significantly more patients who were dissatisfied with the outcome than did group B.
DISCUSSION In addition to the psychological distress that may occur because of the disfigurement caused by nipple inversion, inflammation10 and cancer11 are potential problems. Congenitally inverted nipples result from an underlying disorder of mesoderm development. The etiology of mild to moderate nipple inversion is primarily a lack of tissue support beneath the nipple, preventing the maintenance of normal projection. However, severely inverted nipples are caused by both a lack of tissue support and contraction of smooth muscle and connective tissue around the lactiferous ducts. Based on these phenomena, many surgical methods have been devised to correct inverted nipples.3–7 However, complications, such as nipple necrosis, recurrence, infection, and scarring, may occur. Some surgical methods require cutting of the contracted lactiferous ducts and are therefore not suitable for patients who plan to breastfeed,3,12 and other surgical methods may change the shape or size of the areola.13 Nipple necrosis, relapse, obvious scarring, and insensitivity all occurred in group A in the present study.
FIGURE 4. Grade III inversion before traction (anterior view).
FIGURE 5. Six months after traction treatment (anterior view).
A new method in which wire or sutures are used to place traction on the inverted nipple has recently emerged. Complications associated with the traditional surgical technique can be avoided using this method, and good outcomes have been obtained. Durgun et al.7 used a traction technique to prevent relapse after surgical correction of
FIGURE 6. Lateral view before traction.
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31
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Li et al
FIGURE 9. Seven months after traction treatment (anterior view).
dislocation. To avoid these complications in the present study, the tension of the steel wires was decreased until the patient felt mild pain when the steel was shortened, and the tension was adjusted every week instead of every month. Because the patient's quality of life may be negatively affected by a long traction time,15 it is important to shorten the traction time. Adjustment of the tension during the first week and shortening the wire by 2 to 3 mm weekly can reportedly shorten the total traction time. It can also result in more satisfactory nipple projection with a lower complication rate than earlier traction techniques.8 With our technique, the traction time can be shortened to 2 months for patients with grade I inversion and to only 3 to 4 months for patients with grade II to III inversion. Patient cooperation is the key factor in successfully FIGURE 7. Six months after traction treatment (lateral view).
inverted nipples. Traction and expander techniques can promote tissue regeneration, and the longer the treatment duration, the more tissue will be obtained, thus over correction can prevent recurrence. In an animal study, Zhou et al14 reported that continuous elastic distraction can increase tissue development by promoting the expression of vascular endothelial cell growth factor and the microvessel density in nipples. Traction can also elongate the contraction fibrous tissue and lactiferous ducts, and without the scar contracture accompanied by traditional surgical technique, thus the recurrence is lower. A longer traction time should be implemented to prevent relapse in cases of severe inversion. Thus, early traction techniques involved a traction time of 6 months, and the tension of the steel wires was adjusted every month.8,15 However, these early studies showed that a long traction time negatively affected the patient's quality of life and decreased the treatment compliance. Additionally, high tension could result in complications such as pressure ulcers, areolar depigmentation, and wire
FIGURE 8. Recurrence and scarring after traditional surgery (anterior view). 32
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FIGURE 10. Recurrence and scarring after traditional surgery (lateral view). © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Correction of Inverted Nipples
and depigmentation can be avoided with gradual traction. The herein-described technique, which uses an adjustable traction device of the authors’ own design, can shorten the course of treatment and reduce complications. REFERENCES
FIGURE 11. Seven months after traction treatment (lateral view).
completing the treatment and obtaining a good outcome; therefore, it is very important for the patient to master self-nursing care after traction.
CONCLUSIONS The present study has demonstrated the benefits of the traction method for treatment of inverted nipples, namely, fewer complications and higher patient satisfaction with the outcome than obtained by traditional surgical correction. Additionally, areolar ulceration
1. Park HS, Yoon CH, Kim HJ. The prevalence of congenital inverted nipple. Aesthetic Plast Surg. 1999;23:144–146. 2. Bracaglia R, Tambasco D, Gentileschi S, et al. Recurrent inverted nipple: a reliable technique for the most difficult cases. Ann Plast Surg. 2012;69:24–26. 3. McG Taylor D, Lahiri A, Laitung JK. Correction of the severely inverted nipple: areola-based dermoglandular rhomboid advancement. J Plast Reconstr Aesthet Surg. 2011;64:e297–e302. 4. Hwang K, Kim DH. Half Z-plasty, band release, and cavity filling for correction of inverted nipple. J Plast Surg Hand Surg. 2013;47:93–96. 5. Huang WC. A new method for correction of inverted nipple with three periductal dermofibrous flaps. Aesthetic Plast Surg. 2003;27(4):301–304. 6. Kim DY, Jeong EC, Eo SR, et al. Correction of inverted nipple: an alternative method using two triangular areolar dermal flaps. Ann Plast Surg. 2003;51: 636–640. 7. Durgun M, Ozakpınar HR, Selçuk CT, et al. Inverted nipple correction with dermal flaps and traction. Aesthetic Plast Surg. 2014;38:533–539. 8. Long X, Zhao R. Nipple retractor to correct inverted nipples. Breast Care (Basel). 2011;6:463–465. 9. Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg. 1999;104:389–395. 10. Enomoto S, Matsuzaki K. Treatment of inverted nipple with subareolar abscess: usefulness of high-resolution MRI for preoperative evaluation. Plast Surg Int. 2012;2012:573079. 11. Yu ZG, Jia CX, Geng CZ, et al. Risk factors related to female breast cancer in regions of Northeast China: a 1:3 matched case-control population-based study. Chin Med J (Engl). 2012;125:733–740. 12. Karacaoglu E. Correction of recurrent grade III inverted nipple with antenna dermoadipose flap: case report. Aesthetic Plast Surg. 2009;33:843–848. 13. Taneda H, Sakai S, Kamei C. Correction of recurrent inverted nipples with the Sakai Method. Ann Plast Surg. 2013;71:156–159. 14. Zhou B, Wu GP, An YC, et al. The effect of continuous elastic outside distraction on the expressions of vascular endothelial cell growth factor and microvessel density in female porcine nipple. Aesthetic Plast Surg. 2012;36:723–731. 15. Mu D, Luan J, Mu L, et al. A minimally invasive gradual traction technique for inverted nipple correction. Aesthetic Plast Surg. 2012;36:1151–1154.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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33
An Adjustable-Traction Technique for Correction of Inverted Nipples Wei Li, MM,*† Yi Wu, BM,† Ying Deng, BM,† Ping Zhang, BM,† and Guo Sheng Ren, MD, PhD* Background: Inverted nipples are a common problem in female patients. This deformity impairs the function and appearance of the breast and may cause psychological distress. Existing correctional techniques may result in nipple necrosis, recurrence, infection, and scarring. In this study, we evaluated the efficacy of a minimally invasive inverted nipple correction method involving an adjustabletraction device designed by the authors. Methods: All patients who underwent correction of inverted nipples at the authors’ hospital from April 2003 to March 2014 were retrospectively evaluated. Patients were divided into 2 groups according to the correction technique. In group A, 41 nipples in 25 patients underwent traditional (conventional) surgical correction. In group B, 74 nipples in 40 patients underwent continuous traction using our traction device for 2 to 4 months. All patients were followed up for 6 to 12 months postoperatively (group A) or after finish the course of therapy (group B). Complications and patient satisfaction were compared between the groups. Results: No infection occurred in either group. In group A, 9 patients were dissatisfied, and a severe complication occurred in 1 nipple. In group B, all inverted nipples were corrected, and nipple inversion recurred in 2 patients; repeat traction produced a good outcome. Group B had fewer complications and higher patient satisfaction than group A. Conclusions: This adjustable continuous-traction technique provided better correction of inverted nipples with fewer complications and higher patient satisfaction than did traditional surgical correction. This safe, simple, effective, minimally invasive technique is suitable for correction of various types of inverted nipples. Key Words: inverted nipple, complications, traction, minimal invasion (Ann Plast Surg 2016;76: 29–33)
I
nverted nipple is a common problem in female patients. The incidence of congenital permanently inverted nipples is about 3%1 to 10%.2 This deformity may impair the function and appearance of the breast, induce inflammation of the breast tissue, and cause psychological distress. The various inverted nipple correction techniques that are currently available3–8 can result in complications, such as nipple necrosis, recurrence, infection, and scarring. Thus, correction of inverted nipples while limiting complications is challenging for surgeons. Some earlier methods of traction for correction of inverted nipples are still performed and may be associated with complications, such as nipple necrosis, areolar ulceration, and depigmentation. Therefore, we developed an improved, minimally invasive technique that we have used for correction of inverted nipples since March 2005. We herein describe this technique and retrospectively compare its complication rate with that of a more conventional surgical technique among patients at our hospital. Received December 28, 2014, and accepted for publication, after revision April 7, 2015. From the *Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University; and †Department of Plastic Surgery, Chongqing Emergency Medical Center, Chongqing, China. Conflicts of interest and sources of funding: none declared. Reprints: Guo Sheng Ren, MD, The First Affiliated Hospital of Chongqing Medical University Chongqing, Chongqing, China. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7601–0029 DOI: 10.1097/SAP.0000000000000543
PATIENTS AND METHODS All patients in this study had congenitally inverted nipples. The patients were divided into 2 groups. Group A comprised 41 nipples in 25 patients (age range, 19–38 years). Eighteen patients were unmarried and 7 were married. Nipple inversion occurred bilaterally in 16 patients and unilaterally in 9. Group B comprised 74 nipples in 40 patients (age range, 18– 46 years). Four nipples (2 patients) developed recurrence of inversion after surgical correction at another hospital. Twenty-five patients were unmarried, and 15 were married. Nipple inversion occurred bilaterally in 34 patients and unilaterally in 6. The Han and Hong classification9 of all patients in the 2 groups is presented in Table 1.
Surgical Procedure The procedure and its risks were described to all patients. In both groups, the chest was widely prepared with povidone iodine and draped, and local anesthesia (1% lidocaine and 1:200,000 epinephrine) was administered at the base of the nipples. In group A, surgery was performed under local anesthesia. Three periductal dermofibrous flaps were created according to the technique of Huang, which is described in detail elsewhere.5 Nursing staff provided the postoperative care. In group B, surgery was performed under local anesthesia administered before placement of the traction device. A 5-mL single-use syringe was used to create the traction device. The piston was discarded and the syringe was cut, leaving 1.5 cm at the distal end. Four V-shaped grooves were made at the 3-, 6-, 9-, and 12-o'clock positions in the cut end of the syringe, and 4 holes were made at the other end (Fig. 1). Two 7-cm long, 0.3-mm diameter sterile stainless steel wires were also prepared. Nursing staff provided the posttraction care. The inverted nipple was gradually pulled out using a suture needle and forceps by passing a 21-G needle through the base of the nipple at the 3- and 9-o'clock positions.8 One of the stainless steel wires was placed into the pinhole, and the needle was then withdrawn (Fig. 2). The other stainless steel wire was placed in the same fashion at the 6and 12-o’clock positions. Traction was applied to the nipple, and the wires were pulled over the top edge of the syringe via the notches and threaded through the holes for fixation (Fig. 3). Traction with suitable tension was put on the nipple to keep the inverted nipple just protruding from the surface of breast. All patients were followed up for 6 to 12 months (mean, 10.4 months) by postoperative telephone calls or hospital visits (group A) orafter the traction device was removed (group B).
TABLE 1. Grades of Nipple Inversion in the 2 Groups Group
Group A (n = 41) Group B (n = 74)
Grade I
Grade II
Grade III
9 16
23 34
9 24
P > 0.05 compared with Group B.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
29
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Li et al
FIGURE 1. A 5-mL syringe is used to create the traction device.
Traction Care The patients were followed up on postprocedure days 1, 3, and 7 for dressing changes and observation of the nipple blood supply. The tightness of the wire was adjusted to maintain continuous traction on postprocedure day 7. The patients were allowed to bathe normally after the first week of traction and were educated on how to disinfect the nipple with povidone iodine after bathing. They were instructed to return for wire shortening by 2 to 3 mm per week until the projection of the inverted nipple was 3 mm higher than that of the healthy side in unilateral cases or until the nipple projected 1.5 cm in bilateral cases. Nipple projection will decreases by approximately 4 mm after removal of traction devices8; thus, the projection of the inverted nipple must be overcorrected. This is important to obtaining good nipple projection and preventing relapse. After device placement, traction was maintained for 2 to 4 months. The device was removed after 2 months for grade I inversion, 3 months for grade II inversion, and 4 months for grade III inversion.
Statistical Analysis The categorical data collected included the complication rate and patient satisfaction. These data were assessed with the χ2 statistic using
FIGURE 3. The traction device is placed and fixed.
SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL). Statistical significance was set at P < 0.05.
RESULTS From April 2003 to March 2005, 41 inverted nipples in 25 patients underwent correction using the traditional surgical technique (group A). From March 2005 to March 2014, 74 inverted nipples in 40 patients (group B) underwent correction using the authors’ continuous traction device. The traction duration was 2 to 4 months. During the 6- to 12-month postoperative period, patient satisfaction was evaluated and classified as “satisfied” or “dissatisfied” according to whether the inverted nipple had recurred, whether sensitivity was maintained, and whether scarring had occurred. Complications and patient satisfaction in the 2 groups are presented in Tables 2 and 3. No infection occurred in either group. In group A, 9 patients were dissatisfied, and a severe complication occurred in 1 nipple. In group B, all inverted nipples were corrected with good projection (Figs. 4–11). Two nipples (2 patients demanded removal of the traction device before the scheduled completion of treatment) in group B developed recurrence; traction was reapplied, and good outcomes were obtained. One patient with a grade
TABLE 2. Comparison of Complication Rates Between the 2 Groups Group
Group A (n = 41) Group B (n = 74)
FIGURE 2. A wire is passed through the base of the nipple using a needle. 30
www.annalsplasticsurgery.com
Obvious Scar
Nipple Necrosis
Wire Dislocation
Recurrence
Insensitivity
6*
1
0
5
6*
0
0
1
2
0
*P < 0.05 compared with Group B.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Correction of Inverted Nipples
TABLE 3. Patient Satisfaction Group
Satisfied
Dissatisfied
16 38
9* 2
Group A (n = 25) Group B (n = 40) *P < 0.05 compared with Group B.
III inverted nipple was treated for wire dislocation by changing the site of the wire. Group A had significantly higher incidences of obvious scarring and lack of nipple sensitivity and significantly more patients who were dissatisfied with the outcome than did group B.
DISCUSSION In addition to the psychological distress that may occur because of the disfigurement caused by nipple inversion, inflammation10 and cancer11 are potential problems. Congenitally inverted nipples result from an underlying disorder of mesoderm development. The etiology of mild to moderate nipple inversion is primarily a lack of tissue support beneath the nipple, preventing the maintenance of normal projection. However, severely inverted nipples are caused by both a lack of tissue support and contraction of smooth muscle and connective tissue around the lactiferous ducts. Based on these phenomena, many surgical methods have been devised to correct inverted nipples.3–7 However, complications, such as nipple necrosis, recurrence, infection, and scarring, may occur. Some surgical methods require cutting of the contracted lactiferous ducts and are therefore not suitable for patients who plan to breastfeed,3,12 and other surgical methods may change the shape or size of the areola.13 Nipple necrosis, relapse, obvious scarring, and insensitivity all occurred in group A in the present study.
FIGURE 4. Grade III inversion before traction (anterior view).
FIGURE 5. Six months after traction treatment (anterior view).
A new method in which wire or sutures are used to place traction on the inverted nipple has recently emerged. Complications associated with the traditional surgical technique can be avoided using this method, and good outcomes have been obtained. Durgun et al.7 used a traction technique to prevent relapse after surgical correction of
FIGURE 6. Lateral view before traction.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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31
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Li et al
FIGURE 9. Seven months after traction treatment (anterior view).
dislocation. To avoid these complications in the present study, the tension of the steel wires was decreased until the patient felt mild pain when the steel was shortened, and the tension was adjusted every week instead of every month. Because the patient's quality of life may be negatively affected by a long traction time,15 it is important to shorten the traction time. Adjustment of the tension during the first week and shortening the wire by 2 to 3 mm weekly can reportedly shorten the total traction time. It can also result in more satisfactory nipple projection with a lower complication rate than earlier traction techniques.8 With our technique, the traction time can be shortened to 2 months for patients with grade I inversion and to only 3 to 4 months for patients with grade II to III inversion. Patient cooperation is the key factor in successfully FIGURE 7. Six months after traction treatment (lateral view).
inverted nipples. Traction and expander techniques can promote tissue regeneration, and the longer the treatment duration, the more tissue will be obtained, thus over correction can prevent recurrence. In an animal study, Zhou et al14 reported that continuous elastic distraction can increase tissue development by promoting the expression of vascular endothelial cell growth factor and the microvessel density in nipples. Traction can also elongate the contraction fibrous tissue and lactiferous ducts, and without the scar contracture accompanied by traditional surgical technique, thus the recurrence is lower. A longer traction time should be implemented to prevent relapse in cases of severe inversion. Thus, early traction techniques involved a traction time of 6 months, and the tension of the steel wires was adjusted every month.8,15 However, these early studies showed that a long traction time negatively affected the patient's quality of life and decreased the treatment compliance. Additionally, high tension could result in complications such as pressure ulcers, areolar depigmentation, and wire
FIGURE 8. Recurrence and scarring after traditional surgery (anterior view). 32
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FIGURE 10. Recurrence and scarring after traditional surgery (lateral view). © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 1, January 2016
Correction of Inverted Nipples
and depigmentation can be avoided with gradual traction. The herein-described technique, which uses an adjustable traction device of the authors’ own design, can shorten the course of treatment and reduce complications. REFERENCES
FIGURE 11. Seven months after traction treatment (lateral view).
completing the treatment and obtaining a good outcome; therefore, it is very important for the patient to master self-nursing care after traction.
CONCLUSIONS The present study has demonstrated the benefits of the traction method for treatment of inverted nipples, namely, fewer complications and higher patient satisfaction with the outcome than obtained by traditional surgical correction. Additionally, areolar ulceration
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