INTRODUCTION: Nipple inversion, which is defined as a nipple located on a plane lower than the areola, is a disfiguring condition that

affects approximately 2% of all women 1. Inverted nipples are often congenital, caused by a small nipple base or constricted milk ducts. Inversion can also happen after childbirth, caused by milk ducts scarring due to breastfeeding. However inversion of short duration with palpable breast lump is a sinister sign 2. The inverted nipple presents both cosmetic and functional problems and may create psychological trauma in the patients and nutritional deficiency in the new born infants. Histopathologically it is characterized by less fibroconnective tissue beneath the nipple, shortened and fewer functional lactiferous duct, and short dense fibrous tissue beneath it. Kehrer performed the first surgical correction of inverted nipples in 1879 3.Surgeons use the Han and Hong Nipple Inversion Grading System to quantify the degree of inversion 4.

Grade I: The nipple can easily be pulled out and maintains projection. There is minimal fibrous tissue beneath the nipple. Manual manipulation or a simple buried purse-string suture is adequate to achieve protrusion. Lactation is not impaired. Grade II: The nipple can be pulled out with moderate difficulty, but does not maintain projection, retracting into the breast. The majority of inverted nipples fall into this classification. These nipples have moderate fibrous tissue beneath the nipple. Surgical treatment involves dissection of the nipple to release fibrous tissue bands. Lactiferous ducts are preserved. Lactation is not impaired 5. Grade III: It is difficult or impossible to evert the nipple manually. The least proportion of nipples is this severely inverted. There is severe fibrosis at the base of the nipple so that it is impossible to sever all the fibrous tissue bands without severing ducts, particularly in the central portion of the nipple. Lactation is significantly impaired 5. With time, recanalization of the ducts can result in partial or full functionality.

Several different techniques 6-14 have been developed and are currently in use for correction of inverted nipples. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. Among these different techniques procedures those commonly employed includes dermoglandular/dermofibrous flaps, different suturing techniques, cartilage or even piercing to secure the nipple from its natural tendency to collapse. In our local setup where breast feeding has yet not become obsolete the functional issue is as important as the aesthetic issue and therefore the least invasive procedure yielding consistent results with minimum recurrence rate would be preferable. We at our unit use the simple versatile

REFRENCES: 1: 2: 3: 4: 5:
6: 7: 8: 9: 10: 11:

Schwager, R.G. et al. Inversion of the human female nipple, with a simple method of treatment. Plast. Reconstr. Surg. 54:564,1974. E M Neville, M. Adiseshiah; Clinical significance of recent inversion of the Nipple: a reappraisal. Journal of the Royal society of Medicine. 75: 113-114; 1982. Huang, W. A new method for correction of inverted nipple with three periductal dermofibrous flaps. Aesthetic Plast Surg 2003 Jul-Aug; 27(4):301-4. Han, S. and Hong, Y. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg 1999 Aug; 104(2):389-95; discussion 396-7. Terrill, P. and Stapleton, M. The inverted nipple: to cut the ducts or not? Br J Plast Surg 1991 Jul; 44(5):372-7.
H. L. Wu, X. Huangand S. S. Zheng A New Procedure for Correction of Severe Inverted Nipple with Two Triangular Areolar Dermofibrous Flaps. Aesth Plast Surg, 32: 641-644. 2008. Brent, B., and Bostwick, J. Nipple-areolar reconstruction with auricular tissue. Plas. Reconstr. Surg. 60: 353, 1977. Broadbent, T.R., and Woolf, R.M. Benign inverted nipple: Transnipple-areolar correction. Plast. Reconstr. Surg. 58:673,1976. Elsahy, N.I. An alternative operation for the inverted nipple. Plast. Reconstr. Surg. 57:438,1976. Han, S. Then inverted nipple: its grading and surgical correction. Plast. Reconstr. Surg. 105:1546,2000. Hauben, D.J., and Mahler, D. A simple method for the correction of the inverted nipple. Plast. Reconstr. Surg. 71:556,1983.

12: 13: 14:

Wolfort, F.G., Marshall, K.A., and Cocchran, T.C. Correction of the inverted nipple. Ann. Plast. Surg. 1:294,1978. Yanai, A., Okabe, K., and Tanaka, H. Corrections of the inverted nipple. Aesthet. Plast. Surg. 10:51,1986 Pribaz j. j, Pousti t. Correction of recurrent nipple inversion with cartilage graft . Annals of plastic surgery: 40, 14-17. 1998