title: Application of Nipple Retractor for Correction of Nipple Inversion: A 10-Year Experience.
abstract: BACKGROUND
  Nipple inversion is a relatively common problem in adolescent and adult women; however, most present surgical treatments are prone to injure the lactiferous ducts and impair the breast feeding function. A nipple retractor was developed by us in 2003 to correct nipple inversion to avoid lactiferous duct injury. The details and a 10-year evaluation of this technique were introduced in this paper.
  
  
  METHODS
  The nipple retractor was made from the hollow end of single-use syringe, then eight holes were punctured for sutures crossing the base, and the height of retractor depended on the sizes of nipple-areola complex and breast volume. Two sutures were made to cross beneath the base of the nipple to elevate the nipple, and the hollow retractor was placed on the areola with the nipple and four ends of the sutures in the center, sutures then passed the prefabricated holes on the retractor base and were fixed with knots and suitable tension. The retractor was worn for 3-6 months and then could be removed.
  
  
  RESULTS
  A total of 257 nipples in 136 patients with nipple inversion (unilateral: 15 patients; bilateral: 121 patients) received this operation from Jan 2003 to Dec 2012, among which 233 nipples were successfully corrected (90.7 %), and 24 nipples reoccurred in 2 years. The effective rates of grade I and grade II inversions were significantly higher than that of grade III (P < 0.01). Thirty-two patients with 56 treated nipples underwent labor and breastfeeding, and all the nipples were functional. The complications included fistula after suture removal (19 nipples, 7.4 %), breaking of suture (8 nipples, 3.1 %), erosion of nipple (28 nipples, 10.9 %), and chronic pain (10 nipples, 3.4 %), and all these complications were properly managed.
  
  
  CONCLUSIONS
  The nipple retractor technique is a feasible, effective, and safe method for correction of grade I and grade II nipple inversions, and could also be indicated for primary correction of grade III inversion. Its most significant advantage is that lactiferous duct injury can be avoided and the breast feeding function preserved.
  
  
  METHODS
  Nipple inversion is a common malformation in adolescent and adult women, which can be present unilaterally or bilaterally. It was generally initiated from the adolescent period and could be caused by primary hypogenesis of smooth muscle and supporting tissue of the nipple-areola complex or hypoplasia of lactiferous ducts [1] . Some other secondary factors such as chronic infection, tumor, and previous surgery could contribute to the fibrosis, and some of them were believed to be congenital and hereditary [2, 3]. Since the openings of lactiferous ducts are immersed, inversion might cause reoccurring infection and breast feeding difficulty, and the appearance of the breast would be affected as well, which would impact patients' psychological health. Nipple inversion can be clinically divided into three categories according to Han et al.'s grading rules. In grade I, the nipple is easily pulled out manually and maintains its projection quite well. In grade II, the nipples can be pulled out but cannot maintain projection and tend to go back again. In grade III, the nipple can hardly be pulled out manually. [4] The images of three grades of nipple inversion are present in Fig. 1. Fig. 1 Three categories of nipple inversion grade I inverted nipple(a), grade II inverted nipple(b), grade III inverted nipple(c) Surgical interventions are the most effective treatments at present; however, injury to lactiferous ducts is inevitable in most surgical techniques [1, 5-10]. Some conservative nonoperative techniques have been developed in the last several years, such as a self-retraction and suction device, but only mild cases of grade I are indicated. Several suspension and retraction devices have been reported in recent years [10, 11], and the effect was acceptable, but long-term results were not reported. To simplify the operation procedures and diminish the possibility of lactiferous duct injury, we developed a nipple retractor, which was made from a single-use syringe, to correct nipple inversion from 2003. The details of procedures and techniques are introduced in this paper, as well as a 10-year retrospective analysis.
authors.affiliation: Department of Plastic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
authors.forename: Liu
authors.initials: L
authors.lastname: Yukun
authors.affiliation: Department of Plastic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. gkiseri@126.com.
authors.forename: Guo
authors.initials: G
authors.lastname: Ke
authors.affiliation: Department of Plastic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
authors.forename: Sun
authors.initials: S
authors.lastname: Jiaming
mesh_terms: D000293:Adolescent; D000328:Adult; D001941:Breast Diseases / Q000175:diagnosis / Q000601:surgery*; D015331:Cohort Studies; D004867:Equipment Design; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D009558:Nipples / Q000002:abnormalities* / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000295:instrumentation* / Q000379:methods; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000637:transplantation*; D013525:Surgical Instruments; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology; D055815:Young Adult
keywords: Breast feeding function; Nipple inversion; Nipple retractor