Arch Aesthetic Plast Surg Search

CLOSE


Arch Aesthetic Plast Surg > Volume 23(2); 2017 > Article
Kang, Yun, Song, and Shin: Inverted Nipple Correction Using a Combination of the Perpendicular Suture Method and the Purse-String Suture Method

Abstract

While various surgical methods are used for inverted nipple correction, an optimal technique has not been established. We describe a combination of suture methods including purse-string sutures, based on a report by Gould et al. This is a simple and safe method for inverted nipple correction.

INTRODUCTION

Inverted nipple is defined as a state in which part of the nipple or the entire nipple is retracted below the surface of the areola. Inverted nipples can be classified in accordance with Han and Hong’s classification [1] as follows: grade I (mild), grade II (moderate), and grade III (severe).
Surgical correction aims to achieve aesthetically satisfactory nipple projection without recurrence, while also maintaining the sensory and lactation functions [2]. Various surgical methods have been suggested for correcting inverted nipples, including dermal and dermoglandular flaps, endoscopic release, internal suturing, continuous traction, and the use of artificial dermis [3-8]. The variety of surgical techniques reflects the difficulty of achieving a satisfactory outcome with any single method.
A surgical technique employing 2 horizontal mattress sutures was suggested by Gould et al. [9] in 2015. This is a relatively safe and effective method, but we found that the shape of the nipple base immediately after surgery was angular, and that satisfactory nipple projection was difficult to achieve with time; accordingly, we developed a new method, as described in this report. Using the surgical method of Gould et al. [9] as a benchmark, we surmised that combining this technique with purse-string suturing would produce a better outcome. Thus, we introduce a surgical technique that combines 2 suture-based methods.

IDEA

Surgical procedure

Gould et al. [9] proposed a surgical method for correcting inverted nipples in 2015. Four slit incisions are made in the nipple base (at the 3, 6, 9, and 12 o’clock positions) while the patient is under local anesthesia, and the fibrotic band located at the nipple base is dissected and released. Next, 2 horizontal mattress sutures are performed in a perpendicular direction with 4-0 Vicryl (Fig. 1). We used the same method described above, but followed this with a purse-string suture without an additional incision, as in non-incisional double eyelidplasty or knifeless otoplasty. Starting from the slit incision at the 6 o’clock position, a purse-string suture was placed around the nipple base with 7-0 nylon, followed by 8 stitch points at equal intervals.
The length of the skin incision for the horizontal mattress sutures must be limited to 3 to 5 mm, and no separate incision was made for the purse-string suture. When performing the purse-string suture, a needle was inserted back into the stitch points from which it came out, without a skin incision. The purse-string suture was ligated with proper tension, and the knot was buried beneath the dermis (Fig. 2). The skin incisions were then sutured with 7-0 nylon, antibiotic ointment was applied, gauze was loosely placed, and the wound was disinfected with a nipple protection cup. The temporary traction suture was not removed, but was tied to the nipple protection cup to maintain traction. This traction was removed after 3 to 5 days.

Case

A 50-year-old woman underwent surgery for grade II inverted nipple in her right breast. The patient was monitored for 6 months postoperatively, during which time there were no adverse effects, such as hematoma, bleeding, nipple necrosis, or sensory loss (Fig. 3). The nipple was well maintained without any significant loss of projection after surgery, and the patient was satisfied with the surgical outcome.

DISCUSSION

The creation of lasting nipple projection remains a challenging problem in the correction of inverted nipples. Surgical techniques to correct inverted nipples have been studied, and various methods have been suggested, such as dermal and dermoglandular flaps, endoscopic release, internal suturing, continuous traction, and the use of artificial dermis [3-8,10]. Techniques using sutures have the advantage of reducing incisions and scarring, and are also considered safe. Perpendicular sutures, purse-string sutures, and continuous subcutaneous sutures have been used [11-14]. In particular, we thought that the surgical method published in 2015 by Gould et al. [9] was a safe and effective technique to correct inverted nipples. Therefore, we performed this technique on our patients, but in some cases the patients were not satisfied with the result. They complained of an angular nipple base immediately after surgery and gradual nipple projection loss. However, these patients did not agree for their clinical photographs to be used, meaning that unfortunately there are no clinical photographs in this article.
The technique described herein combines perpendicular absorbable sutures and purse-string non-absorbable sutures. Our surgical method involves first placing a pair of perpendicular sutures using a horizontal mattress suture technique with 4-0 absorbable materi al, followed by a purse-string suture with 7-0 non-absorbable material. The horizontal mattress sutures provide basic support for the maintenance of nipple projection immediately after surgery, and the purse-string suture provides additional strength to maintain projection. Use of a purse-string suture with non-absorbable material prevents the loss of projection with the gradual absorption of the horizontal mattress suture, in which an absorbable material is used. Moreover, the purse-string suture helps to form a nipple base with a more circular shape after surgery.
In the surgical technique presented in our study, 7-0 nylon is used for the purse-string suture, which is finer than the sutures used in previous methods, and only 8 stitches are needed [12,13]. The reduced number of stitches makes surgery simpler than other pursestring suture techniques, thereby reducing the duration of surgery. In addition, the finer thread should reduce the likelihood of the suture material being palpable or exposed after recovery. The strength needed to maintain the projection is reduced by the use of fewer stitches and finer thread, but is compensated for by the use of perpendicular sutures. Combining 2 suture techniques to maintain projection prevents excessive force on the purse-string suture, thereby reducing the risk of reduced blood supply to the nipple [13].
Inverted nipples still present a challenge for plastic surgeons. Our combined use of 2 different suture techniques to provide sustained nipple projection is simple, safe, and reliable. However, the follow-up duration in this study was relatively short, and additional long-term monitoring will be required.

ACKNOWLEDGMENTS

This work was supported by a 2017 education, research and student guidance grant funded by Jeju National University.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Notes

PATIENT CONSENT

Patients provided written consent for the use of their images.

Fig. 1.
Schematic drawing of the operative procedure of Gould et al. [Reprinted from “ Inverted nipple repair revisited: a 7-year experience”, by Gould DJ, Nadeau MH, Macias LH, and Stevens WH, 2015, Aesthet Surg J, 35, pp.156-64. Copyright 2015 by the Oxford University Press. Reprinted with permission].
aaps-2017-23-2-104f1.jpg
Fig. 2.
(A) Four incisions were made at the 12, 3, 6, and 9 o’clock points. The first horizontal mattress suture extended from the 6 o’clock point to the 12 o’clock point. (B) Schematic drawing of the 2 horizontal mattress sutures in a perpendicular direction. (C) The start of purse-string suture placement through an incision at the 6 o’clock position, and reinsertion of the suture through the stitch exit points. (D) Schematic drawing of the purse-string suture.
aaps-2017-23-2-104f2.jpg
Fig. 3.
(A) Before the operation and (B) 6 months afterward.
aaps-2017-23-2-104f3.jpg

REFERENCES

1. Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg 1999;104: 389–95.
crossref pmid
2. Shiau JP, Chin CC, Lin MH, et al. Correction of severely inverted nipple with telescope method. Aesthetic Plast Surg 2011;35: 1137–42.
crossref pmid
3. Lee HB, Roh TS, Chung YK, et al. Correction of inverted nipple using strut reinforcement with deepithelialized triangular flaps. Plast Reconstr Surg 1998;102: 1253–8.
crossref pmid
4. Burm JS, Kim YW. Correction of inverted nipples by strong suspension with areola-based dermal flaps. Plast Reconstr Surg 2007;120: 1483–6.
crossref pmid
5. Chen SH, Gedebou T, Chen PH. The endoscope as an adjunct to correction of nipple inversion deformity. Plast Reconstr Surg 2007;119: 1178–82.
crossref pmid
6. Serra-Renom J, Fontdevila J, Monner J. Correction of the inverted nipple with an internal 5-point star suture. Ann Plast Surg 2004;53: 293–6.
crossref pmid
7. Teng L, Wu GP, Sun XM, et al. Correction of inverted nipple: an alternative method using continuous elastic outside distraction. Ann Plast Surg 2005;54: 120–3.
crossref pmid
8. Yamada N, Kakibuchi M, Kitayoshi H, et al. A method for correcting an inverted nipple with an artificial dermis. Aesthetic Plast Surg 2004;28: 233–8.
crossref pmid
9. Gould DJ, Nadeau MH, Macias LH, et al. Inverted nipple repair revisited: a 7-year experience. Aesthet Surg J 2015;35: 156–64.
crossref pmid pdf
10. McGeorge DD. The “Niplette”: an instrument for the non-surgical correction of inverted nipples. Br J Plast Surg 1994;47: 46–9.
crossref pmid
11. Sapountzis S, Kim JH, Minh P, et al. Correction of inverted nipple with “arabesque”-shape sutures. Aesthetic Plast Surg 2012;36: 339–42.
crossref pmid
12. Peled IJ. Purse-string suture for nipple projection. Plast Reconstr Surg 1999;103: 1480–2.
crossref pmid
13. Kolker AR, Torina PJ. Minimally invasive correction of inverted nipples: a safe and simple technique for reliable, sustainable projection. Ann Plast Surg 2009;62: 549–53.
crossref pmid
14. Cabalag MS, Chui CH, Tan BK. Correction of nipple inversion using a micro-knife and transverse to longitudinal skin closure. J Plast Reconstr Aesthet Surg 2010;63: e627. –30.
crossref pmid


ABOUT
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
AUTHOR INFORMATION
Editorial Office
101-2003, Lotte Castle President 109 Mapo-daero, Mapo-gu, Seoul 04146, Korea
Tel: +82-2-3472-4243    Fax: +82-2-3472-4254    E-mail: ksaps@ksaps.or.kr                

Copyright © 2019 by Korean Society for Aesthetic Plastic Surgery. All rights reserved.

Developed in M2community

Close layer
prev next