In our video series, we chronicle a lot of these wide-awake operations that I perform. But one that’s gaining popularity, at least in my practice, is nipple eversion. Nipple eversion is something that I’ve always done, on awake patients, unless they want it in conjunction with other procedures.
When you have a nipple that’s inverted, it means it points inward instead of outward. There are different grades of that – it could be something as simple as a reaction to cold, and it corrects itself.
But then there are other cases where it’s so severe that even with retraction, there’s such fibrosis or tissue pulling it inward, that it needs surgical intervention. The patient that we’re going to present in today’s video, is a woman who not only has bilateral or two-sided nipple inversion, but also asymmetry of the nipple-areolar complex. We all call it the nipple, but it’s really the whole complex, not only in position to the sternal notch but also in terms of diameter.
So this is an interesting case in a lot of ways.
Number one, we are dealing with a patient who is willing to undergo an awake mastopexy procedure. And number two, we’re dealing with a patient who is willing to have it done at the same time as nipple eversion surgery. She’s also a good sport for allowing us to film this.
The operation begins by everting the inverted nipple. I use a heavy gauge suture, permanent suture to evert the nipple because I feel like it is less injurious to the underlying tissue and also allows me to have great access without any tethering of the nipple skin itself. When I do this, I feel a lot of resistance; as you can see in the video, I can’t even evert the nipple without using instruments.
As we place the suture into this heavily inverted nipple, immediately we’re putting all of the fibrosis – which is scar tissue – and the lactiferous ducts, on the stretch. And when you do that, it allows a needle, in this case, percutaneously to divide these areas of fibrosis. The endpoint of doing something like this is that when I finally release the sutures that are holding it out, the nipple either is flat or everted at baseline.
Of course, scar tissue does tend to recur. And unfortunately, even in the best-executed cases, some degree of recurrence is the norm and not the exception. But I do place these purse-string sutures through the cardinal points of each nipple as a way of preventing recurrence of inversion.
Other things that you can do include splinting the nipple to an everted state, or even injecting things like filler to keep the nipple everted. In cases as extreme as this, however, sometimes an end goal of having a small amount of eversion is acceptable. And in many cases, it is preferred, as women don’t always want to be standing at attention. So this operation is a very simple operation on one hand, yet it is difficult to promise that complete nipple eversion forever is going to occur.
As you can see, I can also pair this with other wide awake procedures.
This case is particularly interesting because I’ve paired it with a mastopexy, which is a breast lift, but rather than lifting the nipple as I’ve done in every other case in my career, I’m actually lowering the nipple in this case. To do this safely with a good scar, you’ve got to literally separate the nipple-areolar complex and the underlying breast tissue from the surrounding breast skin. That way you can freely mobilize it without putting undue tension on any part of the scar.
As you may recall, I had issues with the fact that this nipple-areolar complex was not only higher than the contralateral side, but it was also smaller. It almost looked somewhat underdeveloped, and this may be related to the underlying issues associated with the nipple inversion.
At this point, I’ve completely freed up the nipple-areolar complex and the underlying breast mound from the surrounding skin.
Only now can I in an attention free manner, bring the edges back together to a more widened position and a more symmetric position with the other side. A five-layer closure ensues, and putting more layers in this tissue, not only allows load sharing on multiple levels, but it prevents things like warping and recurrence. Also, it allows for the best scar, because the best scar is the one that has the minimum tension.
At the end of the operation, I placed in an invisible plastic surgery stitch that minimizes track marks on the outside of the nipple-areolar complex and a splint.
As you can see, we can achieve quite a bit in an awake procedure that takes less than an hour. The beauty of this operation is that you don’t have to deal with the ramifications of general anesthetic agents, but also it allows patients to really feel one with their surgeon, and to feel like they’re a part of the process, which is appreciated by most patients.
This operation did, as you can see, allow me to correct for much of the asymmetry in this woman’s breasts. With respect to the nipple eversion, it can be very challenging. There’s a lot of risks associated with the procedure; the most common risk is relapse or re-eversion of the nipple.
We can do a lot of things to try and correct that, but for this and other potential complications, read our blog for more information. Thanks so much, please be sure you subscribe.
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