ORIGINAL ARTICLE BREAST

Correction of Inverted Nipple with ‘‘Arabesque’’-Shape Sutures

Stamatis Sapountzis • Ji Hoon Kim •

Pham Minh • Young Soo Hwang • Rong Min Baek •

Chan Yeoung Heo

Received: 7 July 2011 / Accepted: 29 September 2011 / Published online: 20 October 2011

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011

Abstract

Background Inverted nipples are a common self-concern

for many women and also a relatively aesthetic problem for

the plastic surgeon.

Methods Many techniques for correcting inverted nipples

have been reported, but none is totally successful. To avoid

recurrence and to attain perfect shape of the nipple, the

authors present a minimal-incision technique supported by

‘‘arabesque’’-shape percutaneous sutures. First, four micro-

incisions about 0.5 cm in size, each the circumference of

the nipple, are designed horizontally. Second, after suffi-

cient releasing of the loose connective tissue beneath the

nipple, two 4/0 PDS sutures are made in perpendicular

directions to increase the support and sustain the tissue

under the nipple and to close the way the nipple inverts.

Results This method was used to correct 22 inverted

nipples of 18 patients classified as grade 3 or 4. The entire

nipple remained everted and symmetric during a follow-up

period of 3 months to 1 year except in two cases of

recurrence during the early postoperative period due to a

loose knot.

Conclusion The described technique is simple, safe, and

reliable, providing sustained results over the long-term

follow-up period with a high rate of stable eversion and

patient satisfaction.

Keywords Arabesque-shape suture � Inverted nipple

Inverted nipple refers to a condition in which the entire

nipple or a portion of it is buried inward toward the lac-

tiferous duct. Inverted nipples are a common source of self-

consciousness and concern for many women. It has been

estimated that from 2 to 10% of women are affected by

inverted nipples presenting uni- or bilaterally with varying

degrees of severity, [1–3]. This deformity has been linked

to various aesthetic, functional, and psychological prob-

lems and can be troublesome in breastfeeding.

Inverted nipple can result from congenital or acquired

causes. A large majority of cases are attributable to con-

genital causes.

Many different surgical techniques to correct inverted

nipple have been described such as dermal and dermo-

glandular flaps, endoscopic release, internal suture, con-

tinuous traction, and artificial dermis, suggesting that no

technique is totally successful [4–10]. The diversity of

procedures denotes the lack of a single technique that

reliably results in durable, sustainable correction for this

common problem.

To avoid the recurrence of nipple retraction and to attain

the perfect shape of the nipple and areola tissue, we present

a technique using a minimal incision supported by percu-

taneous sutures that provides sustainable long-term cor-

rection of inverted nipples.

After pulling out the inverted nipples, four micro-inci-

sions about 0.5 cm in size, each the circumference of

S. Sapountzis � J. H. Kim (&) � P. Minh �R. M. Baek � C. Y. Heo

Department of Plastic and Reconstructive Surgery, Seoul

National University, Bundang Hospital, 166 Gumiro, Bundang,

Seongnam, Gyeonggi 463-707, Republic of Korea

e-mail: shymoon78@gmail.com

S. Sapountzis � Y. S. Hwang

Lael-Clinic, Incheon, Republic of Korea

R. M. Baek � C. Y. Heo

Department of Plastic and Reconstructive Surgery,

Seoul National University, College of Medicine,

Seoul, Republic of Korea

123

Aesth Plast Surg (2012) 36:339–342

DOI 10.1007/s00266-011-9827-4

nipple, are designed horizontally. Two sutures then are

performed in perpendicular directions to increase the sup-

porting and sustaining tissue under the nipple and to close

the way the nipple inverts. The way we apply the percu-

taneous sutures resembles the arabesque shapes in Islamic

and European decorative art. With this method, we had

sufficient material and tissue not only to fill the dead space

beneath the nipple but also to drive up the nipple. The

manipulation of postoperative traction is simple and useful.

The procedure leaves minimal scars and involves no

recurrence of inversion.

Patients and Methods

Since 2010, 22 nipples in 18 patients have been corrected

by the described method. According to the criteria of Han

and Hong [11], all the nipples were classified as grade 3 or

4. The mean age of the patients was 26 years (range,

20–37 years), and all the inverted nipples were congenital

in origin. All patients attended routine follow-up visits

approximately 3 to 12 months postoperatively. If no

problems were encountered, the patients were discharged.

The operation is performed with the patient under local

anesthesia only using 1% lidocaine with 1:200,000 adren-

aline. The proposed base circumference of the nipple is

marked by two sets of opposite points: 12 and 6 o’clock

and 3 and 9 o’clock. After infiltration of local anesthetic

solution, a temporary-traction 4/0 silk suture is placed to

evert the nipple and maintain manipulation. With the nip-

ple everted to its desired position, four micro-incisions of

about 0.5 cm each were made using a no. 11 blade exactly

at the four aforementioned points. Next, the erector muscle

of the nipple and the lactiferous ducts were dissected and

sectioned by a small scissors. In the internal wall of the

cylinder of the nipple, we then use a 4/0 PDS suture for the

first couple of micro-incisions: at 6 and 12 o’clock. A loop

stitch with an arabesque-like shape (Fig. 1) is made as the

suture is coming in and out of the dermis. The inner knot is

placed within the interior of the cylinder of the nipple. The

second suture for the 3 and 9 o’clock set is made exactly

the same way (Figs. 2, 3). Finally, the cutaneous incisions

are closed by 6/0 nylon, and a ‘‘donut’’ dressing is applied

to maintain the eversion of the nipple. The simple donut

dressing is used to avoid direct compression of the nipple

until 7 days after the operation.

Results

No complications such hematoma, bleeding, or nipple

necrosis were reported. During the follow-up period

(3 months to 1 year), all the nipples remained everted

(Figs. 4, 5) and symmetric except in two cases of recur-

rence during the early postoperative period due to a loose

knot. Also, in these two cases, after the required reopera-

tion, the result remained stable during the follow-up period.

No alteration in nipple sensation was reported.

Discussion

Schwager et al. [1] suggests that an inverted nipple results

from failure of the underlying mesenchyme to proliferate

Fig. 1 Four 0.5-mm incisions are made at 12, 3, 6, and 9 o’clock

points. The arabesque-shape sutures are applied on the nipple’s base

Fig. 2 a A temporary-traction 4/0 silk suture is placed to evert the

nipple design of the skin incision. b Skin incisions are made using a

no. 11 blade. c The erector muscle of the nipple and the lactiferous

ducts are dissected and sectioned by a small scissors. d Placement of

the first suture

340 Aesth Plast Surg (2012) 36:339–342

123

and push the nipple out of its developmentally depressed

position. Axford [12], in 1889, was the first surgeon to

describe a purse-string suture, along with some excision of

skin. Since then, modifications of this technique have been

suggested. Together with a concern that the purse-string

method may affect the blood supply to the nipple, a new

group of techniques has emerged aimed at supplementing

soft tissue bulk beneath the nipple. Over the years, a

number of different methods have been used including

dermoglandular flaps, auricular cartilage, and alloplastic

material such as synthetic supports to nipple piercing

[4–10].

With the described technique, the aims of inverted

nipple reconstruction have been achieved. After sufficient

release of the block of loose connective tissue beneath the

nipple, arabesque-shape sutures are applied to create a

stable ‘‘floor’’ on the base of the nipple to keep it everted

and cylindrical. A low risk of ischemia postoperatively is

considered to distinguish this method from the purse-string

suture. When the purse-string method is applied, the dead

space pullout under the nipple may remain empty, some-

times causing ischemia. An absorbable thread with an inner

knot is used as a filling material to ensure that the base of

the nipple is filled up and to keep the nipple everted.

Many previous methods using artificial material to fill

up the base of the nipple may have to deal with extrusion

for a long time. The other techniques using dermal-cuta-

neous flaps created many scars and deformities of the

nipple and areola finally. Despite the four small micro-

incisions and the small loss of nipple basement volume

compared with the method of Serra-Remon et al. [7], the

described method remains safe. The scars are minimal, and

cosmetic expectations are well achieved. During the per-

formance of this procedure, lactiferous ducts may be

affected, so young female patients should be advised about

future breastfeeding capacity.

Conclusion

The simple, safe, and reliable method using arabesque-

shape sutures is an ideal procedure for correction of

severely inverted nipples. It provides a good nipple shape

and minimizes the risk of recurrence.

References

1. Schwager RG, Smith JW, Grey GF et al (1974) Inversion of the

human female nipple, with a simple method of treatment. Plast

Reconstr Surg 54:564

2. Park HS, Yoon CH, Kim HJ (1999) The prevalence of congenital

inverted nipple. Aesthet Plast Surg 23:144e6

Fig. 3 a, b Completion of the first suture from the 3 o’clock point to

the 9 o’clock point and then back to the first point. c Tying of the

second knot from the 6 to 12 o’clock points. d The final result

Fig. 4 Before the operation and 6 months afterward. Inverted nipple

correction is performed simultaneously with transaxillary breast

augmentation

Fig. 5 Before the operation and 12 months afterward

Aesth Plast Surg (2012) 36:339–342 341

123

3. Alexander JM, Grant AM, Campbell MJ (1992) Randomized

control trial of breast shells and Hoffman’s exercises for inverted

and nonprotractile nipples. Br Med J 304:1030

4. Lee HB, Roh TS, Chung YK et al (1998) Correction of inverted

nipple using strut reinforcement with deepithelialized triangular

flaps. Plast Reconstr Surg 102:1253–1258

5. Burm JS, Kim YW (2007) Correction of inverted nipples by

strong suspension with areola-based dermal flaps. Plast Reconstr

Surg 120:1483–1486

6. Chen SH, Gedebou T, Chen PH (2007) The endoscope as an

adjunct to correction of nipple inversion deformity. Plast Rec-

onstr Surg 119:1178–1182

7. Serra-Reom J, Fontdevila J, Monner J (2004) Correction of the

inverted nipple with an internal 5-point star suture. Ann Plast

Surg 53:293–296

8. Teng L, Wu GP, Sun XM et al (2005) Correction of inverted

nipple: an alternative method using continuous elastic outside

distraction. Ann Plast Surg 54:120–123

9. Yamada N, Kakibuchi M, Kitayoshi H et al (2004) A method for

correcting an inverted nipple with an artificial dermis. Aesthet

Plast Surg 28:233–238

10. McGeorge DD (1994) The ‘‘niplette’’: an instrument for the

nonsurgical correction of inverted nipples. Br J Plast Surg

47:46–49

11. Han S, Hong YG (1999) The inverted nipple: its grading and

surgical correction. Plast Reconstr Surg 104:389

12. Axford WL (1889) Mammillaplasty. Ann Surg 9:277

342 Aesth Plast Surg (2012) 36:339–342

123