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The techniques described herein were developed to recreate a nipple-areolar complex that avoids the inherent disadvantages of labial and "nipple-sharing" techniques. We have presented a practical, reliable, one-stage method that utilizes other tissues, and has evolved through experience with 14 cases.
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Twenty-two primigravida women who planned to breastfeed began conditioning their nipples six weeks before their expected delivery date by nipple rolling twice a day for two minutes each time; providing gentle friction against the nipple with a terry cloth towel for 15 seconds once a day; and nipple airing for two hours a day, allowing outer clothing to rub against the nipple. Each woman served as her own control, conditioning one nipple but not the other. No nipple ointments or soap were used on either nipple during the course of the study. Each woman was given instructions on breastfeeding techniques to be used after delivery. The women completed two checklists: One revealed how consistently they followed the nipple-conditioning regime; with the other, they rated nipple pain on each breast, for every nursing, during the first five days postdelivery. Ratings were: 1--negligible pain or no pain, 2--definite pain, 3--extreme pain. Seventeen women successfully completed the study. Effect of skin color on the amount of nipple pain was also investigated. The prenatal nipple-conditioning regime significantly reduced the amount of total nipple pain experienced during the first few days of breastfeeding. The amount of extreme pain experienced on the conditioned nipple was significantly (p less than .01) reduced compared to the control nipple. Fair-skinned women reported more nipple soreness on unconditioned nipples, and olive-complected women reported significantly (p less than .01) less nipple soreness on unconditioned nipples.
The adenoma of the nipple (syn.: erosive adenomatosis, papillary adenoma, florid papillomatosis) is a benign tumour of the major nipple ducts and presents chiefly as an eroded oozing and crusted lesion with serous or sanguineous discharge of the nipple or as an indurated nodule. The lesion can be mistaken clinically for Paget's disease of the nipple. The correct diagnosis, however, can easily be established by an incisional biopsy. Pathohistologically, the tumour displays adenomatous and papillomatous proliferation of the milk sinus epithelium. An outer myoepithelial and inner columnar epithelium layer can mostly be distinguished. Atypical cellular features are lacking. Keratin cysts near the mostly eroded epidermal surface are are additional characteristic signs. The resection of the nipple is the therapy of choice. The adenoma of the nipple is no precancerous condition. A typical case of adenoma of the nipple from a 54 year old woman is presented.
Benign circumscribed cutaneous lymphadenosis of the areola of the nipple (Bäfverstedt's disease) occurs in children and adults. We observed 11 cases: 3 men, 3 children and 6 women. The areola undergoes rapid swelling and becomes red. At times the nipple itself is included. Unilateral enlargment and distortion of the nipple area becomes apparent. Sometimes this is associated with a tumor-like infiltration of the retro-mammillary tissue. In Contradistinction to Pagets disease of the nipple and to a mammillary adenoma there is no eczema and no ulceration. The clinical features and the typical pruritic course establish the diagnosis. Healing is spontaneous, but protracted. The aetiology is probably of an inflammatory nature. Treatment with short courses of antibiotics and anti-inflammatory agents resulted in a faster reduction of the cutaneous signs and corroborated the clinical diagnosis. We consider surgical treatment as unnecessary because circumscript benign lymphadenosis of the nipple area has a harmless course.
Recommendations for the care of the nipple postpartum are numerous and variable. Cracks and fissures in the nipple must be prevented to prevent mastitis. A randomized prospective study shows that it does not matter whether powder or ointments or nothing is placed on the nipples after nursing. The incidence of cracked nipples is not significantly changed by theses measures. For the prevention of mastitis the general measures for the prevention of hospital acquired infections are necessary and more important than modifications of the nipple care.
In a series of 51 continent reservoir ileostomies nipple-valve insufficiency developed in 15 patients who were examined radiographically to find the cause for the loss of continency. The radiological diagnosis was confirmed at reoperation. The causes for nipple-valve insufficiency were a total or partial disappearance of the nipple-valve by sliding of the invaginate (7 cases) and dislocation of an undamaged nipple out of the reservoir (8 cases). In these groups the radiological diagnosis was compatible with the operative findings in all but one case. At reoperation a fistula in the nipple-valve was found in 3 cases, but in no instance had this been diagnosed radiologically. A correct preoperative diagnosis is valuable, especially in cases of dislocation, where a danger exists that the real mechanism of valve insufficiency may remain obscure at operation.
Modified radical mastectomy with transplantation of the nipple in the groin for possible breast reconstruction was performed in a patient. Carcinoma developed in the transplanted nipple. Careful pathological examination of the breast tissue from the site of excised nipple should be carried out. In patients showing presence of tumor cells at that site, nipple transplantation may be deleterious.
In 40 breasts with primary carcinoma, the nipple and areola were cut horizontally in order to investigate the frequency of intraductal and invasive cancer. In 20 of these breasts the nipple and/or areola were found to be involved at a depth of 1 cm (50%; 95% confidence limits: 33.8-66.2%). Eleven neoplasms were purely intraductal, eight intraductal as well as stromal, and only one purely stromal. By means of clinical or physical findings, it was not possible to select the breasts in which the nipple and/or areola were not involved. It is concluded that the general use of surgical methods preserving the nipple and areola in treating breast cancer leaves a focus of invasive or intraductal carcinoma in about half the patients. The implications of this are not known.
The records of all patients in whom a mastectomy was performed for carcinoma of the breast at this clinic during a recent two year period were reviewed, and the gross specimens were re-examined to study the incidence of cancerous involvement of the nipple and areola and related local clinical findings. Cancer was present in the nipple or areola, or both, in 12.2 per cent of the specimens. When the nipple and areola were clinically normal, involvement of the nipple and areola by carcinoma was rare if the primary tumor was less than 2 centimeters in diameter and was not situated behind the areola.
Two hundred cases of carcinoma of the breast were examined to determine the extent of nipple involvement. Carcinoma was present in 8 percent of the specimens. Fourteen of the 16 nipples which contained tumor were macroscopically abnormal in reappearance--being either ulcerated, retracted, or attached to an underlying indurated mass. Clinically normal niples are not likely to contain carcinoma. A frozen section across the nipple base should also be used as a safeguard if the nipple is to be used in reconstruction.
In the re-implantation of a ureter into the bladder, vesico-ureteric reflux can be prevented by a ureteric nipple alone, provided the nipple is at least 1.5 cm long. This eliminates the need for an oblique ureteric entry or a submucosal tunnel. Longer nipples may be used although they may lead to difficulties with catheterisation. Reduction in the length of the nipple frequently occurs later.
An unusual case of basal cell carcinoma of the nipple from a 66-year-old women is presented. It is important to differentiate this lesion from other nipple-areolar tumors, especially Paget's disease. This report reviews the literature and adds a case that represents the third reported instance of this tumor of the female nipple.
The inverted nipple has been attributed to hypodevelopment of both nipple and areolomamillary musculature. A number of procedures have been devised to correct this deformity for the purposes of nursing and also for cosmesis. Excision of the entire areola, myotomy of areolomamillary bundles, and partial areolar excision in apposing quadrant triangles have all been used. An operative technique has been designed reflecting some of the older methods and an innovation utilizing areolar V-Y plasties and purse-string sutures to the nipple base for support. This method avoids excision and consequent extensive scarring of the areola. This procedure has been found to have satisfactory functional and cosmetic results in clinical trials to date.
A technique utilizing the inferiorly based dermal pedicle nipple-areolar flap is described. The advantages of this technique are:(1) predictable breast shape based on preoperative markings; (2) direct visibility of all areas for ease of resection and hemostasis; (3) retention of normal nipple duct connections; (4) no impairment of subjective sensation; and (5) adequate blood supply. This technique has particular application in younger women, in whom nipple sensation is quite important. The interruption of the intercostal nerve branches is usually limited because of the thickness and width of the inferior pedicles. Utilizing our modifications of the technique originally described, this versatile flap can now be used routinely in reduction mammaplasties requiring the removal of either small amounts (200 gm) or quite large amounts (2,500 gm) of tissue with consistently satisfactory aesthetic results and excellent patient satisfaction.
A clinical and galactographic investigation was carried out on 103 patients with hematic, serous-hematic, and serous nipple discharge. The age of the patients ranged from 18 to 72 years. A single papilloma was found in 20 cases, diffuse papillomatosis in 2 cases, atypical ductal hyperplasia in 8 cases, and ductal carcinoma in 4 cases (3 of these were infiltrating and 1 was noninfiltrating associated with a diffuse papillomatosis). Mammography gave no indications of carcinoma in any of the 4 cases. In the remaining 49 patients, pictures of ductal hyperplasia, periductal mastitis or sclerosis, sclerosing adenosis, or ductal ectasia were observed. The various types of lesions were often associated. Lacunae, stenosis, or occlusion of the ducts, evidenced by galactography, correlated well with the histologic findings of proliferative lesions of the ductal epithelium. Nevertheless, in practice, it should be the type of discharge that indicates surgery rather than galactographic or cytologic data, which appeared to have little diagnostic value. The frequency with which preneoplastic (or limit) lesions, and also nonsuspect carcinomas were found in patients with a significant nipple discharge confirm the importance of this symptom for a secondary prevention of early diagnosis of mammary neoplastic lesions originating from galactophorous ducts. Finally, complete resection of the galactophorous ducts must be considered as the best treatment in all patients with a suspicious nipple discharge that requires surgery.
Various techniques of reconstruction of the nipple-areola complex are reviewed. An analysis of the criteria for an aesthetically pleasing nipple-areola complex is made. Symmetry appears to be the single most important factor in achieving the objective. More than color, texture, or the amount of projection, symmetry appears to provide the best overall result. Those techniques that treat areolae in identical fashion are more likely to produce symmetry. Reducing the normal nipple size not only provides donor tissue but reduces the problem of projection, which otherwise interferes with achievement of symmetry.
Patients with massive macromastia, or severe ptosis, should be candidates for a reduction mammaplasty by the inferior pedicle transposition technique, instead of by free nipple and areola grafting. With the inferior pedicle technique the blood supply to the nipple and areola remains generous, coming from the entire width of the inframammary fold. By using a keyhole skin flap pattern, a conical breast shape is achieved when the medial and lateral skin flaps are brought together as a skin brassiere. The methods seems safe and simple, and the results have been satisfactory. An unexpected benefit has been the excellent postoperative sensation of the nipple, areola, and the skin of the breasts.