Susan,

When Jan originally posted about her client, I answered her that I didn't
think it was possible for nipples not to have openings, since the
embryology of breast development begins from the outside in.

I have gone back and done further reading, and I see how your explanation
might be possible on the basis of the fact that the outer embryonic layer
of the breast grows inward as solid cords into the middle embryonic
layer, eventually giving rise to the glandular tissue. About halfway
through pregnancy, central canals begin to form midway in the length of
each cord, proceding in both directions: inward toward the future
glandular area, and outward, to eventually pierce the nipple.

The nipple itself begins in an inverted position and near term, becomes
everted by growth of connective tissue beneath it. One wellknown textbook
on breast surgery has a chapter on blunt ducts, which end blindly without
ever forming any lobular tissue at their end. They are apparently very
common under the microscope. It sounds as if blunt ducts might be the
result of canalization that did not finish its progress toward the inner
parts of a breast.

Perhaps it is just as possible for the process of canalization proceeding
outward to stop before it reaches the nipple, perhaps bringing about the
situation you describe.

I have read that this canalization process is supposedly due to placental
hormones. This didn't make sense to me, since placental hormones are
present from the beginning till the end of pregnancy. But perhaps the
receptors to those hormones might not develop till the time for
canalization to occur. At any rate, it would be interesting to find out
if this woman were herself born extremely prematurely, since an extremely
premature baby would miss exposure to placental hormones that are
supposed to trigger fetal breast changes in late pregnancy.

I don't know if any treatment is possible surgically if this were a
developmental phenomenon. I imagine it would be impossible to "drill"
openings through the nipple and downward through the cords to the lobular
tissue. But between pregnancies, if accurate diagnosis were desired, I
wonder if a radiologist would be able to cannulate the nipple to perform
ductography on such a breast to see if, and how far, any ducts extend
inward from the nipple. Perhaps that would be more revealing than just
ultrasound visualization of the tissue.

I imagine this phenomenon would be very frustrating, as well as
uncomfortable for the mother, and for the LC, too, for that matter.

Jean
********
K. Jean Cotterman RNC, IBCLC
Dayton, OH, USA

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