<<What causes these indentations in the nipple surface?
 The nipple surface itself is concave, and difficult to heal probably due to
folding on itself?  Is there a way to fix that?>>

Without having seen this first-hand, I would guess this is a variation of 
development I call "invagination of the nipple...I cannot remember where i 
picked up the term.  It is a "slit" or "dimple" in the center of the nipple, 
and if there is tissue damage inside, it can be very difficult to heal 
unless you find a way to keep the inside of the dimple exposed to air. 
Sometimes a breast shell with a small opening will do the trick.  ALso, have 
mom apply ointment to the raw area inside of the dimple after feedings to 
try and keep the raw "walls" from trying to "heal" together, then get ripped 
apart at the next feeding.

On the other hand, if it is more of a "crater" than a slit, it could be the 
tissue damage from her previous babies altered her anatomy.  If it is a 
wider "crater", she should be able to position it against the breastpad in 
the "open" position until healed.

Hope this is helpful-

Kathy Leeper, MD, IBCLC 

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