<Mom of a 2 month old had a severly damaged left nipple that became
infected
with staph. Now the nipple is nearly completely healed. Since just before
the infection began, that side has been pouring milk.>

The explanation for the copious milk supply is obviously the constant
loss, which is removing milk thoroughly and frequently, which are the key
factors driving supply.

As to why it can leak so freely, has anyone used a magnifying glass to
inspect all around the base of the nipple where it meets the areola?

Sounds as if a fistula into an anteriorly and shallowly placed milk sinus
may have formed as a result of whole process involving the severely
damaged left nipple, even if it began before the infection was obvious
enough to be diagnosed.

During the time it was damaged/infected, it was no doubt excruciatingly
painful. I have many times seen mothers with such pain, when attempting
to latch, reflexively do the fastest thing they can to "unlatch" - they
move the baby away quickly while simultaneously placing sharp traction on
the breast to pull the nipple out without taking the time to break
suction!

Severe traction can cause a tear in what seems to be an "Achille's heel"
area, the skin just at the junction between the nipple and the areola,
just at the base of the nipple.

Perhaps the outer skin here is no thinner than on the rest of the areola,
but when the baby is hanging on to the nipple button for dear life, this
seems to be the area sustaining most torsion and traction, and therefore
at risk for tearing.

If this particular mother had even one milk sinus in that shallow area,
it too may have sustained a microscopic tear.

One of Dr. Hartmann's graduate students who did ultrasound studies of
actual nursings suggests that sinuses do not seem to be as clearly
delineated as the "bicycle-spoke" like diagrams we see in texts.

On ultrasound, a sinus seems to appear to be a collecting area where at
least two ducts converge. This might mean that at least 2 lobes of that
breast would be under constant extra stimulation from the leakage.

I was fascinated by a small factoid I read in pathology and surgery
literature. Under microscopic exam, histologists find a distinct change
in the type of cells deeper inside this junctional area.

A single layer of a type called "squamous (flat) epithelium"  lines the
galactophores inside and leading out of the nipple (and this cell type
continues on over the outer skin of the nipple and areola).

Abruptly, at the internal junction of the galactophore with the milk
sinus, a two layered cell design takes over. (This same pattern continues
in the ducts, ductules and alveoli.)

The cells of the interior layer are "columnar cells", which I gather, can
change their shape somewhat when distended.  The exterior layer of cells
are "myoepithelial cells", which respond to oxytocin during the MER.

Squamous epithelial cells tend to retain their shape and do not stretch
as easily as the columnar cells are designed to do. Perhaps this boundary
in the cell types explains why there is a certain comparative resistance
to leakage from the intact sinuses despite gravity.

Here is a copy of an exchange of letters about a mother with a very
similar complaint from the Lactnet archives:
<To: [log in to unmask]
>Subject: Leaking milk
>Date: Sat, Nov 25, 2000, 2:59 AM
>
> <As a result of poor latching and the yeast early on I
> developed pretty bad abrasions - well they were more like gouges to be
> honest - on both nipples.>
>
> <It left a "hole" at the
> base of my mipple. It looks as though a push pin was stuck in it. The
> main
> frustration is that whenever I have let down (which seems to be a lot
as
> I
> still nurse frequently during the day and even more at night) I have a
> steady stream of milk flow through the hole. It soaks shirts, bed
> clothes,
> my daughters clothes. It sprays in her face, on the floor... it drives
me
> crazy. I'm guessing I lose 6-8 ounces a day through it.>
>
> It sounds to me as if the damage to your nipples was partly a result of
> tearing, and was severe enough to go all the way through several layers
> of tissue directly into a milk sinus that happens to lie particularly
> forward in the breast, closer to the nipple. (Many mothers I have
> examined have their milk sinuses further away from the base of the
> nipple, perhaps 3/4" to 1 1/2".)
>
> It seems to have created a fistula to the surface that has no natural
> resistance such as the normal ductal pathway through the nipple tissue.
> (Each such ductal pathway through the nipple is narrower, hemmed in by
> the longitudinal muscles of the nipple  and lined with a different kind
> of cells which are not as elastic as the sinuses themselves.)
>
> This sounds like a vicious cycle, as the more milk you lose through the
> fistula, the more that breast (or more specifically, the lobe(s)
> communicating with the fistula) produces, and the general oversupply
> might be making the milk ejection reflex that much stronger.
>
> This sounds like a very simplistic question, but what happens when you
> apply direct pressure to the area when you are not nursing? Can you
sense
> when you are going to have a MER? Or is it possible, while nursing, to
> use a finger tip to press on the duct behind (above) the fistula to
slow
> down the squirting in your daughter's face and the general milk loss,
at
> least some feedings when you are awake?
>
> Have you considered consulting a plastic surgeon for a second opinion?
> Not that you could necessarily expect any more support for continued
> nursing.
>
> But some articles about the cosmetic correction of inverted nipples
that
> I have read in their journals leads me to believe that they are very
> knowledgeable about the microanatomy of the nipple-areolar complex.
>
> Direct vision microsurgery would sound like a better idea than blindly
> directed ablation with laser surgery. (Not that I am well-read on
either,
> but it would be important not to harm other sinuses.)
>
> Perhaps part of the consultation might be discussion of ductography by
a
> radiologist by ultrasound or by x-ray to identify whether this is in
fact
> a fistula, and just exactly where the tributary duct(s) are located.
> (Just imagineering here!)
>
> Perhaps a surgical repair of a fistula and the sinus might be possible?
> Or at least a tying off of the duct(s) leading to that particular
sinus,
> which would lead to involution to the lobe(s) of the breast that were
> feeding into it. But it sounds as if you have plenty more lobes doing
> more than an adequate job of production.
>
> Hope these musings might help.
>
> K. Jean Cotterman RNC, IBCLC
> Dayton, Ohio USA

Hi, Thanks for your response. Yes the "finger in the dyke" approach does
work to some extent in terms of stopping the spray in her face when she
pulls off at let down but not for any other situations. I must just
continually leak - or at least leak frequently - as it doesn't work well
for
keeping me dry throughout the day and night. I used to feel the MER
strongly
but don't as much anymore. Also what seems to happen is if I apply
pressure
it will work for the "stream" but I'll still leak continually after. That
breast is easily engorged so I think your theory on the vicious cycle of
milk production is correct.
I would be interested in talking with a plastic surgeon but would like to
have more info before doing so. I guess that's why I put this question to
Dr. newman, just to see if anyone had any similar experiences to relate.
I am open to nursing my daughter into her toddler years so I would like
to
do something if it's possible.>

Perhaps e-mailing the mother in the above post might get some ideas from
her subsequent experience.

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

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