I am reluctant to try and comment over email...but will try.

I cannot come to terms with a physiologic reason why skin would "grow over" 
the nipple pore.  I agree that an "old", recurrent bleb can start to look 
like that, but I can't believe that is the initial mechanism that gets it 
all started.

I can't remember where I heard the theory, but what makes the most sense to 
me based on what I see is that the duct wall gets damaged (from poor latch 
or excessive pump suction) and the milk actually dissects (or burrows) out 
into the tissue surrounding the duct and then can't get out.  The mom 
describes excruciating pain, which seems way out of proportion to what you 
see.  I attribute this to stretching of the duct walls near the opening, 
which stretches the sensory nerves, much like a very full bladder feels.  It 
makes sense to me that the wall of the duct would try and "heal" after 
lancing with the needle, requiring repeat lancing.  Often these ductal pores 
never look the same again...often they appear much wider, or "dilated".

It is harder to explain the ones where the plugged duct seems to come before 
the bleb...

I wish someone would biopsy these and tell us what is REALLY going on!!

Kathy Leeper, MD, IBCLC 

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