It's not really research,but I have found that the more a mom "needs" the shells, the less likely they are to work for this reason:  I find that they can slip in the bra so that the opening is no longer centered around the nipple and the shell can be pressing the nipple instead of at the base of the nipple which is supposed to be the way they work.
Regarding the Hoffman technique, have you noticed how similar it is to Reverse Pressure Softening?  Not exactly the same, but is it possible it was based postpartum effectiveness and what it was doing was not "loosen" the tissue but relieve the edema?  Postpartum breast edema can be easily confused with flat or inverted nipples if one only goes by the outward appearance.  I can't count the number of times a nurse would report that a mom had flat nipples, but when I would ask if they looked that way during the pregnancy, mom would say "no".  Then on observation, it would be areolar edema instead.

Winnie

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