Dr. Mimi, I may be late in reading your request. These thoughts occur to me (with my special interest in reading up on nipple development and anatomy.) <I have a mom with "bulbous" nipples with very tiny aerola (almost mushroom like in appearance). She is day 2 post partum and had a C-section due to fetal distress.> Connective tissue of the nipple and areola can be the radial and circular muscles of the nipple-areolar complex and/or just plain fibrous connective tissue. I think a lot depends on which it is in this case. Also, there is a very rich plexus of lymphatc vessels under the skin in that area. Due to the surgery/IV's etc., Reverse Pressure Softening (see archives) of the areola and breast just beyond it during the first 7-10 days may be one helpful component. If this were my client, I would want to palpate where the milk sinuses are. I did see one mother (of Nigerian descent) who actually had some milk sinuses in the (rather bulbous) nipple, as pulsed compression of the nipple button actually produced continued droplets of milk much as one might get in compressing another mother's areolar sinuses. In such a case, it might not be necessary to feel compelled to get as much tissue in as usual, though the potential for pinching trauma is still plenty. Secondly, I think it's definitely to this mom's advantage to have a careful explanation of the MER, and the fact that the nerves that trigger it under the nipple and in the chest/breast wall can be stimulated manually. (I particularly like the Marmet method and LLL puts out an illustrated sheet demonstrating and explaining it.) IME it takes about 2-3 full minutes for the stimulus to complete the neurohormonal arc to the point where milk issues from the tip of the nipple. Veterinary references frequently refer to this as the most powerful force in moving milk from the glandular area forward. I think we need to cultivate a greater appreciation of that in helping mothers understand and manage their situations. In this situation, this would shorten the actual time baby needed to be laboring with the nipple by 3 minutes each time. I think this, plus use of Paula Meier's work of effectiveness of a flexible nipple shield with premies (if you can find a shield large enough) might be one thing to try. This is likewise a case of relative imbalance between the size of the mouth and size of the nipple (oroboobular disproportion) that time and growth of the infant's mouth may cure. And by all means remember breast compression as explained by Jack. Hope this offers some help. Jean ************ K. Jean Cotterman RNC, IBCLC Dayton, Ohio USA *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html