<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

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