Heidi,
I have a special interest in inverted nipples. Over a period of 3 decades
I have at least 4 unpublished case histories, complete with closeup
photography.
There are many degrees of inversion, but since your friend has never been
pregnant, I would say she is using the term much less loosely than it is
used in reproductive HCP circles.
There are different kinds of terminology in use, but the terminology that
makes the most sense to me is the classification that I saw in the
plastic surgery literature: 1) Invaginated 2) Umbilicated.
1) Invaginated nipples were never "raised" by adequate development of
underlying tissue during late fetal life. (We all begin embryologic and
fetal development with a downgrowth of epithelial tissue, the center of
which begins to descend temporarily in fetal life to start forming the
basis for later ducts).
The appearance of an invaginated nipple is of a fairly tight (my own
personal observation) opening in the circular areolar muscles leading
into a pit. The surface skin of what was meant to be the nipple simply
lines the developmental pit.
IME, there is no actual nipple "button", or at least, a very tiny,
internal protrusion that one might have to have a "scope" to actually
see. The milk ducts/sinuses that develop later in early neonatal life,
puberty, and pregnancy seem to simply empty into this pit.
One mother whom I helped (20+ years ago) had one invaginated inverted
nipple. Despite the use of a hand pump (with a shell-like insert over the
pit) for 10 minutes 4x daily from 6 months of pregnancy onward, no
visible nipple was ever seen. 2 of her aunts, her mother and her
grandmother all had this same condition, so I presume it was genetic.
The milk sinuses seemed to be buried so deeply beneath the pit that I
could not palpate them pre or postnatally. Perhaps they never developed,
and only the ducts behind them were delivering milk from the inner
breast.
Milk leaked copiously enough from the pit postpartum, due to a well
conditioned let-down reflex. Massaging while applying a breast pump to
form a vacuum over the pit allowed a full supply to be collected by pump.
The mother breastfed fully on the unaffected side. When she saw the
pumped milk was unnecessary, and was collecting in her freezer, at 3
weeks, she chose to let the affected side slowly dry up due to other
family responsibilities and time constraints.
At last contact at 4 months, she was exclusively breastfeeding on one
side, and considered her breastfeeding experience to be very
satisfactory.
2) Umbilicated nipples are fully formed nipples that were never finally
"raised" by the last phase of developing tissues beneath. This process is
supposed to take place during late fetal/early neonatal life. If it does
not occur, it fails to elevate the nipple and above the circular muscles
of the areola.
This results in shortened, or not fully developed ducts/milk sinuses in
the area beneath the nipple, which some have referred to as "tethered" or
tied to the tissue underneath.
The appearance is of a somewhat larger (my observation is about 0.5 cm.
or more) horizontal oval or near circular opening in the areola that can
hide all or part of the nipple button down inside it.
(Dimpled, adhesed, and bifurcated nipples, by Chele Marmet's
classification, seem to me to be variations of this type.) Some can be
extracted manually on stimulation, but others can't be seen, and can't
even be differentiated from invaginated nipples without more
intervention.
One woman I helped (10+ years ago) had bilateral umbilically inverted
nipples which required 2-3 weeks of double pumping 3x daily at 37 weeks
gestational age to bring them into view and get them to eventually stay
out for 10 minutes after pumping. The milk sinuses were not actually
palpable at term, but were palpable postpartum.
She went on to breastfeed for 6 weeks with no discomfort and considered
her experience a success. The time frame was her choice, having to do
with arbitrary supplementation, which I couldn't dissuade her from. I
understand more now, and might have done things differently postpartum.
You mention <This probably makes this woman sound over anxious, but
knowing her, she is
truly trying to prepare herself to do what is best for her future husband
and family with careful forethought and planning! >
My hope is that we encourage our daughters and other young women to think
likewise. I think we could learn a lot with more serial closeup
photography, from the newborn (especially prematures) period and all
stages beyond.
The part about the future husband leads me to believe this is already
somewhat of a cosmetic problem in the relationship. Perhaps she might
have a plastic surgeon insert nipple jewelry bars UNDER (not through) the
nipple as described (from memory, at the moment) in a letter citing use
of the principle of tissue expansion in the July 1999 issue of the
American Journal of OB-GYN.
Because of the many procedures described in plastic surgery journals
worldwide, my guess is a plastic surgeon would propose something else
more invasive, extensive and expensive.
But the procedure that has already been done in late pregnancy for at
least 3 mothers who went on to breastfeed successfully might be the
option least painful, expensive and less likely to damage her future
lactational course.
If this approach appeals to her, she should continue her mental
preparation with this reference so that she can "shop around" and be very
assertive about what kind of procedure she will consent to have done.
She might even wish to avoid a plastic surgeon and choose a physician
from some other specialty (e.g. her GYN, or a dermatological surgeon,
since the entire breast develops from dermal tissue and has been
described extensively in an anniversary issue of The Journal of
Investigative Dermatology in 1975.
I would caution her to stay away from non-medical body jewelry piercers.
I hope this has been of some help.
Jean
***************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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