Treating inverted nipples

What do I do for inverted nipples?

Mothers with inverted nipples may want to consider treatment to help the nipples come out. The options include nipple root stretching, breast pumps, devices called nipple everters, and surgery. None is guaranteed to work. Nipple root stretching and pumping can be done during and after pregnancy, while nipple everters can only be used before delivery. Surgery, which is done before pregnancy, carries risks, including damage to the milk ducts which can make it impossible for milk to leave the breast. Mothers with partially inverted nipples may be able to breastfeed using a nipple shield. This too may help to bring out the nipples.

A) Nipples can be temporarily or permanently inverted

Inverted nipples can be identified before or during pregnancy, or after birth. This is done using the pinch test.

If you do the pinch test when you are pregnant, the nipple root may feel a little tight. This is normal. As mothers go through pregnancy, the root usually becomes more elastic and easier for the baby to latch onto. If the nipple feels very tight, this abnormality may persist after the birth of the baby.

When inverted nipples are caused by engorgement or mastitis, the nipple condition is  temporary and settles when the underlying problem is treated. Abscesses can cause temporarily or permanently inverted nipples.    

Nipples that have been inverted since puberty (congenital) and inverted nipples caused by breast surgery, chest trauma, and scarring from piercings will likely cause permanently inverted nipples. These may improve with treatment. Mothers with breast cancer will have different management.  

B) Describing treatment for correcting inverted nipples

Treatment for all degrees of inverted nipples should be considered. 

There are a few options for treating inverted nipples but none is guaranteed to work. If these are not effective in helping the baby latch and breastfeed, mothers still have the option to express to provide breast milk for their babies. 

1) Inverted nipple treatment options 

Treatments include: 

  • Nipple root stretching
  • Pumping
  • Devices that help pull the nipple out (nipple everters)
  • Surgery

Mothers with partially inverted nipples may be able to breastfeed using a nipple shield. This too may help to bring out the nipples.

2) Timing of tools to treat inverted nipples

The tools can be used at different times.

Table: Timing of Tools to Treat Inverted Nipples

If you are pregnant, there is a risk that correcting inverted nipples using nipple root stretching, pumping, or nipple everters will stimulate the nipples and cause the brain to release oxytocin. This hormone makes the uterus contract. Make sure that the method you use does not stimulate contractions. This is especially important if you are at risk of premature labour. Please discuss this with your health-care providers before using any of these tools.  

Surgery for inverted nipples should be avoided during pregnancy and while breastfeeding or breast milk feeding.

C) Nipple root stretching

There is virtually no research on the use of nipple root stretching to correct inverted nipples but we have found it mildly to moderately effective.

The technique is similar to that of the pinch test, but in nipple root stretching, the pointer finger and thumb stretch the root instead of just feeling it.

Mothers may hold the stretch for five to ten seconds, release, and repeat. Holding the stretch for longer may fatigue the hands. To obtain the best results, mothers should do this for at least 10 minutes at each session and numerous times each day.  

A lot of mothers watch a movie or television to pass the time.

Ensure that:

  • You do not stimulate contractions if you are pregnant.
  • Your nipples and areola are at most only mildly tender after stretching.

Nipple root stretching is similar to manual expression. One study (Forster 2017) showed there was no increased risk of premature labour when mothers used manual expression twice a day to obtain colostrum from 36 weeks of pregnancy onward. This is reassuring for mothers using nipple root stretching prenatally.

Nipple root stretching can also be used after the baby's birth if there are latching problems.

D) Pumping

There is virtually no research on the use of pumping to correct inverted nipples before the baby’s birth but we have found it mildly to moderately effective.

Before the baby’s birth, mothers can use a breast pump to draw out the nipple. This can be done with a hand or electric pump. The timing is up to the mother. To obtain the best results, mothers should pump for at least 10 minutes at each session and do this numerous times each day.

Ensure that:

  • You do not stimulate contractions if you are pregnant.
  • Your nipples and areola are at most only mildly tender after pumping.

Once the baby is born and if the baby cannot latch, regular expressing for the baby's milk will often stretch the nipple root.

E) Nipple everters

1) Describing nipple everters

There is some evidence that nipple everters are effective in fixing inverted nipples (Arsenault 1997; Kesaree 1993; McGeorge 1994; Nabulsi 2019; Patel 2008)

2) Types of nipple everters

There are devices you can buy to help pull out inverted nipples, including:

  • Evert-It™
  • LatchAssist™
  • Niplette™
  • Pippetop™
  • Supple cups™

These devices all use suction to pull out the nipple. They come in a range of sizes, shapes, and prices. 

You can also make your own from a 10-cc medical syringe by cutting off the tip and putting the plunger into the barrel through the cut end. Unlike the above commercial devices, this cannot be worn inside a bra.

3) When to use nipple everters

Nipple everters are generally used well before the baby is born. Once the colostrum and milk amounts increase, milk will leak out of the breast when exposed to the suction of a nipple everter. The leaked milk will fill the device and the suction is lost.

If you are using a commercial nipple everter, please follow the manufacturers instructions.

Here are some points to consider:

  • There is a risk of soreness or damage to the nipple if the device is not used properly, particularly if it is left in place for too long and your nipple cannot tolerate this.
  • Stop using the device if you develop skin changes or excess pain. Mild discomfort is acceptable and likely when you first start using the device.
  • Do not sleep with the device in place.
  • Ensure that the device does not stimulate contractions.
  • While some devices are clearly too big to be worn inside of a bra, others may fit. However, using the device under a bra may result in it being pushed into the areola, causing pain or skin damage. 

F) Surgery for inverted nipples

Surgery is another way to evert nipples. It should be restricted to severely inverted (Grade 3) nipples.

Survery involves cutting the areolar skin and other tissues of the nipple root. It can be done in a way that spares the milk ducts onot (Feng 2019; Hernandez Yenty 2016). There is little research on breastfeeding success after surgery that spares the milk ducts (Stone 2021). 

Surgery comes with a risk of complications (Gould 2015; Yukun 2016).

If you are considering this operation, please discuss the possibility of breastfeeding after surgery with your surgeon. Ask to what extent the ducts will be spared. We have cared for two mothers who had this surgery. Because of extensive damage to the ducts, neither were able to obtain any milk by breastfeeding or pumping.

References

Arsenault G. Using a disposable syringe to treat inverted nipples. Can Fam Physician. 1997;43:1517–1518
 
Feng R, Li W, Yu B, Zhou Y. A modified inverted nipple correction technique that preserves breastfeeding. Aesthet Surg J 2019;39:NP165–NP175
 
Forster DA, Moorhead AM, Jacobs SE, et al. Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. Lancet. 2017 Jun 3;389(10085):2204-2213
 
Gould DJ, Nadeau MH, Macias LH, et al. Inverted nipple repair revisited: a 7-year experience. Aesthet Surg J. 2015 Feb;35(2):156-64
 
Hernandez Yenty QM, Jurgens WJ, van Zuijlen PP, et al. Treatment of the benign inverted nipple: A systematic review and recommendations for future therapy. Breast. 2016 Oct;29:82-9
  
Kesaree N, Banapurmath CR, Banapurmath S, et al. Treatment of inverted nipples using a disposable syringe. J Hum Lact. 1993 Mar;9(1):27-9
 
McGeorge DD. The "Niplette": an instrument for the non-surgical correction of inverted nipples. Br J Plast Surg. 1994;47(1):46–49
 
Nabulsi M, Ghanem R, Abou-Jaoude M, et al. Breastfeeding success with the use of the inverted syringe technique for management of inverted nipples in lactating women: a study protocol for a randomized controlled trial. Trials. 2019;20(1):737. Published 2019 Dec 16
 
Patel Y. Inverted nipples: correction using a simple disposable syringe. East Afr Med J. 2008;85(1):51–52

Stone G, Shauly O, Gould DJ. Crowdsourcing the Public's Perception and Systematic Review of Nipple Inversion and Its Repair. J Womens Health (Larchmt). 2021 May 14

Yukun L, Ke G, Jiaming S. Application of Nipple Retractor for Correction of Nipple Inversion: A 10-Year Experience. Aesthetic Plast Surg. 2016 Oct;40(5):707-15