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Correction of the Inverted Nipple With an Internal 5-Point Star Suture

José Serra–Renom, MD, PhD, Joan Fontdevila, MD, and Jaume Monner, MD

To date, many of the methods reported for the surgical treatment of the inverted nipple include insertion of autologous or heterologous material to provide volume and projection to the nipple, thereby avoiding recurrence. In cases of severely inverted
nipple with severe fibrosis and shortening of the lactiferous ducts, the authors’ technique combines the pulling out of the nipple and the release of the fibrosis and retracting ducts with the introduction of a stitch of polyglactin as filling material, performing an internal star
suture in only one surgical intervention, without the need for using graft material, or local flaps that introduce scars around the nipple. The technique is simple, with excellent and long-lasting results. (Ann Plast Surg 2004;53: 293–296)

The most recent techniques described for the treatment of the inverted nipple include the introduction of autologous material in the nipple with local plastic surgery procedures or
grafts after sectioning of the lactiferous ducts and the erector muscle. These techniques involve visible scars such as in interventions using local dermal–fat flaps of areolar tissue.1–6

Other techniques require a donor zone and lengthen operative time, as in interventions using cartilage grafts.7,8 In this study we present the use of a surgical technique for the severely
inverted nipple, or grade III inverted nipple, as described by Han and Hong,1 in which the nipple remains protruded when it is pulled out, and sectioning of the lactiferous ducts and an
internal “star” stitch to avoid both nipple collapse and introduction of heterologous filling material. We do not perform the purse-string suture, to avoid possible nipple ischemia.


It is verified in advance that the patient has a grade III inverted nipple with fibrosis and retracted ducts. Anesthetic cream is applied to the area to be treated with an occlusive
dressing for 30 minutes, followed by anesthesia with lidocaine at 2% without epinephrine (Fig. 1A). When anesthesia of the area has been achieved, we pull out the nipple with a
skin hook, which provides traction to the apex, and we make a small incision (approximately 0.5 cm) between the 5- and 7-o’clock positions, at the teloareolar junction, with a no. 11
scalpel (Fig. 1B). We dissect and section the erector muscle of the nipple and the lactiferous canaliculi using small scissors with a blunt point.

In the internal wall of the cylinder of the nipple we then use a 3–0 braided polyglactin suture with a straight needle, making 5-point star stitches entering and exiting through the same hole for each stitch without leaving suture material externally, and use a loose knot placed centrally within the interior of the cylinder of the nipple. We suture the cutaneous incision with 5–0 nylon and make a dressing using a hemisphere obtained from half a ping-pong ball covering the areola to provide support for a 3–0 nylon stitch that keeps the nipple everted. The ping-pong ball has a window to control stitch traction (Fig. 1C). This dressing is maintained for 8 days, after which the nipple remains protruded (Fig. 1D).

Figure 2 shows all the steps of the procedure.


This technique has been used in 12 patients ranging in age from 18 to 46 years (mean age, 24 years), with a satisfactory evolution and no relapse (Figs. 3 and 4).


In the techniques for inverted nipple correction it is fundamental to avoid recurrence. To do this, many techniques described previously create constriction at the base level of
the nipple to limit collapse, or introduce internal material to create a pocket in the nipple after pulling out the canaliculi and the erector muscle of the nipple. However, these materials
(eg, silicone, Teflon, PTFE) have the problem of extrusion.

Other techniques use dermal–fat cutaneous flaps of the areola to keep the nipple everted, but these procedures create many scars in the areola, and the aesthetic results are not
satisfactory because they deform the areola and the nipple.1–6

Our technique creates a ring at the base of the nipple to keep the nipple protruded. We also use polyglactin as the filling material using a star suture to ensure the nipple remains everted, cylindric, and respects the angle formed by the teloareolar junction.

This technique is completely different from the pursestring suture, which causes ischemia in this instance. Furthermore, there would still be a loss in volume when the erector
muscle and the lactiferous ducts are sectioned. When you effect a purse-string suture, the pullout cannot be maintained because it is empty. The 5-point star suture and inner knotting
keeps the nipple pulled out and avoids the recurrence, because the cylinder is filled with the suture material. Moreover, the risk of ischemia is less than with a purse-string suture.

The type of dressing applied during the immediate postoperative period is important. We construct a dressing consisting of a halved ping-pong ball in which a window is made to supervise that the traction suture, which runs from the apex of the everted nipple toward the vertex of the cone, maintains the eversion during the healing process without excessive tension. This dressing, which is very useful to avoid relapse, remains knotted during the first 8 postoperative days. The patient is then advised not to wear garments that compress the nipple for several months.

This technique is not advised for those patients who wish to maintain their breast-feeding capacity, because it obliterates the galactiferous ducts.


1. Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg. 1999;104:389–395.
2. Serra–Renom JM. Nipple–areola reconstruction with dermal flaps. Personal technique. Rev Med Univ Navarra. 1985;29:185–188.
3. Wolfort FG, Marshall KA, Cochran TC. Correction of the inverted nipple. Ann Plast Surg. 1978;1:294.
4. Broadbent TR, Woolf RM. Benign inverted nipple: trans-nipple–areola

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