Inverted nipple: causes, explanations and treatment

Breasts are seen as a symbol of femininity, but they also serve a biological function by producing milk to feed a baby. An inverted nipple, or retracted nipple, can, however, make breastfeeding impossible when the nipple is drawn too far inward (invaginated) and is therefore out of reach for the infant. Beyond the functional aspect, this condition can also be a source of self-consciousness for the women affected by it, particularly in intimate settings. Fortunately, there are several solutions that can correct this issue and make the nipple project out from the areola. Causes, stages, diagnosis, treatments: here is everything you need to know to overcome an inverted nipple.

A reminder about the anatomy of the female breast

The breasts are held against the chest by ligaments. They are made up of a varied combination of connective and fatty tissue together with the mammary gland. On the outside, they consist mainly of a pigmented area surrounding the nipple (the areola) and the nipple itself, which forms the end of the breast and the opening through which milk is projected via the milk ducts.

Although the great majority of women have nipples that protrude from the breast, a significant proportion of them have inverted or retracted nipples, which can prove problematic, particularly for their self-confidence. According to a reference review published by the NIH (StatPearls, Rao, 2023), inverted nipples affect 10 to 20% of the population, making them far more common than people imagine. Inverted nipples are a benign condition in the vast majority of cases, and most women who have them are unaware of it, or do not know that it is possible to have it corrected.

What is an inverted nipple?

An inverted nipple is a nipple that is pinched and retracted, sinking into the areola because of an abnormality of the milk ducts, much like what can happen at the navel (umbilicus). Two mechanisms can cause it:

• milk ducts that are too short, which mechanically pull the nipple inward and prevent milk secretions from reaching it;
• ducts that are coiled or fibrosed, whose traction keeps the nipple drawn in.

In most cases, inverted nipples are bilateral and therefore affect both breasts. This problem should not be confused with a flat nipple, which, although it barely protrudes from the areolar area, still stands out and is not truly drawn into the areola: a flat nipple projects spontaneously or in response to cold or stimulation, whereas an inverted nipple remains pulled inward.

Inverted nipples can impair the sucking process and prevent women from breastfeeding, as the baby cannot latch on properly to feed for any length of time. Added to this functional aspect is the aesthetic one: this condition sometimes leads the women concerned to seek correction, even though, most of the time, they do not dare to consult about this kind of problem. Finally, inverted nipples can be a daily nuisance when they cause recurrent itching (pruritus) or maceration in the fold of the areola.

The stages of an inverted nipple: the Han & Hong classification

Not all inverted nipples are alike, and it is the degree of retraction that determines the most suitable solution. The internationally used reference is the Han & Hong classification, cited in the medical literature (NIH StatPearls; Mangialardi review, 2020), which distinguishes three grades based on how easily the nipple can be brought out and the extent of duct fibrosis:

• Grade 1 — the nipple can be drawn out manually, keeps its projection for a while and shows minimal fibrosis. This is the mildest form, often manageable with non-surgical solutions;
• Grade 2 — the nipple can be brought out but retracts again as soon as it is released; the ducts are shorter and the fibrosis more pronounced;
• Grade 3 — the nipple remains fully inverted and cannot be brought out, with significant fibrosis. This is the grade that most often calls for surgery.

This grading explains why a single term covers very different situations: a grade 1 nipple that retracts only in response to cold does not require the same treatment as a grade 3 nipple that is permanently fixed.

What explains this dysfunction?

Several factors can explain the appearance of an inverted nipple. The condition, most often benign, can first of all be congenital (present from birth), much like, for example, the congenital anomaly of tuberous breasts. In that case it often stems from heredity, with milk ducts that are too short and mechanically draw the nipple toward the areola.

It can also be explained by an acquired cause, which is why the recent appearance of a retracted nipple always warrants a medical opinion. When a previously normal nipple retracts on one side only, this can be an early warning sign of a breast problem that needs to be investigated promptly, particularly in women over 50: a recently developed nipple inversion can reveal duct ectasia, Paget’s disease of the nipple or, more rarely, a tumour. A stable, bilateral inversion that has always been present is, on the other hand, benign in the vast majority of cases.

Some nipples also show this phenomenon only intermittently, usually when they are stimulated or exposed to cold for too long. Lastly, retraction can result from the placement of a piercing leading to sub-areolar abscesses, or from inflammatory after-effects, both of which are also best assessed by a doctor.

Inverted nipples and menopause

The question often comes up after the age of 50: a nipple that retracts at menopause must be distinguished from a long-standing inversion. With involution of the mammary gland and the fibrous changes linked to ageing, nipples may appear more drawn in. This change is usually unremarkable, but any recent and asymmetrical change (a single nipple that retracts, changes in appearance, or is accompanied by discharge) warrants a breast examination, supported by a mammogram and/or ultrasound, to rule out an underlying cause before considering any aesthetic correction.

How do you know if a nipple is inverted?

A simple test allows you to check. It involves gently pressing on either side of the areola with the thumb and index finger (the Hoffman test), or stimulating the edge of the nipple. If it comes out and stays projected, it is normal or simply flat. If, on the other hand, the nipple tends to sink inward, you can conclude that it is inverted and that treatment may be considered. It is always advisable to inform an expectant mother who wishes to breastfeed that she has an inverted nipple during a prenatal consultation, so that she is aware of the possible difficulty or impossibility of breastfeeding and can make the necessary arrangements in advance.

Is it possible to breastfeed with an inverted nipple?

An inverted nipple does not systematically prevent breastfeeding, particularly at grades 1 and 2. Several minimally invasive solutions exist to help the baby latch on to the breast:

• it is first of all possible to stretch the nipple manually so that the baby can latch on to it. Despite difficulties at the start, the mother can hope to draw the nipple out with less and less effort after a while;
• another solution, suited to mildly inverted nipples of grade 1 or 2, is the use of a niplette. This is a small device that gradually suctions the nipple outward; with regular use (often several weeks), it can eventually help the nipple stay out;
• if the nipple remains stubborn, the new mother can use a breast pump or silicone nipple shields, which make sucking easier in some cases;
• finally, stimulation just before the feed can bring the nipple out enough in certain situations.

If none of these methods work, formula feeding remains a perfectly suitable alternative. It is important to remember that difficulty breastfeeding is not the only reason to correct an inverted nipple: breast lift surgery also addresses a legitimate psychological discomfort.

The surgical solution for an inverted nipple

Nipples that do not come out of the areola (typically grade 3) may require surgery. This procedure, most often performed under local anaesthesia, aims to release or divide the fibrosed milk ducts so that the nipple can stay projected above the breast. It requires a prior consultation so that the patient is fully aware of what is involved and of the expected results.

The procedure of dividing the milk ducts to correct an inverted nipple can indeed, in some cases, compromise future breastfeeding. Contrary to a common misconception, this procedure is therefore not designed to make future breastfeeding easier, but rather to overcome an aesthetic concern or a day-to-day functional discomfort. From a purely functional standpoint in a woman who wishes to breastfeed, the less invasive solutions described above should be preferred. There are also duct-preserving techniques (dermal flap plasties) that aim to correct the inversion without dividing them. Correcting an inverted nipple, on the other hand, carries no additional risk for a future pregnancy and no increased risk of breast cancer.

The prior consultation

The prior consultation aims to confirm the presence of an inverted nipple and to determine its grade. The surgeon will in particular assess the configuration of the retraction (grade 1, 2 or 3), whether it is bilateral or not and how long it has been present. If the inversion is moderate and the nipple is able to come out when stimulated, surgery is not always necessary. A mammogram and/or an ultrasound are usually prescribed for recent and/or unilateral inversions, especially in the event of nipple discharge. The surgical technique is reserved for women whose breasts have finished growing (generally around the age of 17).

How the inverted-nipple correction procedure is performed

Correcting an inverted nipple is a relatively quick procedure (about 30 minutes) and minimally invasive, carried out on an outpatient basis (going home the same day). The surgeon releases or divides the bands and milk ducts that hold the nipple back, in order to bring it out. The incision is made on the nipple or at its base, within the areola. Additional steps, such as a small skin plasty centred on the nipple, are sometimes added to stabilise the result. A specific dressing is kept around the nipple for a few days after the procedure.

Results and recovery after the inverted-nipple correction procedure

The procedure to restore the shape of the nipple is not very painful, and recovery generally requires only a follow-up consultation a few days later. The sutures used are most often absorbable and leave only minimal scars, which become almost invisible thanks to their location within the areola, where the skin is heavily pigmented.

The projection of the nipple is visible as soon as the procedure ends, even though the final shape can take several weeks to take its true form. In cases where the nipple is extremely inverted and cannot be corrected in a single procedure, a second procedure may prove necessary afterwards. A partial recurrence remains possible — this is the main limitation described in the literature when fibrosis is severe — hence the importance of a procedure adapted to the grade and of regular follow-up.

Insurance coverage and durability of the result

Because correcting an inverted nipple is most often an aesthetic procedure, it is generally not reimbursed by France’s national health insurance. Coverage can only be considered in rare, specific medical contexts, assessed on a case-by-case basis; the detailed quote is provided at the consultation. When the procedure is well suited to the grade, the result is long-lasting, with the nipple keeping a natural, symmetrical projection. This correction can also be part of a more comprehensive approach, for example alongside a breast reduction or a reshaping of the breasts, and ties in with the topics covered in our article on breast asymmetry correction.