2d:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/0fma7nlq6immz.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/1chr5wkk3j58k.js","/_next/static/immutable/chunks/37kmmh_zm4dov.js","/_next/static/immutable/chunks/311zvdjfxff-f.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js"],"default"] 2e:T579c,

Summary Table

Feature	Detail
Risk Factors	Congenital (bilateral, present since puberty), short lactiferous ducts, periductal fibrosis, recurrent subareolar abscess/infection, prior breast surgery, and underlying breast malignancy (new-onset unilateral inversion in older women)
Etiology	Congenital shortening or fibrosis of lactiferous ducts pulling the nipple inward; acquired forms result from periductal inflammation, duct ectasia, or infiltrating carcinoma causing ductal retraction
Patient Presentation	Nipple that retracts below the areolar surface; may be longstanding and bilateral (benign) or recent-onset and unilateral (concerning for malignancy); breastfeeding difficulty is a common complaint in younger women
Classic Physical Exam	Nipple sits at or below the level of the areola; pinch test determines if the nipple can be manually everted (Grade 1) or remains permanently retracted (Grade 3); periareolar skin changes, dimpling, or peau d'orange raise suspicion for carcinoma
Key Diagnostic Results	Clinical diagnosis by inspection and pinch test; ultrasound or mammography if acquired inversion to rule out underlying mass; biopsy if imaging is suspicious
Management	Observation and reassurance for congenital Grade 1; Hoffman exercises or suction devices for breastfeeding mothers; surgical correction (purse-string or duct division) for Grade 2 and 3 causing functional or cosmetic concern; urgent workup and oncologic referral for acquired inversion with suspicious features
Keywords	"Nipple that has always been turned inward," "difficulty latching," "new nipple retraction," "unable to evert the nipple," "slit-like nipple"

1. Pathophysiology

The nipple is normally maintained in its protruding position by the balance between the outward pull of smooth muscle fibers in the nipple (the muscularis mammillae) and the anchoring tension of the lactiferous ducts beneath it. In congenital inverted nipple, the lactiferous ducts are abnormally short or fibrotic from birth, creating a tethering force that pulls the nipple below the areolar plane. Because this is a developmental variant, it tends to be bilateral and symmetric, and the patient will report that the nipple has never protruded normally since breast development at puberty.

In acquired inverted nipple, the mechanism differs depending on the cause. Periductal mastitis and mammary duct ectasia lead to chronic inflammation around the subareolar ducts, which over time produces fibrosis and duct shortening, gradually retracting the nipple inward. This is the most common benign acquired cause and is strongly associated with smoking, which damages the subareolar duct lining and promotes bacterial superinfection.

The most concerning acquired cause is infiltrating breast carcinoma. Tumor cells invade and contract the lactiferous ducts or Cooper ligaments, producing a unilateral, progressive retraction of a previously normal nipple. This is why exam vignettes emphasize the distinction between longstanding bilateral inversion (benign) and new-onset unilateral inversion in a woman over 40 (red flag for malignancy). The retraction in carcinoma is typically fixed and non-evertible because the fibrotic infiltration is irreversible.

Understanding these mechanisms explains why the pinch test is clinically useful: if the underlying ducts are merely short but pliable (congenital Grade 1), gentle compression at the base of the nipple will evert it temporarily. If the ducts are fibrosed or infiltrated, eversion is impossible.

2. Classification and Clinical Manifestation

Han and Hong Grading System

Grade	Evertibility	Duct Status	Clinical Features	Functional Impact
Grade 1 (Minimal)	Easily everted by finger pressure or cold stimulation; maintains projection temporarily	Mildly shortened but patent; minimal fibrosis	Nipple appears flat or slightly indented at rest but protrudes with stimulation	Breastfeeding usually possible with technique modification
Grade 2 (Moderate)	Can be everted with manual traction but immediately retracts when released	Moderately fibrotic and shortened; partially patent	Nipple sits below the areolar plane; slit-like or dimpled appearance	Breastfeeding is difficult; infant has trouble latching
Grade 3 (Severe)	Cannot be everted by any manual maneuver	Severely fibrotic, constricted, or obliterated ducts; dense subareolar fibrosis	Nipple is deeply invaginated; may develop chronic maceration, dermatitis, or recurrent infection in the inverted skin fold	Breastfeeding is not possible; recurrent local infection is common due to trapped moisture and debris

By etiology

Type	Onset	Laterality	Associated Features	Clinical Significance
Congenital	Present since puberty	Usually bilateral	No skin changes, no mass, no discharge	Benign; cosmetic or breastfeeding concern only
Acquired (benign)	Gradual over months to years	Unilateral or bilateral	History of periductal mastitis, duct ectasia, smoking, or prior breast surgery; may have associated nipple discharge (thick, greenish)	Warrants imaging to exclude malignancy, but often inflammatory
Acquired (malignant)	Progressive over weeks to months	Unilateral	Palpable mass, bloody nipple discharge, skin dimpling, peau d'orange, axillary lymphadenopathy	Requires urgent imaging and tissue biopsy

3. Diagnostic Workup

Test	Role	Key Findings
Physical examination (pinch test)	Best initial assessment	Determines grade (1, 2, or 3); assesses evertibility; identifies associated skin changes, masses, or discharge
Mammography	Best initial imaging for women over 40 with acquired inversion	Spiculated mass, architectural distortion, microcalcifications suggest malignancy; duct ectasia may show tubular densities
Breast ultrasound	Best initial imaging for women under 30, or adjunct to mammography	Subareolar abscess, dilated ducts (duct ectasia), solid mass vs. cystic lesion; useful for guiding biopsy
Breast MRI	Problem-solving tool when mammography and ultrasound are inconclusive	High sensitivity for invasive carcinoma; useful for evaluating the extent of disease
Core needle biopsy	Most accurate (confirmatory) test when imaging is suspicious	Histopathological confirmation of carcinoma, periductal mastitis, or granulomatous inflammation
Ductography (galactography)	Adjunct when nipple discharge is present	Identifies intraductal papilloma or ductal carcinoma in situ

The first step is always a careful history and physical examination. The critical question is whether the inversion is congenital (lifelong, bilateral, no associated changes) or acquired (new, unilateral, progressive). For a young woman with bilateral inversion since puberty who presents asking about breastfeeding, no imaging is necessary. The diagnosis is clinical.

For any acquired inversion, especially in a woman over 40, the next step is mammography. This serves as the best initial screening tool to identify an underlying mass, architectural distortion, or suspicious calcifications. In women under 30, ultrasound is preferred as the initial imaging modality because the dense breast parenchyma in younger patients limits mammographic sensitivity.

If imaging reveals a suspicious lesion (irregular borders, spiculation, heterogeneous enhancement), the next step is core needle biopsy, which is the gold standard for definitive tissue diagnosis. Fine needle aspiration is less preferred for solid breast lesions because it cannot distinguish invasive from in situ carcinoma and has a higher rate of insufficient sampling.

If the presentation includes nipple discharge alongside inversion, ductography can be considered to map the involved duct, though it has largely been supplemented by high-resolution ultrasound and MRI in current practice.

4. Management and Treatment

Clinical Scenario	Management	Details
Congenital Grade 1, no functional complaint	Reassurance and observation	No intervention needed; patient education that this is a normal variant
Congenital Grade 1, breastfeeding difficulty	Hoffman exercises, nipple shields, suction devices	Hoffman technique: place thumbs at the base of the nipple and stretch outward, performed several times daily starting in late pregnancy; breast shells worn inside the bra apply gentle constant pressure
Congenital Grade 2	Suction devices first; surgical correction if conservative measures fail	Nipple aspirator devices (e.g., Niplette) worn for several weeks can stretch the ducts; if unsuccessful, surgical release of the shortened ducts is indicated
Congenital Grade 3	Surgical correction	Requires division of the fibrotic lactiferous ducts; counsel the patient that breastfeeding will not be possible after duct division
Acquired, benign (periductal mastitis/duct ectasia)	Treat the underlying cause first	Antibiotics for active infection (amoxicillin-clavulanate 625 mg TID for 7 to 14 days covers typical mixed flora); smoking cessation; incision and drainage if subareolar abscess has formed; surgical excision of the affected duct (Hadfield procedure) for recurrent cases
Acquired, suspicious for malignancy	Urgent imaging followed by tissue biopsy; oncologic referral	Do not attempt cosmetic correction; the priority is histopathological diagnosis; management follows breast cancer staging and treatment protocols

For congenital cases, the approach is graded by severity and functional impact. Grade 1 inversion in a patient with no breastfeeding concerns requires only reassurance. If the patient wishes to breastfeed, Hoffman exercises are the first-line conservative approach: the patient places both thumbs at the nipple base and gently presses inward while stretching the thumbs apart, which gradually elongates the shortened ducts. This is performed 2 to 3 times daily, ideally starting during the third trimester.

If conservative measures fail, or for Grade 2 and 3 inversion, surgical correction is indicated. The key surgical decision is whether to preserve or divide the lactiferous ducts. Duct-preserving techniques (purse-string suture, dermoglandular flap) attempt to maintain breastfeeding capability but have a higher recurrence rate, particularly for Grade 3. Duct-dividing techniques provide more reliable correction but permanently eliminate the ability to breastfeed. This tradeoff must be clearly discussed with the patient before surgery.

For acquired inversion due to periductal mastitis, the acute infection is treated first with broad-spectrum antibiotics covering both aerobic and anaerobic organisms (amoxicillin-clavulanate is the usual choice). If a subareolar abscess has formed, it requires incision and drainage, ideally through a periareolar incision. Recurrent subareolar abscess with fistula formation is managed definitively with excision of the involved duct and fistula tract (Hadfield procedure or total duct excision). Smoking cessation is emphasized because tobacco use is the strongest modifiable risk factor for recurrent periductal mastitis.

For acquired inversion suspicious for malignancy, cosmetic correction is deferred entirely. The priority is completing the diagnostic workup (imaging and biopsy) and referring the patient to surgical oncology. Attempting to surgically correct the nipple before ruling out carcinoma is an error.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Paget disease of the nipple	Can cause nipple distortion and retraction; also raises concern for underlying malignancy	Paget disease presents with eczematous, crusting, or erythematous changes of the nipple-areola complex, often with pruritus and bloody discharge; inverted nipple alone without skin changes points away from Paget
Mammary duct ectasia	Can cause acquired nipple retraction with discharge	Duct ectasia produces thick, greenish or brownish bilateral discharge from multiple ducts; the retraction develops slowly; usually affects perimenopausal women; no palpable mass
Periductal mastitis (Zuska disease)	Causes subareolar inflammation and can produce secondary nipple inversion	Distinguished by acute periareolar pain, erythema, and abscess formation, often in a young smoker; may form a recurrent fistula draining at the areolar margin
Inflammatory breast carcinoma	Can cause nipple retraction with skin changes	Inflammatory carcinoma presents with diffuse breast erythema, warmth, edema, and peau d'orange affecting more than one-third of the breast; rapid onset; skin biopsy shows dermal lymphatic invasion
Fat necrosis of the breast	Can produce a firm, retracted area near the nipple mimicking carcinoma	Patient will have a history of prior trauma or surgery to the breast; imaging may show oil cyst or dystrophic calcification; biopsy shows necrotic fat and foamy macrophages, not malignant cells
Breast abscess (non-subareolar)	Can cause skin retraction if located near the nipple	Distinguished by acute onset of fever, focal tenderness, and fluctuant mass; ultrasound shows a fluid collection; resolves with drainage and antibiotics

6. Traps and High-Yield Pearls

The most common trap with inverted nipple questions is failing to recognize the difference between congenital and acquired inversion. When a vignette describes a young woman with bilateral inversion "since she was a teenager" who now asks about breastfeeding, the correct answer is reassurance and conservative measures (Hoffman exercises, suction devices), not imaging or biopsy. Students who reflexively order mammography for every nipple abnormality will choose the wrong answer here.

The reverse trap is equally important: when a vignette presents a 50-year-old woman with new-onset unilateral nipple retraction, the answer is never "reassurance." Even if no mass is palpable on exam, the next step is mammography (or ultrasound if under 30), because acquired unilateral inversion is considered a sign of possible underlying malignancy until proven otherwise. The test-writer is assessing whether you can identify the red flags for breast cancer presenting as nipple retraction rather than dismissing it as a benign cosmetic issue.

Another frequently tested point is the grading system and its implication for duct preservation. If the stem tells you the patient has Grade 3 inversion and wants to breastfeed in the future, you should recognize that surgical correction will require duct division, making future breastfeeding impossible. The question may test whether you appropriately counsel the patient about this tradeoff.

Finally, for periductal mastitis causing secondary inversion, remember the association with smoking. A vignette describing a young female smoker with recurrent subareolar abscesses and progressive nipple retraction is testing your ability to identify Zuska disease and recommend both surgical management (duct excision) and smoking cessation as part of the treatment plan. Neglecting to address smoking is a common oversight that test-writers exploit.

1e:["$","$L2d",null,{"article":{"id":"9104a95d-0a68-408d-a5a0-b2ce6053cd21","title":"Inverted Nipple","content":"$2e","category":"Reproduksi","created_at":"2026-05-16T07:55:08.327737+00:00","status":"published","subcategory":null},"questionCount":2,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]