Inverted nipple correction

What is inverted nipple correction?

An inverted nipple is a nipple that does not project forward and lies below the plane of the areola.¹ The areola is the darker area surrounding the nipple. It arises when the fibrous bands beneath the nipple and the shortened lactiferous ducts pull it inwards.¹ Surgery aims to release that traction so that the nipple stays out.

A review reports that the condition affects 2 to 10 per cent of women.¹ Such a wide range shows that the studies worked with different definitions and age groups; there is no single exact figure.

The lifelong form is the most common. Inversion that appears later is less frequent and can develop after breast cancer, inflammation around the ducts, previous breast surgery or breastfeeding.¹ This distinction is taken up separately later in the article.

This operation does not change the volume of the breast, does not lift a sagging breast, does not reduce the size of the areola and does not create a new nipple after cancer treatment. Each of these is a separate procedure. If volume is to be added or reduced, breast augmentation and breast reduction are discussed separately, and if the breast needs lifting, so is breast lift.

Are a flat nipple and an inverted nipple the same thing?

They are not the same. A flat nipple does not project beyond the plane of the areola but is not drawn inwards either; an inverted nipple lies below the plane of the areola.¹ Both are part of anatomical variation. Australia's institutional pregnancy and baby information states that a flat or inverted nipple can make it harder for the baby to latch at first, but that breastfeeding is often possible.²

Not every difference in appearance is a condition requiring surgery. An inversion that causes no complaint does not call for a procedure.

Who is it suitable for?

Reasons for seeking assessment fall under two headings, functional and related to appearance. Functional complaints listed include difficulty with breastfeeding, irritation of the area and recurrent infection.¹ Discomfort about appearance is also a reason in its own right; the two groups do not stand in for one another and can be present together.

Not having surgery is also an option. An inverted nipple does not by itself create a health problem; the decision is made according to what the person's complaint is and whether their expectation can be met by surgery.

The lower age limit in this practice is 18. Surgery is not planned while breast development is incomplete.

What comes first when the inversion has developed later?

An inversion that has been present for a long time and one that has newly appeared are not the same thing. The National Health Service (NHS) counts a nipple newly turning inwards among the breast changes that need assessment, and advises seeing a doctor about any breast or nipple change that is different from usual.³ The same source states plainly that these signs can have other causes and do not by themselves mean cancer.³

If a nipple newly turning inwards is accompanied by a lump that can be felt, bloody or spontaneous discharge from the nipple, a pulling-in of the skin or a new change in the skin of the nipple, these are taken into the assessment as well.³ The absence of pain does not make assessment unnecessary. This is not defined as a visit to emergency care; seeing a doctor is enough.³

In such a situation the order is to investigate the cause first. Because a cosmetic correction can mask the appearance of an underlying cause, it is not planned before the assessment is complete. Which tests are requested is determined by the history and the examination findings; the same tests are not applied to everyone.

What is assessed at the examination?

The examination covers how long the inversion has been present, whether one or both sides are affected and whether it has changed over time. In Byun's series of 108 people, both sides were affected in 101 and one side in 7; in Jeong and Lee's series of 26 people, both sides were affected in 21 and one side in 5.⁴⁵ Involvement of both sides is therefore the more common form, but one-sided involvement is not by itself a warning sign.

Whether the nipple can be drawn out by hand and whether it keeps its projection when released are also assessed. The area is examined for discharge, a lump, skin change and signs of irritation. Any previous procedure on the area is recorded.

The breastfeeding history and any plan to breastfeed in future are part of the examination. That information bears directly on the choice of method and is taken up in the breastfeeding section of this article.

How is the degree of inversion determined?

This practice uses the 3-grade classification proposed by Han and Hong. The classification rests on 107 nipples in 60 people treated between 1993 and 1997, and the grade was set by preoperative assessment and confirmed by the operative findings.⁶ A review refers to it as the generally accepted classification in the field.¹

Grade	What it corresponds to at examination
1	The nipple is easily drawn out by hand and keeps its projection when released6
2	The nipple can be drawn out but cannot keep its projection and turns inwards again6
3	The nipple can hardly be drawn out by hand6

In the original publication the amount of fibrosis accompanying each grade and the method applied in that series are described together.⁶ This is not a test that can be applied at home, and the classification does not by itself decide on surgery.

It can be shown that the classification is in wide use in the field.¹ In this search, however, no study was found measuring its agreement between observers or its success in predicting the choice of method in an independent group of patients. For that reason it is not called a validated scale here; it should also be said that this does not mean it has been shown to be invalid.

How is the operation planned?

The operation can be carried out under general or local anaesthesia; which is appropriate is determined by the extent of the procedure, whether one or both sides are treated and the person's state of health. In this practice the operation usually takes 1 hour and the hospital stay is planned as 1 night.

The starting point of planning is to release the fibrous bands drawing the nipple inwards and, once released, to set up support that will keep the nipple out.⁶ The methods used in this practice are a support suture, a tissue flap and a distraction system.

Can the lactiferous ducts be preserved?

Methods are divided into two main groups according to whether the lactiferous ducts are preserved.⁷ Preserving the ducts matters not only for breastfeeding but also for nipple sensation, since the nerve to the nipple runs along the duct system.⁵

In a systematic review of 13 studies, a nipple turning inwards again was reported in 2 of 350 nipples, that is 0.6 per cent, with duct-preserving methods, and in 16 of 161 nipples, that is 9.9 per cent, with methods that damage the ducts.⁷ The authors of the review state that there is no statistical evidence that the duct-damaging method is superior, and recommend that the first choice should be a duct-preserving method.⁷ All 13 studies included sit at the lowest step of the evidence scale, and the differences between the studies meant that a meta-analysis could not be performed.⁷

A duct-preserving method is therefore the first choice. Dividing the ducts in part or in full comes up where the fibrosis is severe and adequate release cannot be achieved with the ducts preserved; in Han and Hong's original description this situation is set out for grade 3.⁶ Being grade 3 does not, however, mean the ducts will be divided: in a series of 209 nipples treated with a suture method intended to preserve the ducts, 64 nipples were grade 3.⁴ The decision is made on the examination and the findings during surgery.

How do a support suture, a tissue flap and a distraction system differ?

Support suture: Sutures placed at the base of the nipple after the fibrous bands are released, holding it out. In a series of 209 nipples this method was applied through 2 small incisions and with few sutures.⁴

Tissue flap: Where the support beneath the nipple is insufficient, small flaps prepared from the surrounding tissue are brought under the nipple to form a base.⁶ In a series of 47 nipples this method was used to create a support resembling a tent suspension.⁵

Distraction system: A method applying continuous traction to the nipple through a device placed externally or passed through the tissue. It was first described in 1994.⁸ The review follows this group as a separate technical heading.¹

Which method is chosen is determined by the grade, the amount of fibrosis, whether a procedure has been carried out before, and the plan about breastfeeding. The name of the technique does not by itself mean that all the ducts have been preserved or that breastfeeding has been secured.

Do non-surgical methods work?

Non-surgical approaches have three separate aims and these should not be confused: making it easier for the baby to latch during breastfeeding, correcting the shape permanently, and preparing the nipple before pregnancy.

A review states that non-surgical approaches such as manual traction, piercing and vacuum treatment can be used in grade 1 only.¹

Breast shells and Hoffman's exercises in pregnancy: In a randomised trial of 96 people, sustained improvement in nipple anatomy was 52 per cent among those advised to use shells and 60 per cent among those not advised to, and the difference was not significant. Six weeks after delivery, 24 of 48 people not advised to use shells and 14 of 48 people advised to use them were breastfeeding.⁹ Advising shells therefore appears not to have raised the likelihood of breastfeeding but to have lowered it. No difference was found between the exercise groups.⁹

The inverted syringe technique: In a randomised pilot trial of 54 breastfeeding people, the group using an inverted syringe did not do better than the group receiving standard care; exclusive breastfeeding at 1 and 3 months and any breastfeeding at 6 months were higher in the standard care group.¹⁰ The authors report that the inverted syringe technique was not associated with improvement in breastfeeding outcomes.¹⁰ The sample is small, a substantial proportion of those approached declined to enter the trial, and the drop-out rate was high; the result should therefore not be read as firm evidence of harm either.¹⁰

Electric pump compared with the inverted syringe: In a randomised trial of 60 breastfeeding people, breastfeeding was established by day 3 after delivery in 18 of 30 people in the syringe group and 17 of 30 in the pump group, and the difference was not significant.¹¹ On the third day the proportion with no pain or mild pain was higher in the pump group.¹¹ This trial has no standard care arm; the result is a comparison of two methods, not evidence of permanent correction.

A distraction device before pregnancy: In a randomised trial covering 230 people with grade 1 and grade 2 inverted nipples, a group using a distraction device for 6 months before pregnancy was compared with a control group doing daily exercises. The success rate reported by the trial was 84.9 per cent for grade 1 and 79.3 per cent for grade 2, against 52.5 per cent and 38.9 per cent in the control group.¹² The trial defines its primary outcome as being able to breastfeed for 4 months after a full-term pregnancy.¹² This result does not cover grade 3 and is not the same as using a simple device such as a breast shell.

To draw it together, there are approaches that may help with breastfeeding support, but no evidence was found in this search that every device and every grade achieves permanent correction.

Incisions, sutures and treating one or both sides

Incisions are placed at the base of the nipple, on the line where it meets the areola, and are kept small; the aim is for the scar to stay at that natural border.⁴ Closure uses buried support sutures holding the nipple out together with sutures closing the skin. Sutures that dissolve on their own do not need to be removed; sutures that do need removal are taken out within 2 weeks in this practice.

If both sides are affected, the procedure is mostly carried out in the same session. If one side is affected, the appearance of the other nipple is used as the reference, but the two sides are not expected to be identical.

This procedure can be carried out in the same session as another breast operation. In that case the length of the operation, the recovery timetable and the risks change according to the added procedure; the intervals in this article are for inverted nipple correction carried out on its own.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹³ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁴ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁵ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁶ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Accompanying conditions: Diabetes and blood pressure are expected to be under control before surgery. If there is an active infection in the body, the operation is postponed.

Medicines: Blood thinners and some herbal products can increase bleeding. You need to state every medicine and supplement you take. Prescribed medicines should not be stopped on your own decision.

Plans about breastfeeding and pregnancy: A plan to breastfeed is discussed before surgery; that information affects both the choice of method and the timing. During breastfeeding, and in the period just after it ends, the breast tissue is changing. No study was found in this search determining how long after breastfeeding the operation should be carried out; the timing is decided for each person.

Active problems in the area: If there is irritation, cracking or active infection of the nipple, these are expected to have settled before surgery.

What is recovery like?

The intervals below are a general framework. They can vary with the extent of the operation performed, the person's work, the speed of healing and the surgeon's practice.

• The operation is carried out under general or local anaesthesia and usually takes 1 hour
• The hospital stay is mostly 1 night
• The first check-up takes place within the first week
• Sutures that need removal are taken out within 2 weeks; sutures that dissolve do not need removing
• Bruising takes 7 to 10 days to fade
• Marked swelling takes 1 to 2 weeks to subside
• Returning to work takes 1 week for most people
• At least 1 week is allowed before driving
• Strenuous sport is postponed for 2 to 4 weeks
• A full return to daily life takes 2 to 4 weeks
• Slight residual swelling can last 2 to 3 months, and the shape of the nipple is assessed at the end of that period

In the first days, swelling, bruising, tenderness and a feeling of tightness in and around the nipple are expected. Because of the swelling in this period the final shape cannot be assessed.

What should you pay attention to after surgery?

Dressings and pressure on the nipple: The essential point is that no pressure is applied over the nipple, and the dressing is prepared so as to ensure this. Whether a protective device is used, and for how long, varies with the procedure performed and is stated by the surgeon. There is no fixed interval here that holds for every method.

Bra and clothing: A soft, seam-free bra or undergarment that puts no pressure on the nipple is preferred. Tight clothing that creates friction is not worn in the first weeks.

Sleeping: Lying on the back, or with the upper body slightly raised, is more comfortable for most people in the first weeks. When you can move to sleeping on your side or front depends on how healing is going and on your surgeon's advice.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Pain: Pain and tenderness in the nipple occur in the first days and are controlled with the painkillers provided. Pain is expected to lessen steadily; increasing pain is not left to wait for a check-up.

Movement: The arms can be used for everyday tasks within the limits of pain. In the first weeks, movements that rub against or press on the nipple are avoided. Staying still for long periods is not right either. Short walks are advised early on and reduce the risk of a clot.

Driving: At least 1 week is allowed. You can drive once you can wear the seatbelt comfortably, perform steering movements and an emergency stop without pain, and are no longer taking painkillers that cause drowsiness.

Sexual activity: Sexual activity can resume once you feel comfortable and everyday movements no longer cause marked pain. In the first weeks, pressure on and friction against the nipple should be avoided.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

How do the scars change?

Because the incisions are kept small and placed at the base of the nipple, the scar is usually limited.⁴ Even so, a scar-free result cannot be promised. In a review of 33 studies, among the 11 studies reporting the quality of the scars, the scars were described as minimal apart from 8 nipples.¹

A scar takes 6 months to 1 year to mature. Over that period the colour and the raised quality of the scar are expected to lessen. A scar that stays raised or wide may need further care or correction.

Risks and complications

The headings below are grouped by subject rather than by frequency. There is no reliable and comparable ranking of frequency for this operation; a risk given without a figure is without one because it has not been measured, not because it is rare.

Turning inwards again and loss of projection

Turning inwards again is the distinguishing risk of this operation and is taken up in a separate section. Some loss of projection is not the same outcome as turning inwards again. In a series of 47 nipples, nipple height measured immediately after surgery averaged 10.8 millimetres and was measured at 9.0 millimetres at a check-up averaging 14 months; 90 to 100 per cent of the projection was maintained in 45 nipples, and 1 person lost 40 per cent of the projection in both nipples.⁵

Problems involving sensation and the lactiferous ducts

Sensation in the nipple can change. In a series of 209 nipples, no permanent loss of sensation was reported.⁴ In a series of 47 nipples, a contraction response to brush stimulation was obtained after surgery in every nipple.⁵ In a series of 19 people, 1 person developed a temporary loss of sensation.¹⁷

These findings point in a favourable direction, but they have limits. Obtaining a contraction response does not show that every kind of sensation has been fully preserved.⁵ In this search, no study was found giving a rate of temporary or permanent change in sensation measured with standard tests at defined time points. That gap cannot be turned into a conclusion that sensation is bound to be impaired, nor into a conclusion that sensation is preserved.

Where the lactiferous ducts are divided, milk transfer may be impaired; preserving the ducts is a functional aim for that reason.⁷

Bleeding, infection and wound problems

Bleeding, haematoma, infection, the wound opening and tissue loss in the nipple are possible. In a series of 209 nipples, the wound opened in 1 nipple and was re-sutured in the outpatient clinic; in the same series no haematoma, infection, nipple necrosis or hypertrophic scar was reported.⁴ In a series of 19 people, no major complication such as necrosis, infection or haematoma was reported.¹⁷

These are raw counts from single-centre series, not pooled rates given with confidence intervals. Zero events being reported does not mean the risk does not exist.

Anaesthesia and general surgical risks

Reactions related to anaesthesia, allergic reactions and pain persisting after surgery can occur. These are assessed together with state of health and the extent of the procedure.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

Can the inversion come back?

It can. In a review covering 33 studies and 3,369 nipples, a nipple turning inwards again was reported in 131 nipples, that is 3.89 per cent; the spread between studies runs from 0 per cent to 34.1 per cent and the average follow-up was 23.9 months.¹ That wide spread shows that a single rate cannot be taken as holding for every method and every grade.

Where figures are given by method group, the two reviews do not give the same ranking. The review of 13 studies reported 0.6 per cent for duct-preserving methods and 9.9 per cent for methods that damage the ducts, while the review of 33 studies split the duct-preserving group into three and gave different rates for tissue flaps, sutures and distraction systems respectively.⁷¹ The two reviews do not use the same set of studies, the same grouping or the same inclusion criteria, and neither is a meta-analysis comparing methods. For that reason one of them is not picked out and presented as the single correct rate.

Figures have been reported in single-centre series as well. In a series of 209 nipples, partial turning inwards again occurred in 3 nipples and repeat surgery was carried out with the same method.⁴ In a series of 35 nipples covering people already operated on or with severe presentations, no turning inwards again was reported and correction could not be achieved in 1 nipple.¹⁷ Correction not being achieved in the first place and turning inwards again later are not the same outcome.

If the nipple turns inwards again, the approach is to assess it afresh. In the series above, repeat surgery was carried out with the same method.⁴

Is breastfeeding possible after surgery?

The situation without surgery needs separating out first. Institutional information states that a flat or inverted nipple can make it harder for the baby to latch at first, but that breastfeeding can be possible with support from a midwife and a lactation consultant.² It therefore cannot be said that surgery is needed in order to breastfeed.

As to the situation after surgery, a systematic review and meta-analysis published in 2026 pooled breastfeeding success after nipple repair across 6 studies and reported it as 84 per cent, with a 95 per cent confidence interval of 76 to 89.¹⁸ That figure cannot be converted directly into one person's likelihood of breastfeeding. The studies do not share a definition of breastfeeding success, and exclusive breast milk or a set duration was not required in all of them; furthermore, some of the studies included report their results per person and some per nipple.¹⁸¹²

There is also a directly observed example: in a series of 26 people, 5 people who had children after surgery were recorded as successful in breastfeeding.⁵ That record does not show the duration of breastfeeding or whether feeding with breast milk alone was achieved.

No study was found in this search comparing breastfeeding outcomes for duct-preserving and duct-dividing methods using the same definition, the same denominator and the same follow-up period. A systematic review also states that breastfeeding outcomes were not reported consistently across all the studies.⁷ For that reason it is said neither that breastfeeding is secured if the ducts are preserved nor that breastfeeding is lost after surgery. A plan to breastfeed is discussed before surgery and is kept in view when the method is chosen.

What can be expected from the result?

The aim of the operation is to get the nipple to stay out and to keep it that way. A review lists the aims of treatment as lasting projection and shape, preservation of sensation, preservation of the lactiferous ducts, and minimal scarring.¹

The two nipples are not expected to be identical. Some loss of projection can be part of the ordinary course and does not mean the nipple has turned inwards again.⁵

No guarantee can be given about breastfeeding or sensation. The figures reported in the sections above are group-level results and do not determine the result a person will see.

Surgery does not resolve every concern about the body. The expectation should relate to the complaint or the wish about appearance that the person has described; copying another person's anatomy is not a criterion for the decision to operate.

Having tried non-surgical methods without result says nothing about the outcome of surgery. These are different procedures with different aims.

When should you contact a doctor?

In a person who has not had surgery, a nipple newly turning inwards, a lump that can be felt, bloody or spontaneous discharge, a pulling-in of the skin or a new change in the skin of the nipple call for seeing a doctor.³ These signs do not by themselves mean cancer, but they do need assessing.³

After surgery, the following are not left to wait for a check-up:

• Swelling and hardening that keep increasing
• Pain that worsens or is not relieved by painkillers
• Darkening or loss of colour in the nipple
• The wound opening, bleeding or foul-smelling discharge
• Fever, redness and increased warmth
• One-sided leg pain and swelling, sudden shortness of breath or chest pain

About the numbers in this article

The anaesthesia, the duration of the operation and the hospital stay, the use of sutures, the timetable for bruising, swelling and shape, and the intervals for returning to work, to driving, to sport and to daily life in full are the clinical framework approved by the surgeon. No fixed interval is given for a protective device; that decision varies with the procedure performed.

The research figures come from particular outcome definitions and sets of studies. Some of the rates in this article are pooled estimates given with a confidence interval; others are raw counts from single-centre series and carry no confidence interval. The two should not be read as carrying equal weight.

The denominators differ from one another. Some figures are given per person and some per nipple; in cases involving both sides, one person carries two nipples. In the breastfeeding results the denominator is people who gave birth. The rates are therefore not added together and none of them is one person's risk.

The 3.89 per cent given for turning inwards again is an average combining different methods and different grades; the same review reports that the spread between studies runs from 0 per cent to 34.1 per cent.¹ Because there are some differences in denominators and percentages between the text and the table of that review, the rates for the method groups have not been taken into this article.¹

The data in the smoking cessation paragraph cover a range of operations.¹⁴¹⁵ In the results reported from Tang, the relative risk was 0.73 with a 95 per cent confidence interval of 0.60-0.89 for those who stopped at least 2 weeks before, and 0.71 with a 95 per cent confidence interval of 0.61-0.82 for those who stopped at least 4 weeks before.¹⁶ The 27 per cent and 29 per cent relative reductions in the shared paragraph are not an absolute complication rate specific to this operation.

A number not being given for a risk in this article does not mean that the risk does not exist.

References

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9. Alexander JM, Grant AM, Campbell MJ. Randomised controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples. BMJ. 1992;304(6833):1030-1032. doi:10.1136/bmj.304.6833.1030 ↩ ↩²

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