Nipple Surgical Techniques

There are three main types of nipple surgeries: nipple reduction surgery, nipple enlargement surgery, and surgery to repair inverted nipples. Nipple piercings are also potentially damaging to lactation.

Nipple Reduction Surgery

Nipple reduction surgery is performed for women who have long nipples on one or both breasts and desire to have them reduced in length. The surgery is primarily cosmetic and not performed to reduce pain or increase functionality.   There are many nipple reduction surgical techniques, ranging from removal of the tip of the nipple to a procedure that removes a cylinder of skin around the neck of the nipple in order to insert the nipple more deeply into the breast.  It is commonly accompanied by both areola reduction and breast augmentation or reduction surgeries, taking advantage of the incision around the areola to insert the implant or remove tissue.(1)   When the surgery involves reduction of just the nipple, lactation is not likely to be affected as neither the nerves nor the ducts within the nipple are severed, although it is possible that scar tissue may form on the area where the nipple tissue was removed, reducing or eliminating milk exit pathways.(2) When nipple reduction surgery involves reduction of the areola, where the ducts and critical nerves are concentrated, milk production is at risk. The surgery may be combined with breast reduction or augmentation surgeries.  In such cases, the capability of future milk production also depends upon the breast reduction or augmentation surgical technique.
 
Nipple Enlargement Surgery

Nipple enlargement surgery is performed for a woman who has nipples that are normal in projection and shape, but who wants them to be larger. There are several techniques to enlarge nipples, usually incorporating tissue grafts.  There is a minute risk of scarring that can reverse the enlargement, resulting in a nipple that is reduced beyond the original size, which can negatively affect latching.  In most cases, nipple and lactation functionality are unlikely to be affected since neither the nerves nor the ducts within the nipple are severed.

Inverted Nipple Release Surgery

Kehrer performed the first surgical correction of inverted nipples in 1879.(3) Surgeons use the Han and Hong Nipple Inversion Grading System to quantify the degree of inversion:(4)

• Grade I: The nipple can easily be pulled out and maintains projection.  There is minimal fibrous tissue beneath the nipple.  Manual manipulation or a simple buried purse-string suture is adequate to achieve protrusion. Lactation is not impacted.
  
  
• Grade II: The nipple can be pulled out with moderate difficulty, but does not maintain projection, retracting into the breast.  The majority of inverted nipples fall into this classification.  These nipples have moderate fibrous tissue beneath the nipple.  Surgical treatment involves dissection of the nipple to release fibrous tissue bands.  Lactiferous ducts are preserved.  Lactation is not impacted.(5)
  
  
• Grade III: It is difficult or impossible to evert the nipple manually.  The least proportion of nipples is this severely inverted.  There is severe fibrosis at the base of the nipple so that it is impossible to sever all the fibrous tissue bands without also severing ducts, particularly in the central portion of the nipple.  Lactation is significantly impacted. (6) With time, recanalization of the ducts can result in partial or full functionality.

As the Han and Hong Nipple Inversion Grading System demonstrates, surgery to correct congenital or acquired nipple inversion can impair lactation functionality, depending upon the degree of inversion and the type of technique used. 

Nipple Piercings

While not technically a surgical procedure, nipple piercing is a potentially invasive practice that has gained popularity in the past decade. Though mothers may have concerns about its impact on breastfeeding, it has not been observed to be a problem by most lactation experts, although it may add to or enlarge the outlets for milk to exit the breast. There is a theoretical risk that unusual or extensive scarring due to site infections or poor piercing technique could obstruct milk flow and drainage.  Barbara Wilson-Clay and Kay Hoover describe an anecdotal report of a mother for whom one of nipple piercings appeared rather scarred; the baby did not seem to like that side as well. (7)   Overall, mothers who have nipple piercings without complications should not be concerned that they are contributing factors to any milk production problems they may be facing.  Removal of any nipple rings or bars during feedings is recommended, of course.