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A simple technique is described for the surgical correction of inverted nipples: a combination of a method utilising the excision of three rhomboid skin areas of nipple and areola with local areolar flaps filling the post-excisional dead space beneath the nipple, based on the principle of de-epithelialised "turn-over" flaps.
Following reconstruction of the breast after mastectomy it is common practice to allow a "settling" period before grafting the nipple-areola complex. A selection of external nipple-areola prostheses are described which can be used until surgical reconstruction can be carried out and which are helpful in determining the correct position of the nipple-areola grafts. It has been found that some patients actually prefer to use the prostheses permanently for dress purposes rather than undergo an additional operation.
Gynecomastia and bloody nipple discharge are very rare in childhood. In this report, a case of infantile gynecomastia together with bloody nipple discharge is presented. A hemorrhagic discharge was expressible from the mammary gland. Endocrinologic findings were within the normal limits. Because of persisting bleeding, a subcutaneous mastectomy was performed. The specimen was reported as gynecomastia. This boy is the first reported prepubertal gynecomastia with bloody nipple discharge in the medical literature.
Advances in the area of computerized image analysis applied to mammography may have very important practical applications in automatically detecting asymmetries (masses, architectural distortions, etc.) between the two breasts. We have developed a fully automatic technique to detect the breast border and the nipple, this being a necessary prerequisite for further image analysis. To detect the breast border, an algorithm that computes the gradient of gray levels was applied. To detect the nipple, three algorithms were compared (maximum height of the breast border, maximum gradient, and maximum second derivative of the gray levels across the median-top section of the breast). A combined method was also designed. The algorithms were tested on 156 digitized mammograms. The breast segmentation results were evaluated by two expert radiologists and one physicist. In 89% of the mammograms, the computed border was in close agreement with the radiologist's estimated border. Segmentation results were acceptable to be used in computer-aided diagnostic schemes. The mean distance between the position of the nipple indicated by two radiologists by consensus and the position calculated by the computer was 6 mm.
Between 1960 and 1984, 20 selected patients with Paget's disease of the breast confined to the nipple were treated conservatively with radiotherapy alone (17/20 pts) or limited surgery and radiotherapy (3/20 pts). Median follow-up was 7.5 years. No patients died of breast disease. Three patients had recurrence in the treated breast, and were treated by mastectomy. All recurrences were located in the nipple or areola and were all Paget's disease, without associated intraductal or invasive carcinoma. No axillary node recurrences occurred. The actuarial 7-year probability of living free of disease with breast preserved was 81%. Among the 15 patients who had a minimum follow-up of 3 years, without recurrence, 12 (80%) had a good cosmetic result. These results suggest that radiation therapy could be an effective alternative to radical surgery in the treatment of patients with Paget's disease of the nipple without concomitant breast tumor.
Nipple and areola reconstruction is an important component of breast reconstruction and numerous techniques have been reported. Each has its own advantages and disadvantages. A novel variation in nipple-areola complex reconstruction utilising a 'Button-Hole' is presented which can be advantageous in women with smaller nipples. Review of thirteen patients with a mean follow up of 39 months showed durable Long-term results. In selected patients, this technique is a useful alternative to the many others currently employed.
Though milky nipple discharge is frequently seen in neonates, blood stained discharge from the nipple is an exceptionally rare phenomenon. We noted a case of a three-month-old baby girl who presented with bilateral blood stained nipple discharge without signs of inflammation; engorgement or hypertrophy and which subsided without any intervention. This case is reported along with literature review about managing this rare condition.
BACKGROUND: Fluid can be non-invasively aspirated from the breast nipple (nipple aspirate fluid, NAF). NAF may have many colors, including clear, white, yellow, green, and red/brown. While bloody spontaneous nipple discharge has been linked with breast cancer, the association of NAF color with cancer is not established. Our hypothesis was that red/brown NAF color was associated with breast cancer. The purpose of this study was to assess (1) if red/brown NAF is associated with the presence and progression of breast cancer, (2) the influence of prior needle or surgical biopsy on NAF color, and (3) if an association between NAF color and breast cancer was found, to develop a cancer predictive model including NAF color and cytology, and clinical information. METHODS: Specimens were obtained from 848 breasts between 1999 and 2004 after subjects enrolled in an IRB approved protocol to evaluate biologic markers of breast cancer. Cytologic evaluation was performed on Papanicolaou-stained cytospin preparations of NAF. RESULTS: Red/brown NAF was associated with breast cancer when considering all samples (p<0.001) and samples from women who did not undergo recent surgery (p=0.005). Needle biopsy did not, but surgical biopsy did influence NAF color. For the 327 women with NAF collected from both breasts, there was a significant association between red/brown NAF color and the presence of breast cancer (p=0.005). Red/brown NAF was more common in breasts with ductal carcinoma in situ than atypical hyperplasia (p=0.008). The optimal model, included NAF color, cytology, and age, was 92% sensitive and 61% specific in predicting if a woman had breast cancer. CONCLUSIONS: NAF color was associated with the presence of breast cancer and the progression from precancer to cancer in a population of women who presented to a breast cancer evaluation clinic. NAF color contributed to a highly predictive breast cancer detection model. Additional studies are warranted to determine the usefulness of NAF color in the assessment of women who present for breast cancer evaluation.
Nipple discharge is common, and is associated with a malignancy in 5-20% of cases. Physical examination and the colour or clarity are of importance. Cytology and galactography have little value in the evaluation of nipple discharge. Age is considered one of the most important risk factors for breast cancer. We describe the valuable contribution of magnetic resonance imaging in evaluating an elderly patient with nipple discharge where clinical and mammography examinations were negative.
Diagnosis and treatment of ductal and/or nipple candidiasis in breastfeeding women is complicated by the variety of symptoms women experience. The differential diagnosis includes candidiasis of the nipple, candidiasis of the breast, bacterial infection of either nipple or breast, and other less common problems such as Raynaud's syndrome. Diagnosis and treatment are based on history, physical examination, and presenting symptomatology because cultures of breast milk are often inconclusive. Differential diagnoses and treatment options are reviewed.
We present a case of a 33-year-old woman who underwent excisional breast biopsy due to a left nipple mass. Histological examination revealed the morphologic and immunohistochemical pattern of syringomatous adenoma of the nipple. This is a rare lesion of the breast that can clinically mimic breast carcinoma, but harbors a benign and only locally aggressive course. Awareness of both the clinician and the pathologist for the possibility of diagnosing this tumor in the nipple region is mandatory to avoid mastectomy and lymph node dissection.
BACKGROUND: Minimally invasive techniques are being used increasingly in patients with benign and malignant breast diseases. The purpose of this study was to compare the diagnostic yield of 2 groups of patients who underwent either minimally invasive microductectomy or major duct excision for pathologic nipple discharge. METHODS: Two hundred thirty-five patients who underwent nipple exploration and duct excision and were part of an institutional review board-approved database were included in this retrospective analysis. Preoperative imaging, ductal washing cytology, surgical specimen size, and final histopathology were compared among 95 patients who underwent microductectomy by using intraoperative ductoscopy and 140 patients undergoing standard major duct excision. RESULTS: Mean age of patients undergoing microductectomy was 53 versus 55 years in patients undergoing major duct excision. Preoperative mammogram was negative or benign in 92% and suspicious in 8% of patients in both the microductectomy group and the major duct excision group. A ductal abnormality was identified by preoperative ductography in 43 of 56 (77%) patients in the microductectomy group versus 74 of 92 (80%) patients in the major duct excision group. Ductal cytology was benign in 81% and 80% of patients tested, respectively. Mean specimen size was significantly smaller in patients who underwent microductectomy (9.2 cm3) as compared with major duct excision (12.6 cm3). Although the percentage of patients with atypical ductal hyperplasia or lobular carcinoma in situ was similar among the 2 groups (9% vs 10%), only 3 of 95 (3%) patients within the microductectomy group were found to have carcinoma within the resection specimen as compared with 12 of 140 (9%) within the major duct excision group (P = .03). Mean specimen size of the patients diagnosed with carcinoma was 8.6 cm(3) in the microductectomy group as compared with 15.5 cm3 in the major duct excision group (P = .014). CONCLUSIONS: These data confirm that patients who present with single duct pathologic nipple discharge usually have benign pathology as the etiology. However, in a small percentage of patients an occult carcinoma might be present. Major duct excision appears to detect a higher percentage of occult carcinoma when compared with minimally invasive microductectomy, which might be related to the larger sample size of the resection specimen.
The nonstress test and the nipple stimulation contraction stress test were performed at the Medical College of Georgia and the University of Mississippi Medical Center, with the use of common maternal state protocols, minimum criteria for baseline fetal heart rate reactivity, and follow-up of abnormal test results. At the Medical College of Georgia, 656 patients were studied with nonstress tests used as the primary test, whereas at the University of Mississippi Medical Center, 614 patients were managed with the nipple stimulation contraction stress test used as the primary test. Both populations were comparable in regard to pregnancy complications, gestational age, birth weight, perinatal outcomes, cesarean section rates, and the incidence of positive contraction stress tests. Specificity and positive and negative predictive values were similar for both tests. The extended nonstress test had higher sensitivity but also required significantly longer mean duration of testing. The corrected perinatal mortality rate for a reactive nonstress test or negative nipple stimulation contraction stress test was zero within one week of the last test. We conclude that both tests provide excellent primary methods of fetal surveillance and that the decision to use one test rather than the other should be made on the basis of considerations of cost, convenience, time availability, and the presence of specific test contraindications or pregnancy complications.
It is well known that nipples reconstructed using local tissue flaps slowly flatten. Furthermore, patients with implant reconstruction show the highest amount of nipple projection loss. This article describes some modifications to the technique proposed by Thomas et al in order to maintain flap projection. We undertook a prospective study to evaluate the effectiveness of our technique, named 'arrow flap'. We compared a series of patients with unilateral breast reconstruction (16 implants, 16 TRAM flaps) who underwent nipple reconstruction using either the 'modified star flap' or the 'arrow flap'. The statistical significance of the results was determined by Student's t test. The arrow flap proved to have a higher residual projection and these results were statistically significant. Furthermore, it has been equally useful on implant and autologous reconstructions. This technique is easy to learn and to perform. The procedure is reliable and patient satisfaction and compliance are very good.
Many surgical procedures performed in the thoracic region can easily damage cutaneous nerves important for the sensory innervation of the female breast. A better understanding of the distribution of these cutaneous nerves will help prevent impaired sensation after breast surgery. Therefore an anatomical study was performed on the cutaneous innervation of 12 breasts of 7 female cadavers. Special emphasis was placed on the nipple-areola complex. The origin, course and final destination of each cutaneous nerve was established and the contribution of each branch was determined by the area it innervated. Differences were evaluated using analysis of variance. The cutaneous innervation of the female breast is derived medially from the anterior cutaneous branches of the Ist-VIth intercostal nerves and laterally from the lateral cutaneous branches of the IInd-VIIth intercostal nerves. The nipple-areola complex is consistently supplied by the anterior and lateral cutaneous branches of the IVth intercostal nerve, with additional innervation by cutaneous branches of the IIIrd and Vth intercostal nerves. This study shows an equal importance of both the anterior and the lateral cutaneous branches of the intercostal nerves. During surgical procedures one should try to avoid damage to the anterior and lateral cutaneous branches of the IIIrd, IVth and Vth intercostal nerves, with special attention to the IVth intercostal nerve which is the consistent nerve to the nipple-areola complex.
Bloody nipple discharge in infancy has been rarely reported in the medical literature. Its cause is unknown. We report a three-year-old male infant and a five-month-old female infant with bloody nipple discharge. Because of persistent bloody discharge, a subcutaneous mastectomy was performed in the boy; the problem resolved in the girl after a period of observation. The specimen showed histologic changes identical to those seen in adult mammary duct ectasia. All the endocrinologic work-up was normal. We suspect that bloody nipple discharge in infancy is underreported. This is a benign condition with histologic changes similar to adult mammary duct ectasia and if persistent, should be properly investigated; biopsy or excision are not indicated.
We report the coexistence of pemphigus vulgaris and Paget's disease of the nipple in a patient with a documented history of pemphigus and a 2-year complaint of an eczematous breast lesion. A biopsy taken from the lesion showed the characteristic histologic features of both pemphigus and Paget's disease of the nipple. Immunohistochemical technics revealed intercellular IgG deposits characteristic of pemphigus and intracellular staining with antibody to epithelial membrane antigen in the cytoplasm of Paget's cells. This report is the first describing the coexistence of these two distinct disease entities in one tissue sample. This case underscores the necessity of early biopsy of recalcitrant nipple lesions even in the presence of another, well-documented skin disorder.
The purpose of this study was do compare breast papilla (nipple) development to the established criteria of secondary sexual maturation. One hundred and sixty-eight girls (100 black and 68 white) ranging in age from 2-21 years had their papilla diameter measured and their Tanner stage assessed. Minimal nipple development occurred from stages PH1-PH3 (2.91-4.08 mm) and B1-B3 (2.75-3.96 mm) or premenstrually (3.61 mm). Significant growth occurred beyond stages PH3, B3 (PH4-7.22 mm, Ph5-9.36 mm, B4-7.74 mm, B5-9.47 mm) and near or after menarche (7.82 mm for girls 0-2 years post-menarche, 9.23 mm for girls 2-4 years post-menarche and 9.65 mm for girls more than four years after menarche). A more objective definition for breast stages B4 and B5, based on nipple diameter, may now be feasible, thus enhancing the precision with which physiologic events occurring toward the close of puberty can be studied.