The nipple

Absence of the nipple is rare, and usually associated with amazia (congenital absence of the breast).

Supernumerary nipples not uncommonly occur along a line extending from the anterior fold of the axilla to the fold of the groin (Fig. 46.9). This constitutes the milk line of lower mammals.

Nipple retraction

This may occur at puberty or later in life. Retraction occurring at puberty, also known as simple nipple inversion, is of unknown aetiology. In about 25 per cent of cases it is bilateral. It may cause problems with breastfeeding and infection can occur, especially during lactation, owing to retention of secretions.

Treatment

Treatment is usually unnecessary, and it may spontaneously resolve during pregnancy or lactation. Simple cosmetic surgery can produce an adequate correction but has the drawback of dividing the ducts. Mechanical suction devices have been used to attempt to evert the nipple with some effect. Recent retraction of the nipple may be of considerable pathological significance. A slit-like retraction of the nipple may be due to duct ectasia and chronic periductal mastitis (Fig. 46.10a), but circumferential retraction, with or without an underlying lump, may well indicate an underlying carcinoma (Fig. 46.10b).

Cracked nipple

This may occur during lactation and be the forerunner of acute infective mastitis. If the nipple becomes cracked during lactation, it should be rested for 24—48 hours and the breast emptied with a breast pump. Feeding should be resumed as soon as possible.

Papilloma of the nipple

Papilloma of the nipple has the same features of any cutaneous papilloma (Fig. 46.11) and should be excised with a tiny disc of skin.

Retention cyst of a gland of Montgomery

These glands, situated in the areola, secrete sebum, and if they become blocked a sebaceous cyst forms.

Chancre of the nipple

This very rare condition usually occurs by infection from a syphilitic buccal ulcer in the mouth of the partner, although can be seen in the wet-nurse of a syphilitic baby. The mother of such an infant is immune to reinfection from her own child.

Eczema

Eczema of the nipples is a rare condition and is bilateral, and usually associated with eczema elsewhere on the body.

Paget’s disease

Paget’s disease of the nipple must be distinguished from the eczema.

Abnormal discharges from the nipple

Discharge can occur from one or more lactiferous ducts. Management depends on the presence of a lump (which should always be given priority in diagnosis and treatment) and of the presence of blood in the discharge or discharge from a single duct. Mammography is rarely useful except to exclude an underlying impalpable mass. Cytology may reveal malignant cells but a negative result does not exclude a carcinoma.

A clear, serous discharge may be ‘physiological’ in a parous woman or may be associated with a duct papilloma or mammary dysplasia.

A blood-stained discharge may be caused by duct ectasia or less commonly a duct papilloma or carcinoma. A duct papilloma is usually single and situated in one of the larger lactiferous ducts and is sometimes associated with a cystic swelling beneath the areola.

A black or green discharge is usually due to duct ectasia and its complications.

Treatment

Treatment must firstly be to exclude a carcinoma by occult blood test and cytology. Simple reassurance may then be sufficient, but if the discharge is proving intolerable an opera­tion to remove the affected duct or ducts can be performed. Figure 46.12 illustrates some causes of nipple discharge. Microdochectomy. It is important not to express the blood before the operation as it may then be difficult to identify the duct in theatre. A lacrimal probe or length of stiff nylon suture is inserted into the duct from which the discharge is emerging. A tennis raquet incision can be made to encompass the entire duct, or a periareolar incision used and the nipple flap dissected to reach the duct. The duct is then excised. A papilloma is nearly always situated within 4—5 cm of the nipple orifice.

Cone excision of the major ducts (after Hadfleld). When the duct of origin of nipple bleeding is uncertain or when there is bleeding or discharge from multiple ducts, the entire major duct system can be excised for histological examination without sacrifice of the breast form. A periareolar incision is made and a cone of tissue is removed with its apex lust deep to the surface of the nipple and its base on the pectoral fascia. The resulting defect is obliterated by a series of purse-string sutures. It is important to warn the patient that she will be unable to breast feed after this and may lose nipple sensation.