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.
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
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.
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.