Breast dimpling—the puckering or retraction of skin on the breast—results from abnormal attachment of the skin to underlying tissue. It suggests an inflammatory or malignant mass beneath the skin surface and usually represents a late sign of breast cancer; benign lesions usually don't produce this effect. Dimpling usually affects women older than age 40, but also occasionally affects men.
Because breast dimpling occurs over a mass or induration, the patient usually discovers other signs before becoming aware of the dimpling. A thorough breast examination may reveal dimpling and alert the patient and nurse to a problem.
Obtain a medical, reproductive, and family history, noting factors that place the patient at a high risk for breast cancer. Ask about pregnancy history because women who haven't had a full-term pregnancy before age 30 are at higher risk for developing breast cancer. Has her mother or a sister had breast cancer? Has she herself had a previous malignancy, especially cancer in the other breast?
Ask the patient if she has noticed changes in the shape of her breast. Is any area painful or tender, and is the pain cyclic? If she's breast-feeding, has she recently experienced high fever, chills, malaise, muscle aches, fatigue, or other flulike signs or symptoms? Can she remember sustaining trauma to the breast?
Carefully inspect the dimpled area. Is it swollen, red, or warm to the touch? Do you see bruises or contusions? Ask the patient to tense her pectoral muscles by pressing her hips with both hands or by raising her hands over her head. Does the puckering increase? Gently pull the skin upward toward the clavicle. Is the dimpling exaggerated?
Observe the breast for nipple retraction. Do both nipples point in the same direction? Are the nipples flattened or inverted? Does the patient report nipple discharge? If so, ask her to describe the color and character of the discharge. Observe the contour of both breasts. Are they symmetrical?
Examine both breasts with the patient lying down, sitting, and then leaning forward. Does the skin move freely over both breasts? If you can palpate a lump, note its size, location, consistency, mobility, and delineation. What relation does the lump have to the breast dimpling? Gently mold the breast skin around the lump. Is the dimpling exaggerated? Examine breast and axillary lymph nodes, noting any enlargement.
Breast abscess.Breast dimpling sometimes accompanies a chronic breast abscess. Associated findings include a firm, irregular, nontender lump and signs of nipple retraction, such as deviation, inversion, or flattening. Axillary lymph nodes may be enlarged.
Breast cancer.Breast dimpling is an important but somewhat late sign of breast cancer. A neoplasm that causes dimpling is usually close to the skin and at least 1 cm in diameter. It feels irregularly shaped and fixed to underlying tissue, and it's usually painless. Other signs of breast cancer include peau d'orange, changes in breast symmetry or size, nipple retraction, and a unilateral, spontaneous, nonmilky nipple discharge that's serous or bloody. (A bloody nipple discharge in the presence of a lump is a classic sign of breast cancer.) Axillary lymph nodes may be enlarged. Pain may be present, but isn't a reliable symptom of breast cancer. A breast ulcer may appear as a late sign.
Fat necrosis.Breast dimpling from fat necrosis follows inflammation and trauma to the fatty tissue of the breast (although the patient usually can't remember such trauma). Tenderness, erythema, bruising, and contusions may occur. Other findings include a hard, indurated, poorly delineated lump, which is fibrotic and fixed to underlying tissue or overlying skin as well as signs of nipple retraction. Fat necrosis is difficult to differentiate from breast cancer.
Mastitis.Breast dimpling may signal bacterial mastitis, which usually results from duct obstruction and milk stasis during breast-feeding. Heat, erythema, swelling, induration, pain, and tenderness usually accompany mastitis. Dimpling is more likely to occur with diffuse induration than with a single hard mass. The skin on the breast may feel fixed to underlying tissue. Other possible findings include nipple retraction, nipple cracks, a purulent discharge, and enlarged axillary lymph nodes. Flulike signs and symptoms (such as fever, malaise, fatigue, and aching) commonly occur.
▪ Because any breast problem can arouse fears of altered body image, mutilation, loss of sexuality, and death, allow the patient to express her feelings and provide emotional support.
▪ Prepare the patient for diagnostic testing, such as mammography, thermography, biopsy, ultrasonography, and cytology of nipple discharge.
▪ Explain what to expect during diagnostic testing.
▪ Explain the importance of clinical breast examination and mammography following the American Cancer Society guidelines.
▪ Teach the patient how to perform breast self-examination.
▪ If the patient breast-feeds and has mastitis, advise her to pump her breasts to prevent milk stasis, to discard the milk, and to substitute formula until the breast infection resolves.
▪ Teach the patient about the cause of breast dimpling and the treatment plan after a diagnosis is established.
Read excerpts from these other book chapters related to Breast dimpling:
Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
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Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7 
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