Drs. Spear et al. propose a new classification to evaluate the postoperative high-riding nipple.1 This ratio uses as its landmarks the nipple level, the inframammary fold, and the superior breast margin, based on a method reported previously by Mallucci and Branford.2 The method is not compared to existing classifications that measure the nipple level (as opposed to a treatment algorithm).3,4 The authors use the term “nipple displacement” synonymously with nipple malposition. Nipple displacement, however, is defined more precisely as the vertical distance between the nipple level and the level of maximum breast projection (Fig. 1).4
By consensus, the nipple is correctly positioned at the apex (i.e., the most projecting point) of the breast mound.4 Therefore, this level is the most appropriate vertical landmark for evaluation of nipple position. Measurements that do not relate the nipple level to this plane are bound to fall short. Some traditional measurements are not helpful. The distance to the sternal notch varies with torso length. The level of the inframammary crease is often hidden in photographs and is known to drop after breast augmentation and rise after vertical mastopexy, undermining its usefulness as a landmark.4 Because the correct nipple position is in relation to the breast mound only, further classification as relative, absolute, or complex is unnecessary.
The superior border of the breast (where the breast starts and the chest wall stops) is usually not a well-defined landmark and is therefore subject to interpretation, undermining the reliability of any ratios based on it. This limitation is apparent in the authors’ Figures 4 and 5.1 In these patients, the horizontal reference line appears to intersect the upper pole of the breast lower than its takeoff on the chest wall, unlike Figures 6 and 7.
The authors do not illustrate any patients with breast ptosis, in whom the inframammary fold is hidden in photographs. Presumably, the lower pole level is substituted for the inframammary fold in these patients. The authors indicate that upper-to-lower ratios greater than 45 percent are normal.1 However, values close to 100 percent would likely be abnormal, indicating that the nipples are too low. Ideally, a nipple-level classification would be applicable to both high- and low-riding nipples. These deficiencies point to the greater practicality and simplicity of using nipple displacement4 as a guide.
A “skyward” nipple inclination of 20 degrees, advocated by Mallucci and Branford,2 and repeated here,1 is an unnatural appearance; the correct nipple inclination is neutral.4 The ideal upper pole contour is not concave. Women prefer upper pole convexity5; the breast parenchymal ratio should be greater than 1:1, not less.4 Like Mallucci and Branford,2 the authors use oblique photographs. These views are difficult to standardize because of differences in rotation. Lateral photographs are preferred. Lateral images can also be used to evaluate breast projection and upper pole projection, which are other important parameters related to breast shape.4 Frontal views need to be standardized. Dropping a shoulder can affect the appearance of nipple asymmetry (authors’ Fig. 4).1
Spear et al. report using secondary augmentations and mastopexies, combinations, and human acellular dermal matrix as remedies for nipple overelevation but do not show any examples and provide little description.1 The single example of surgical treatment shows a reconstruction patient treated with a nipple-areola transposition flap, followed by another operation to inject fat and substitute a shaped implant, with some improvement but at the cost of upper pole scarring. The authors report 100 percent patient satisfaction and there is no mention of complications.
Because this is a retrospective chart review, the frequency of this complication remains unknown. Only patients who complained of the problem underwent treatment. In fact, nipple overelevation is so prevalent, this problem is often overlooked by plastic surgeons as a complication unless it is quite severe. In my review of mammaplasty publications (that no doubt include disproportionately favorable outcomes), 41.9 percent of patients had at least one overelevated nipple.6 In my own experience, this rate was 29.6 percent.7
Because correction of the high-riding nipple is so difficult, prevention is essential and merits discussion. The design of the inverted-T mammaplasty, featuring nipple transposition, consistently produces nipple overelevation, which is not prevented by limiting the vertical limb length to 5 cm.6 This problem can be minimized by (1) using the vertical mammaplasty technique with nipple repositioning rather than transposition, and (2) intraoperative determination of nipple position.7 Preoperatively marking a keyhole or mosque-dome pattern unnecessarily commits the surgeon to a nipple level. By waiting until the new breast mound has been created and then marking the nipple position at or slightly below (which is my preference today) the apex, the surgeon can better ensure that the nipple will not be located too high on the breast mound. By oversewing the nipple-areola and then marking the skin resection intraoperatively,7 skin tension is balanced, improving areola circularity and avoiding the common inverted-teardrop areola deformity.6
If a high-riding nipple is encountered, it may be treated by repositioning the implant as superiorly as possible using an open capsulotomy and lower capsule repair, combined with a horizontal elliptical inframammary skin resection, as originally described by Millard et al. (Fig. 1).8 If the patient does not have breast implants, these should be considered both to restore upper pole fullness and to act as a fulcrum, providing counterresistance to the downward pull caused by the inframammary skin resection and allowing the nipple-areola to slide up and over the implant. This skin resection procedure can be repeated if necessary. Any incisions above the areola are avoided, as they trade one problem for another. As is so often the case, an ounce of prevention is worth a pound of cure.
The author has no conflicts of interest to disclose. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kans. 66211
1. Spear SL, Albino FP, Al-Attar A. Classification and management of the postoperative, high-riding nipple. Plast Reconstr Surg. 2013;131:1413–1421
2. Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: Analysis of the ideal breast. J Plast Reconstr Aesthet Surg. 2012;65:8–16
3. Regnault P. Breast ptosis: Definition and treatment. Clin Plast Surg. 1976;3:193–203
4. Swanson E. A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012;129:982–992 discussion 993
5. Hsia HC, Thomson JG. Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation. Plast Reconstr Surg. 2003;112:312–320 discussion 321
6. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301
7. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e
8. Millard DR Jr, Mullin WR, Lesavoy MA. Secondary correction of the too-high areola and nipple after a mammaplasty. Plast Reconstr Surg. 1976;58:568–572
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