Journal Logo


Repairing the High-Riding Nipple with Reciprocal Transposition Flaps; and Classification and Management of the Postoperative, High-Riding Nipple

Bovill, Esta S. Ph.D., F.R.C.S.(Plast.); Macadam, Sheina A. M.D.; Lennox, Peter A. F.R.C.S.

Author Information
Plastic and Reconstructive Surgery: January 2014 - Volume 133 - Issue 1 - p 57e-58e
doi: 10.1097/
  • Free


We read with interest the recent article by Spear et al.1 describing a useful technique for correction of the postoperative, high-riding nipple, and the subsequent review and classification.2 We too have found nipple-sparing mastectomy reconstruction with either expanders or single-stage implants to confer an excellent aesthetic outcome in suitable patients. With increasing volume and laxity of the skin envelope, however, the potential for shear at the mastectomy flap/implant pocket interface increases, manifest by a tendency for the nipple-areola complex to migrate superolaterally during the postoperative recovery and/or expansion phase. This aesthetically undesirable outcome may also be exacerbated by, but is not exclusive to, postreconstruction radiotherapy.

Several other solutions have been described in the literature, including techniques where the nipple is lowered through a buttonhole,3 transposed as a flap, or Z-plasty.4 Excision and repositioning as a graft may result in the least scarring, but at the risk of nipple loss. Techniques that involve elevating the entire breast relative to the nipple have been described both by elevating the inframammary fold3 and with the use of implants or tissue expanders,3,5 but are less useful for correcting multiple vectors of displacement. Thus, given that these techniques may be complex and often provide suboptimal results,4 prevention should be preferable to cure. We currently use a simple suture technique to anchor the spared nipple-areola complex to the underlying implant pocket, which maintains its position on the breast mound throughout the expansion/postoperative period.

The nipple-sparing mastectomy is performed and submuscular pocket created as described previously. Care is taken to ensure optimal placement of the device such that the nipple-areola complex is located and marked at the pinnacle of the breast mound, or for expanders, once the desired intraoperative fill volume is achieved. The nipple-areola complex dermis is then tacked to the muscle pocket using three 4-0 absorbable monofilament anchoring sutures (Fig. 1). The radial mastectomy scar may also be anchored in this way (Fig. 2). Intraoperative sitting of the patient is invaluable, not only in the key assessment of the final nipple-areola complex placement but also in ensuring that no adverse skin folding or traction on the nipple-areola complex is caused by the anchoring sutures. A drain placed between the muscle and skin flap reduces potential shear. The remainder of the procedure and postoperative management is unaltered.

Fig. 1
Fig. 1:
On-table marking of the nipple-areola complex.
Fig. 2
Fig. 2:
Three-point fixation of the nipple-areola complex to the underlying implant pocket.

We have successfully used this technique over a series of 25 consecutive alloplastic reconstructions following nipple-sparing mastectomy, evenly split between two-stage expander and single-stage reconstructions. Postoperative irradiation was also administered in 16 percent. No revisions to the nipple-areola complex were required over the median 6-month follow-up period (range, 2 to 12 months). Given that the technique results in negligible additional operative time, complications, and costs, we suggest that it be included among solutions to this difficult problem.


Dr. Lennox is a speaker for LifeCell Corp.

Esta S. Bovill, Ph.D., F.R.C.S.(Plast.)

Sheina A. Macadam, M.D.

Peter A. Lennox, F.R.C.S.

Division of Plastic Surgery

University of British Columbia, and

Burn, Plastic & Trauma Unit

Vancouver General Hospital

Vancouver, British Columbia, Canada


1. Spear SL, Albino FP, Al-Attar A. Repairing the high-riding nipple with reciprocal transposition flaps. Plast Reconstr Surg. 2013;131:687–689
2. Spear SL, Albino FP, Al-Attar A. Classification and management of the post-operative, high-riding nipple. Plast Reconstr Surg. 2013;131:1413–1421
3. 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
4. Frenkiel BA, Pacifico MD, Ritz M, Southwick G. A solution to the high-riding nipple-areola complex. Aesthetic Plast Surg. 2010;34:525–527
5. Colwell AS, May JW Jr, Slavin SA. Lowering the postoperative high-riding nipple. Plast Reconstr Surg. 2007;120:596–599


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2014American Society of Plastic Surgeons