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A Process for Quantifying Aesthetic and Functional Breast Surgery

I. Quantifying Optimal Nipple Position and Vertical and Horizontal Skin Excess for Mastopexy and Breast Reduction

Jia, Yihong M.D.; Wang, Xiaojun M.D.

Author Information
Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 421e-422e
doi: 10.1097/01.prs.0000438449.55529.81
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We read with great interest Dr. Tebbetts’ July 2013 article on two major procedures in breast surgery, “A Process for Quantifying Aesthetic and Functional Breast Surgery: I. Quantifying Optimal Nipple Position and Vertical and Horizontal Skin Excess for Mastopexy and Breast Reduction.”1 We are looking forward to applying his workflow to our daily practice.

Having studied this article, we have seven points where clarification or an explanation from Dr. Tebbetts would be sincerely appreciated.

  1. In the first two steps of “Quantifying Vertical Skin Excess,” the most superior point of the (postoperative) areola is marked 2 cm superior to the (postoperative) nipple position on the meridian. From this point, a distance equal to the diameter of the (postoperative) areola plus the desired nipple-to–inframmary fold distance is measured inferiorly.
    • 1.1 The desired postoperative values, rather than preoperative measurements, are used for preoperative planning and marking. Is this correct?
    • 1.2 If planned postoperative areolar diameter is not 4 cm, should the 2 cm in defining the most superior point of the (postoperative) areola be changed to 1/2 of the postoperative areolar diameter?
    • 1.3 Why is desired nipple-to–inframammary fold distance measured from the most inferior point of the postoperative areola, instead of from the postoperative nipple position, as its name suggests?
  2. In the next step of “Quantifying Vertical Skin Excess,” vertical skin excess is calculated as postoperative superior-most point of the areola—to–inframammary fold distancepostoperative areolar diameterdesired nipple-to–inframammary fold distance; a formula later defines vertical skin excess as “existing nipple-to–inframammary fold dimension − most superior point of the areola to desired nipple-to–inframammary fold distance.1
    • 2.1 Does the first formula correctly reflect Figure 9 of the original article?
    • 2.2 Is the author’s formula equivalent to vertical skin excess = preoperative nipple-to–inframammary fold distancepostoperative areolar diameterdesired nipple-to–inframammary fold distance?
    • 2.3 If the answer to both these questions is “yes,” then postoperative superior-most point of the areolar–to–intramammary fold distance should equal preoperative nipple-to–inframammary fold distance, which is obviously wrong. What is the explanation?
    • 2.4 If the present nipple is N, the author’s method first marks Ninferior measuring desired nipple-to–inframammary fold distance superiorly from the inframammary fold. Then Nsuperior is marked by bringing Ninferior to the apex of the (simulated postoperative) lower pole and projecting that level onto the breast. The plan in the vertical dimension is to bring N, Ninferior, and Nsuperior together, while preserving an areola of postoperative areolar diameter. It can be easily calculated from simple sketching that vertical skin excess equals Nsuperior− Ninferior. Does this relationship apply to the author’s own measurements? Why or why not?

There are also three minor errors that may affect the reader’s attempts at understanding and further reading: (1) In suggesting an alternative to the proposed desired nipple-to–inframammary fold distance, the article refers to “Figure 1,” which should be “Table 1”; (2) in presenting the rate of hematoma, data concerning reduction patients should be “122 reduction patients (1.6 percent)” instead of “124…”; and (3) reference 13 should be an article addressing fellow surgeons’ application of Dr. Tebbetts’ principles and techniques, but a seemingly irrelevant study is listed.

In the end, we thank the editors and reviewers for sharing Dr. Tebbetts’ practice, and we thank Dr. Tebbetts for answering our questions.


The authors have no financial interests to declare in relation to the content of this communication.

Yihong Jia, M.D.

Xiaojun Wang, M.D.

Division of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Beijing, People’s Republic of China


1. Tebbetts JB. A process for quantifying aesthetic and functional breast surgery: I. Quantifying optimal nipple position and vertical and horizontal skin excess for mastopexy and breast reduction. Plast Reconstr Surg. 2013;132:65–73


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