The breast is a subcutaneous structure situated between the second and sixth ribs.4,6,7 The ideal breast is not ptotic, and its shape is maintained by taut Cooper’s ligaments. The ideal nipple position needs to be defined in 2 planes. In the y-axis or vertical plane, it should be in the middle of the breast or just lateral to the midline.4 In the x-axis or horizontal plane, it should be level with the midpoint of the humerus, or marginally (1.5 mm) below.4,5 The curve of the IMF should form a semicircle,4 and its inferior most point should be situated at the level of the sixth rib.4,8 Westreich4 in his study of the “perfect” breast did not find a correlation between body length (patient height) and nipple position, which was always situated at the level of the midhumerus.
As the breast enlarges, the nipple position deviates from the breast meridian (Figs. 1–3). This is more pronounced in patients with a raised BMI (Fig. 3). This nipple displacement may be explained by changes in the ligamentous anatomy.9,10 Matousek et al9 reported that the breast is globally surrounded by taut ligaments. The medial breast ligaments are short and taut compared with the lateral ligaments, and hence, in some patients, as the breast enlarges, the nipple is displaced medially from the breast meridian. This occurred in 19% (19 patients; 38 breasts) of patients (Table 1) in this study. In contrast, the ligaments forming the inferior-lateral breast base are more tenuous and appear to stretch more easily, resulting in inferolateral displacement of the nipple. In this study, the nipple position was found to be displaced laterally to the breast meridian in 45% of cases (45 patients; 90 breasts; Fig. 3). Clinically, extrapolating the data from this study suggests that if the preoperative nipple position is used to mark the breast midline (thus, nipple position after breast reduction), the new nipple position would be situated either too far medially and/or laterally in 64% of cases, marring the aesthetic results.
This study also shows that, as the breast enlarges, the position of the IMF also descends(Fig. 4). Again, this is aggravated in patients as the BMI increases (Fig. 5). This implies that as the breast enlarges globally, the base/footplate also increases in surface area. This descent of the IMF is also probably due to attenuation of the superficial ligaments constituting the IMF. There was a tendency for patients with increasing age to also have a lower situated IMF, but this did not reach statistical significance (P = 0.54; Fig. 6).
The position of the IMF was never ever at the midpoint of the humerus—the ideal aesthetic point4 in any patients in this study. In fact, more commonly, the projected IMF position was, on average, only 5 cm above the cubital fossa, indicating the extend of its descent. Hence, it is suggested that the position of the IMF in breast reduction be fixed to prevent further descent.11,12 This is achieved by anchoring the IMF to both rib periosteum and pectoralis fascia. Additionally, this maneuver splints the IMF, which reduces tension at the angle of sorrow.11 Interestingly, IMF fixation is well described in breast augmentation3,13,14 to prevent inferior migration of the prosthesis.
The lower position of the IMF has other clinical implications: in most techniques of breast reduction, the new nipple position is marked relative to the position of the IMF (Pitanguy’s point). If Pitanguy’s point is used to mark the new nipple position at breast reduction, the new nipple position would be situated much lower than middle of the length of the humerus. In fact, patients in this study would have the new nipple position (on average) positioned approximately three quarters down the length of the humerus. In contrast, if the midhumeral point was used, the new nipple position would be situated too high after breast reduction.
It is also our policy to mark the new nipple position at the level of the IMF. (Pitanguy’s point). The descent of the IMF implies that the new nipple position is marked a longer distance from the suprasternal notch than if the midhumeral point is used. To maintain the aesthetic ratio of SN-N:N-IMF, the distance from N-IMF (vertical limbs in keyhole/inverted T pattern) also needs to be made longer. In patients having a vertical mammoplasty, the new nipple is marked even lower than the position of the IMF projected onto the breast, with the obvious implications. Extrapolating these data suggests that patients may need to be advised of a longer, flatter upper pole, which is likely to occur after reduction.
The superomedial pedicle is becoming more popular in breast reduction due to its robust and reliable vascularity.14 When the NAC is displaced laterally relative to the breast meridian, rotation and inset of the pedicle are enhanced. However, when the NAC is displaced medially, a conventionally designed keyhole pattern would impede pedicle rotation, even if a back cut is performed. Iorio et al15 reported lengthening the vertical limb of the keyhole to address the medially deviated nipple areola complex.
There are some shortcomings to this study. Macromastia is a clinical diagnosis of enlarged breasts, and all the patients who presented had clinical symptoms of backache and shoulder pain, rather than aesthetic concerns. No patients with ideal breasts were seen, so the comparison of macromastia with the ideal breast was derived from the literature. All the patients were measured in the standing position. Furthermore, there were no cases of gross chest asymmetry, but minor chest wall asymmetry may have been missed. Additionally, this study is not addressing the outcome of these patients after breast reduction but rather investigated anthropometric changes that occur in patients presenting with enlarged breasts.
This is the first study to report on changes occurring in 100 consecutive patients presenting for breast reduction. As the breast enlarges, there is displacement of the nipple areolar complex, either laterally (45%) or medially (19%) from the breast meridian. This nipple displacement is more common in patients as the BMI increases. Hence, using the (preoperative, but displaced) nipple position to mark the breast midline may result in a new nipple position that is not on the breast meridian. This study also shows that the IMF descends in patients with breast hypertrophy, again these changes are aggravated as the BMI increases. Hence, if Pitanguy’s point is used to mark the new nipple position after breast reduction, this will result in the new nipple been situated in a lower position than in the middle of the humerus.
We wish to acknowledge Shameem Jaumdally for assistance with the statistical analysis.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
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