Marking the position of the nipple-areola complex for mastopexy and breast reduction surgery.

In the analysis of plastic surgery of the breast, in addition to size, form, and symmetry, the appropriate position of the nipple areola has the greatest influence on our aesthetic assessment. The position of the nipple defines the point of highest projection and is a reference point for orientation during the removal of the parenchyma and skin. The static methods used for marking the location of the nipple-areola complex are based on measurements of distances from fixed anatomical points. The technique of parenchyma imbrication can be effectively applied for the positioning of the nipple. The dynamic shaping of the breast parenchyma creates the desired breast shape, shows the point of highest projection with upper pole fullness, and makes the marking of the nipple-areola complex simpler and more precise. Parenchyma imbrication can yield good results in shaping small or medium sized breasts, and in cases of breast reduction, where the parenchyma resection is less than 1000 g. On moving pictures or statues, the power of femininity as manifested in the beauty of the breasts—whether covered or uncovered—is always an arousing image. Breast surgery poses a special challenge for the plastic surgeon, as an attractive cleavage is to be created by symmetrically positioned, taut, and full breasts.1–5 The nipples should occupy the point of highest projection and be in ideal proportion to body weight and height. The beauty of the breasts is not only influenced by the shape, size, and proportions, it is also affected by the appropriate position of the nipples. In adolescence, the nipple is located on the vertical meridian, above the submammary fold, on the highest point of breast curvature, at a distance of 18 to 23 cm from the jugular notch.6,7 The change in the location of the nipples follows the changes in the shape and volume of the breast parenchyma—it moves downward with the stretching of the skin, at first to the level of the submammary fold, and then below it.8–10 The forward-pointing position of the nipples changes to a downward position. The occurrence of parenchyma dislocation and the downward movement of the nippleareola complex are influenced by many factors, including weight gain or loss, gravidity, lactation, congenital malformations, endocrine disorders, glandular hypertrophy or atrophy, the stretching and thinning of the skin, changes in the biomechanical properties of the skin, loosening of the adhesion of the muscle-parenchyma interface, decrease in the adhesion of the skin-parenchyma interface, decrease of the elasticity of breast suspensory ligaments, and the habit of not wearing a bra. In conjunction with mastopexy, breast augmentation, or breast reduction, the most important element of preoperative planning is the marking of the proper position of the nipples.11–13