Turkish Journal of Plastic Surgery

: 2022  |  Volume : 30  |  Issue : 1  |  Page : 5--10

Use of the superior breast border landmark for planning reduction mammoplasty: Objectively analysis with long-term follow-up period

Can Ilker Demir, Emrah Kağan Yaşar, Mehdi Asadov, Murat Şahin Alagöz 
 Department of Plastic, Reconstructive and Aesthetic Surgery, Kocaeli University Faculty of Medicine Plastic, Izmit, Turkey

Correspondence Address:
Dr. Can Ilker Demir
Kocaeli Üniversitesi Tip Fakültesi Umuttepe Kampüsü, Izmit, Kocaeli


Aims: The aim of this study was to evaluate the reliability of the upper breast border (UBB) in determining the new location of the nipple and to objectively analyze long-term nipple position compared to pre-operative markings. Patients and Methods: Thirty-eight patients (76 breasts) patients who underwent superomedial pedicle, reverse-T scar breast reductions and who had long-term (>12 months) follow-up data were included. The sternal notch to the nipple, nipple to inframammarian fold (N-IMF), nipple to chest midline, and areola diameter were measured and recorded at the time of preoperative, markings, and long-term follow-up visit. Statistical Analysis Used: The differences in measurements were compared using a paired, two-tailed T-test, and a P < 0.05 was considered statistically significant. Results: The average follow-up time was 17.9 months (range 12–41 months). The nipple was located, on average, 0.95 cm lower on postoperative assessment compared to preoperative marking (P = 0.060). The nipple was located, on average, 0.75 cm lateral on postoperative assessment compared to preoperative marking (P < 0.001). The average postoperative increase in the N-IMF distance between marking and the long-term follow-up visit was 1.75 cm (P < 0.001). The areola diameter was increased 0.21 cm on postoperative assessment compared to preoperative marking (P < 0.001). Conclusions: The nipple position moved down and the N-IMF distance was greater than planned. However, the nipple was usually located at the area of the greatest projection of the breast due to almost equal elongation of the superior and inferior poles. The outcome of breast reduction procedures in which the postoperative nipple position is planned using the UBB was good.

How to cite this article:
Demir CI, Yaşar EK, Asadov M, Alagöz M&. Use of the superior breast border landmark for planning reduction mammoplasty: Objectively analysis with long-term follow-up period.Turk J Plast Surg 2022;30:5-10

How to cite this URL:
Demir CI, Yaşar EK, Asadov M, Alagöz M&. Use of the superior breast border landmark for planning reduction mammoplasty: Objectively analysis with long-term follow-up period. Turk J Plast Surg [serial online] 2022 [cited 2022 Jun 29 ];30:5-10
Available from: http://www.turkjplastsurg.org/text.asp?2022/30/1/5/333752

Full Text


The aim of breast reduction surgery is to create a breast with an ideal shape, form, and volume. However, these criteria alone are not sufficient for a successful result. Symmetrical and correctly positioned nipples are essential for good postoperative outcomes. The ideal nipple position is defined by the vertical meridian of the breast, above the inframammarian fold (IMF) and in the area of the breast that projects the most.[1],[2] When the breast has sagged because of advanced age, pregnancy and giving birth or following weight loss, this point changes inferiorly and its tip turns upward. Therefore, in breast reduction surgery, the nipple-areola complex (NAC) is transposed to an ideal position using various pedicle techniques. The most important step in this procedure is the determination of the final postoperative nipple location, which is often determined by measurements made between fixed anatomical points.[3],[4] Positioning of the nipple based on the sternal notch-nipple distance (18–23 cm), finger test, the bisecting point of the distance between the olecranon and acromion, the breast parenchyma imbrication method, and the projection of the IMF on the breast are the most common techniques.[5],[6] Planning of the postoperative nipple position using fixed anatomical points may lead to variable outcomes, as the location of the breast on the chest wall, its volume, upper pole fullness, and the amount of ptosis may differ from patient to patient. Using these techniques, there is a risk of displacement of up to 1.5 cm in the vertical plane in the long term.[5] For instance, planning according to the distance to the sternal notch in high-or low-set breasts or planning according to the IMF in a ptotic breast may result in a less than ideal result.

Hall-Findlay suggested that patient-specific planning using the upper breast border (UBB) is more effective in achieving the ideal result.[7] In our clinical practice, the new nipple is placed 7–9 cm inferior to the UBB in preoperative drawings, and the rest of the planning is based on this reference point. Patients were operated on using the superomedial pedicled inverted-T scar technique. Objective assessment of the positioning of the postoperative nipple was made by measuring the nipple position, breast lower pole length, NAC diameter, and nipple-midline distance at least 1 year after surgery.

The aim of this study was to evaluate the reliability of the UBB when planning reduction mammoplasty by statistically comparing pre-, post-operative, and planned measurements.

 Patients and Methods

Between April 2017 and May 2019, 38 patients (76 breasts) who underwent reduction mammoplasty were available for long-term follow-up visits at least 1 year after surgery and were included in this study. Local institutional ethics committee approval was obtained (project no: 2021/214), and all procedures were in accordance with the Declaration of Helsinki. Patients with a previous history of breast surgery were excluded from the study. Patient comorbidities such as diabetes mellitus, rheumatological disease, coronary artery disease, hypertension, and smoking were noted. The average body mass index (BMI) of the patients, complications included seroma/hematoma, cellulitis, superficial nipple necrosis, and the surgical revision rate were recorded. Excision specimen weights were recorded. Preoperative marking was performed in all patients (see below). In addition, the following postoperative measurements were made, at least 1 year postoperatively: The distance from the nipple to inframammarian fold (N-IMF); suprasternal notch to nipple (SSN-N); nipple to chest midline (N-M); and areolar diameter.

Markings were made in the standard position with the patient standing. Standard breast landmarks were marked, including the SSN, M, IMF, breast meridian, and UBB. The breast was pushed slightly up and the point where it incorporated the chest wall was marked as the UBB. This border often starts from the inferior border of the preaxillary fold or a few centimeters inferior to this border. A line, between 7 cm lateral to the clavicula and 9–11 cm lateral to the midline, was determined as approximately the breast meridian. The anticipant nipple position was marked 7–9 cm below the UBB on the breast meridian. This distance was kept shorter in patients with small breast expectations, and longer in patients with larger breast expectations. The superior border of the NAC was marked at 2 cm above the nipple. A “mosque dome pattern,” measuring 4.2 cm diameter, was marked on the breast. The breast was transposed lateral-superior and medial-superior respectively, and the vertical axis of the meridian was transposed to the displaced medial and lateral breast tissue. To prevent tight closure, the amount of excision was definitely checked with the pinch test. After the N-IMF distance was determined (between 7 and 9 cm), it was extended medially and laterally and combined at the level of the IMF. Smooth and curvilinear horizontal lines were drawn to prevent dog-ear deformity. The base of the pedicle was designed such that one-half of the base was in the areolar opening superiorly and terminating at approximately 2 cm superior to the junction of the medial vertical and horizontal limbs inferiorly. The pedicle base width measured 8–10 cm approximately, a one-to-one ratio of length to the base width. The drawings were checked bilaterally for symmetry [Figure 1].{Figure 1}

All surgeries were performed under general anesthesia. A single dose of intravenous antibiotic was given before the incision. Local anesthesia infiltration was not used in any patient. Liposuction was not used for any patient. A drain was placed in each breast and was removed when the daily amount was <30 cc. The patients were discharged after an average of 1–2 days of follow-up in the hospital. All patients used antibiotic treatment for 1 week and supportive bras for 1 month. Patients were asked not to exercise for a month [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

Statistical analysis

When evaluating the findings of the study, IBM SPSS Statistics, version 22 (IBM Inc., Armonk, NY, USA) was used for statistical analysis. Suitability of parameters to normal distribution was evaluated with Kolmogorov-Smirnov and Shapiro Wilks tests and it was found that all data were normally distributed.

The differences in preoperative markings and postoperative measurements were compared using a paired, 2-tailed t-test, and P < 0.05 was considered statistically significant.


The average age of the patients was 34.3 (range 20–54) years. The average resection weight was 893.8 g (250–1680) for the right breast and 879.9 g (250–1660) for the left breast. The average follow-up time was 17.9 months (range 12–41 months). The average BMI was 27.5 (range 22.3–30.1).

The average distance from the sternal notch to the nipple was 29.91 ± 3.73 cm before surgery, 20.24 ± 1.11 cm at the marking, and 21.15 ± 1.48 cm at the long-term follow-up visit. The average inferior displacement of the nipple between the marking and long-term follow-up visit was 0.95 cm (−1 to + 3.5). This change was not statistically significant (P = 0.060). The average distance from the nipple to the IMF was 15.03 ± 2.18 cm before surgery, 8.79 ± 0.47 cm at the marking, and 10.44 ± 1.58 cm at the long-term follow-up visit. The average increase from the nipple to the IMF between the marking and long-term follow-up visit was 1.75 (0–4.0) cm. This change was statistically significant (P < 0.001). The average preoperative areolar diameter was 7.75 ± 0.75 cm. The fixed diameter of our areolar template was 4.2 cm. The average areolar diameter was 4.22 ± 1.17 cm at the long-term follow-up visit. The average increase of the areola diameter between the marking and long-term follow-up visit was 0.21 (−0.7 to +1) cm. This change was statistically significant (P < 0.001). The average distance from the nipple to the midline was 14.12 ± 1.46 cm before surgery, 10.14 ± 0.84 cm at the marking and 11.06 ± 1.0 cm at the long-term follow-up visit. The average increase from the nipple to midline between the marking and long-term follow-up visit was 0.75 (−2.4 to + 1.5) cm. This change was statistically significant (P = 0.035) [Table 1] and [Table 2].{Table 1}{Table 2}


The beauty of the breast is closely related to the position of the nipple as well as the shape, volume, and projection. There are different opinions regarding the ideal position of the nipple. Blondeel et al.[8] felt that the breast should be slightly laterally to the meridian and the most projected point of the breast is more aesthetically successful. However, Hall-Findlay[9] suggested that it is difficult to bring the superiorly located nipple to its normal position and that the midpoint of the breast should be slightly inferior and lateral to the meridian. Other authors have suggested that it should be above or slightly inferior to the sub-mammary fold, at the highest point of the breast curvature or at a distance of 18–23 cm from the jugular notch.[1],[2],[10] This position is disrupted by displacement to the inferior of the sub-mammarian fold over time, due to changes in breast volume and shape.[11],[12] To achieve ideal positioning of the NAC ideally, reduction mammoplasty surgery that combines various pedicle techniques and skin excision patterns is required. The most important step of these procedures is to determine the position of the nipple since it is the reference point for the amount of tissue to be excised. However, parameters such as the length of the vertical legs and pedicle thickness must be carefully planned.

The new nipple position is often determined using fixed anatomic landmarks of the body. Most surgeons have recommended determination using the preoperative IMF level. Positioning based on the sternal notch to nipple distance (18–23 cm), finger test, the bisecting point of the distance between the olecranon and acromion, and the breast parenchyma imbrication method is other commonly used methods.[5],[6] In these methods, there is a risk of displacement of up to 1.5 cm over the long term.[5] This displacement is affected by preoperative planning as well as the technique used. To reduce this risk, the placement of the breast on the chest wall and breast footprints should be carefully evaluated in preoperative drawings. For example, if planning according to the SSN in a “low breast” with a long clavicula-upper pole distance, this may result in excessive tissue excision and an excessively high nipple. For this reason, analyzing the effect of planning on footprints will increase result in better esthetic outcomes. In reduction mammoplasty surgery, the superior footprint, where the UBB incorporates the chest wall, does not change. For this reason, Hall-Findlay suggested that the UBB is a perfect anatomical landmark in planning and that determining the nipple according to the upper pole of the breast is more successful in achieving the goal.[7] This border can be marked easily when the breast is folded upward but usually cannot be determined in the patients with high BMI and a thick subcutaneous fat layer. [Figure 4] shows how the method of determining the nipple affects the postoperative result.{Figure 4}

There have been many studies evaluating long-term nipple position and inferior pole distance after breast reduction surgery.[13],[14],[15],[16],[17],[18],[19] Bitik and Uzun,[20] in a study where the upper margin of the NAC was planned at the IMF level, found that there was a 1 cm superior displacement of the nipple in the long term and suggested that the vertical pillars should be planned in the supine position where the effect of gravity disappears. Similarly, Ahmad and Lista[18] showed that a superomedial pedicle in the vertical scar technique resulted in a displacement of 1 cm superiorly and attributed this to the vertical pillars supporting the NAC. Smithson et al.[19] observed that the notch-nipple distance lengthened in parallel with the amount of tissue excised. These results showed that this elongation is not related to the amount of excision. Freiberg and Carr[15] showed that the SSN-N and N-IMF distances extended by < 1 cm and this difference was not statistically significant. From these studies, it may be concluded that the NAC is displaced in the vertical plane in the long term, regardless of the technique used after breast reduction surgery and the amount of excised tissue. We contend that this is due to mistakes in preoperative planning, along with residual volume, skin quality, and body weight changes. Since planning the nipple at the incorrect point before surgery will directly affect the amount of tissue remaining, it will result in displacement, regardless of the technique used. Thus, in our practice, preoperative drawing is begun by firstly determining the new nipple position. This point is positioned 7–9 cm inferior to the UBB and 9–11 cm lateral to the midline. Exact measurements within these ranges are decided according to the breast volume desired by the patient. Longer measurements are appropriate in patients who want large volume breasts. By making the remaining markings according to this reference point, it was possible to achieve a result close to our predicted target, using the superomedial pedicle inverted-T scar technique.

While the average planned SSN-N distance was 20.12 cm, this distance was on average 21.07 cm at a mean follow-up of 17.9 months. In contrast to other studies, there was an average of 0.95 cm (−1 to + 3.5) inferior displacement of the nipple, but it was not significant (P > 0.05). In our opinion, the most important reason for this displacement was the natural result of aging and time-dependent gravity. Another factor may be the contracture of the horizontal part of the inverse-T scar that pulls the nipple inferiorly. Tight closure may increase the risk of contracture in the scar, distorting both the location of the nipple and the shape of the NAC. Tension-free closure and excision of the skin if indicated, can reduce this risk.

In numerous studies, the NAC is replaced superiorly. This is undesirable because complicated surgical procedures are required to correct this. One of the most important reasons is sagging, due to too much volume remaining in the lower pole. Careful planning of vertical pillars is therefore important. Studies have shown that the inferior pole distance increases in the long term.[17],[20] This must be taken into consideration in planning. If the length of the pillars is left longer than necessary, excess glandular tissue in the lower pole of the breast will sag, resulting in the superior displacement of the nipple or bottoming-out deformity. In contrast, if the pillars are planned too short and too much tissue is excised, displacement is inevitable due to lower pole failure. In our technique, the aim was to keep the vertical pillar distance equal to the UBB-N distance breast or a little longer and keeping the nipple at the midpoint of the breast. This distance increased in the long term by an average of 1.75 cm. We attribute this to the fact that the nipple maintains its position relative to the reduced breast because of the balanced elongation in the distance from the superior and inferior borders of the breast. Another important point is that the amount of glandular tissue left in the inferior pole prevented the breast from sagging from its own weight. For this reason, the skin and glandular tissue lengths in the pillars should be planned equally and measurements should be made again during the operation. Consequently, we observed that the lower pole of the breast sagged more than the nipple clinically (1.75-0.95 = 0.8 cm). According to this observation, we believe that planning the N-IMF distance 0.8 cm shorter than the UBB to nipple the nipple-areolar complex would be at the proper position in the long term.

Displacement of the nipple in the horizontal plane is less uncomfortable than in the vertical plane, and it is recommended to be slightly lateral to the breast meridian.[8],[21] In our study, the average distance of the nipple to the midline in preoperative drawings was 10.15 cm, which had increased to average of 10.9 cm in the long term. There was an average of 0.75 cm (−2.4 to + 1.5) lateral displacement from the planned position, and this was statistically significant (P = 0.035). Since slight lateralization of the nipple is acceptable, we recommend planning the nipple on the breast meridian. The areola diameter increased by a mean of 0.21 cm in the long term, due to the nature of the scar.

These results provide objective measurements to confirm our supposition that the NAC migrates to the inferior and lateral positions at long-term follow-up when compared with preoperative skin markings. In addition, it was confirmed that the distance from the N-IMF lengthens over time, but pseudoptosis does not occur following this procedure. We believe that the vertical pillars should be marked slightly shorter than the UBB-N distance so that in the long term, the nipple-areolar complex would be at the proper position and the UBB is a useful landmark in planning reduction mammoplasty surgery. The limitation of the study is that there was no control group.


The long-term stability of the position of the NAC in this study suggests that this marking technique is a predictable and dependable option for primary breast reduction. Further, larger comparative studies using other nipple placement techniques may support our findings. If our results are confirmed, this will lead to improved outcomes after primary breast reduction surgery in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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