Classification aids high nipple surgery decision-making

By Lynda Williams, Senior medwireNews Reporter

Surgeons have devised a system to help determine the severity of high nipple-areola complex (NAC) in patients after cosmetic or reconstructive breast surgery.

The team compared the vertical distance from the top of the breast to the nipple compared with the vertical height of the entire breast to give a percentile, where zero percentile is the upper breast border and 100 percentile is the lower border. High NAC was classified as mild (45-35th percentile), moderate (34-25th percentile) or severe (<25th percentile).

Scott Spear (Georgetown University Hospital, Washington, DC, USA) and co-workers applied the system to 41 breasts in 25 women (average age 44.3 years). In all, 27% of patients were classified as having mild NAC displacement, 56% moderate displacement, and 17% severe displacement.

The researchers also classified nipple displacement as being relative, absolute, or complex using the relationship between the sterna notch, NAC, and inframammary fold.

High NAC was reported by the patients after an average of 2.5 procedures. Thirty-two percent of patients had undergone nipple-sparing mastectomy, 29% augmentation and mastopexy, 27% augmentation alone, 10% mastopexy, and 2% skin-sparing mastectomy with nipple reconstruction.

Overall, surgical intervention was recommended for 54% of breasts, and correction was performed on 36% of mild cases, 56% of moderate cases, and 71% of severe cases. Corrective procedures included mastoplex, reciprocal transposition flaps, augmentation and mastopexy, augmentation alone, and reciprocal skin graft. Augmentation used human acellular dermax matrix to support the inframammary fold and maintain the implant in a submuscular position.

After a median of 4 months, all patients who underwent revision surgery for high NAC position were satisfied with the result, Spear et al report in Plastic and Reconstructive Surgery.

The team explains that the revision procedure depends on whether the patient will benefit most from correction of the position of the breast mound, the nipple, or both.

"Whether to initially address the breast or the nipple should be dictated by the more severe or more easily correctable deformity," the researchers recommend.

"Generally, it is preferable to correct the position of the breast mound first. Ultimately, the proposed classification system takes into account both the nature and the severity of the high riding nipple in an effort to guide the best surgical management."

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