Ideas and Innovations
Marking the Position of the Nipple-Areola
Complex for Mastopexy and Breast Reduction
Surgery
Gusztáv Gulyás, M.D., Ph.D.
Budapest, Hungary
Give me a place to stand and rest my lever on, and I can
move the earth.
—Archimedes (287–212 B.C.)
In the analysis of plastic surgery of the breast,
in addition to size, form, and symmetry, the ap-
propriate 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 paren-
chyma and skin. The static methods used for
marking the location of the nipple-areola com-
plex are based on measurements of distances
from fixed anatomical points. The technique of
parenchyma imbrication can be effectively ap-
plied for the positioning of the nipple. The dy-
namic shaping of the breast parenchyma creates
the desired breast shape, shows the point of high-
est projection with upper pole fullness, and
makes the marking of the nipple-areola complex
simpler and more precise. Parenchyma imbrica-
tion can yield good results in shaping small or
medium sized breasts, and in cases of breast re-
duction, 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 uncov-
ered—is always an arousing image. Breast
surgery poses a special challenge for the plas-
tic surgeon, as an attractive cleavage is to be
created by symmetrically positioned, taut,
and full breasts.1–5 The nipples should oc-
cupy the point of highest projection and be
From the National Institute of Oncology. Received for publication April 17, 2003; revised July 15, 2003.
DOI: 10.1097/01.PRS.0000122404.10073.55
2085
in ideal proportion to body weight and
height. The beauty of the breasts is not only
influenced by the shape, size, and propor-
tions, 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 nipple-
areola complex are influenced by many fac-
tors, including weight gain or loss, gravidity,
lactation, congenital malformations, endo-
crine disorders, glandular hypertrophy or at-
rophy, the stretching and thinning of the
skin, changes in the biomechanical proper-
ties of the skin, loosening of the adhesion of
the muscle-parenchyma interface, decrease
in the adhesion of the skin-parenchyma in-
terface, decrease of the elasticity of breast
suspensory ligaments, and the habit of not
wearing a bra. In conjunction with mas-
topexy, breast augmentation, or breast re-
duction, the most important element of pre-
operative planning is the marking of the
proper position of the nipples.11–13
2086
METHODS
Positioning of the Nipple Based on Statistical Data
Because of individual variations in physical
features, the positioning of the nipple based
on statistical data (optimal jugulum-nipple dis-
tance, 18 to 23 cm) is only useful in terms of
orientation. The expected height of the nip-
ples must in all cases be determined through
individual measurements (Fig. 1).
Marking the Location of the Nipples with the Use
of Fingers
The “finger test” is the most commonly used
technique, where the four fingers are placed in
the submammary line, and the thumb, in op-
position to the middle finger, shows the ex-
pected height of the nipple (Fig. 2).
Projection of the Lateral Endpoint of the
Submammary Fold onto the Line of the
Breast Meridian
The submammary fold crosses the lateral ax-
illary line and continues toward the back. From
the lateral endpoint of the submammary fold, a
horizontal line is drawn onto the frontal sur-
face of the chest and the nipple is placed on
the point of intersection along the breast me-
ridian. As a means of marking the expected
position of the nipple, this method is less
widely used (Fig. 3).
FIG. 1. Breast asymmetry, hypertrophy, ptosis, and nipple-
areola complex position above and under the submammary
line. Distance from the left nipple to the jugular notch is 25
cm, and that from the right nipple to the jugular notch, 21.5
cm.
PLASTIC AND RECONSTRUCTIVE SURGERY, June 2004
FIG. 2. Four-finger test, showing nipple positioning. The
thumb is in opposition to the middle finger.
The Lassus Method for Marking the Position of the
Nipple-Areola Complex
The technique invented by Claude Lassus de-
termines the bisecting point of the distance be-
tween the olecranon and acromion in a standing
position with arms at the sides. This height is also
marked on the breast meridian in the horizontal
plane. The upper edge of the areola is located 2
cm below this point (Fig. 4).14
The Method of Breast Parenchyma Imbrication
The previous methods mark the expected
height of the nipple-areola complex on the
breast meridian in such a way that this height is
related to a fixed point, the submammary line
or the midpoint of the olecranon-acromion
distance on the upper arm. Dynamic imbrica-
tion recreates the optimal shape and form of
the breast parenchyma in a fashion similar to
the modification by molding of a round sili-
cone breast implant to a conical one (Fig. 5).
Through the manual reshaping of the breast
parenchyma into a conical shape, the method
of dynamic imbrication reveals the position
that indicates the point of highest projection
along the breast meridian. The marking of this
point determines the central location of the
nipple. In a standing position, the meridians of
the breasts are marked under and above the
nipples. In a sitting position facing the patient,
Vol. 113, No. 7 / POSITION OF THE NIPPLE-AREOLA COMPLEX
FIG. 3. (Left) The lateral submammary line projection to the breast. The position of the new
nipple-areola complex is a crossing point of the breast meridian and the horizontal line from the
lateral endpoint of the submammary line. (Right) Nipple positioning with projection of the
submammary line onto the breast meridian.
FIG. 4. Lassus method for marking the height of the nip-
ple. The upper edge of the areola is located 2 cm below the
bisecting point of the distance between the olecranon and
acromion.
the middle fingers of the hands are used to
prop up medial and lateral sides of the breast
while simultaneously pushing the parenchyma
with the thumbs toward the center of the
2087
breast. The breast is molded into the desired
shape with the use of the fingers (Fig. 6).
At the point of highest projection on the
thus fashioned breast, the nipple is marked.
The circle representing the areola is drawn
in at the point of the height marked on the
breast meridian. While the lateral and me-
dial curves are determined by the tension
and pressure of the fingers, the imbricating
position of the thumbs provides the fullness
of the upper pole and, in this way, the high-
est point of projection becomes clearly visi-
ble. When performing the dynamic paren-
chyma imbrication procedure again as a
form of checking, the circle of the areola
should become taut and indicate the highest
point of the breast cone.
The newly molded shape of the breast
should be examined frontally and in medial
and lateral profile. The correspondence— or
lack thereof— of the expected height of the
nipple and the point of highest projection
should be apparent. After the final adjustment
of the markings, the planned height of the
nipple must be marked on the appropriate
point of the meridian on the opposite side.
With the help of dynamic imbrication, the
height of the nipple on the opposite breast
must be checked. In case of breast asymmetry,
the method shows the best possible shape at-
2088 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2004

FIG. 5. (Left) Demonstration of the molding and shaping of a round silicone implant to a
conical shape. (Right) The two thumbs imbricate the implant centrally and in a superior direction.

FIG. 6. (Left) Marking with dynamic parenchyma imbrication. The two thumbs imbricate the breast parenchyma in a superior
direction, and the fingers mold the conic shape of the breast. The imbrication of breast parenchyma creates adequate projection,
and the upper pole contour is round. The nipple should be localized and marked to the highest point of the breast. The basal
width of the breast will be more narrow. (Center) The lateral view demonstrates the projection of the breast parenchyma. The
highest point of the breast should be controlled and marked. (Right) Four fingers force the medial and lateral part of the breast
to the midline. Imbrication creates the fullness of the upper inner quadrant of the breast.

tainable through surgery. Optimally posi-
tioned, forward-pointing nipples located on
the point of highest projection with the help of
parenchyma imbrication will follow changes in
breast volume and those associated with aging
and will continue to show a natural position
years after the operation (Figs. 7 through 10).
DISCUSSION
The position of the nipples is to be marked
symmetrically along the horizontal plane, at
equal height along the meridian, and defines
the point of the highest projection of the
breasts.6,7 A low placement of the nipples can
give the impression of an unsuccessful proce-
dure. In contrast, if the position of the nipples
is too high or upward-pointing, they may be-
come visible in the cleavage line and give the
breasts a grotesque appearance. The low position
of the nipples is relatively easily corrected. How-
ever, if the position is too high, it can only be
corrected through a complicated surgery proce-
dure, and in severe cases may require the use of
an expander. Patients find a 0.5-cm to 1-cm me-
Vol. 113, No. 7 / POSITION OF THE NIPPLE-AREOLA COMPLEX 2089

FIG. 7. (Left) Breast hypertrophy and pseudoptosis of the left breast. The level of the nipple-areola complex preoperatively.
(Center) Periareolar mastopexy, 5 weeks postoperatively; the level of the nipple-areola complex is overcorrected by 1 cm. (Right)
Photograph showing periareolar mastopexy, 2-year postoperative result. The level of the nipples is equal.

FIG. 8. (Left) Breast hypertrophy; the nipple-areola complex is 6 cm below the submammary line. (Right) One year after 650-g
central parenchyma reduction and vertical mastopexy. The nipple-areola complex is at the level of the submammary line.

FIG. 9. (Left) Breast hypertrophy and ptosis. The nipple-areola complex is 6 cm below the submammary line.
(Right) Preoperative oblique view.

dial or lateral dislocation of the nipples consid-
erably less disturbing than the displacement of
the nipple in an upward or downward direction
in relation to the horizontal line.
Many techniques locate anatomical refer-
ence points and mark the height of the nipple
in relation to fixed points at the appropriate
height of the meridian, above the ptotic nip-
ple. Marking the nipple-areola complex for
mastopexy or reduction mammaplasty with the
method of static measurements has a risk of 1
to 1.5 cm of nipple dislocation.
The maneuver of dynamic imbrication of the
parenchyma creates a naturally shaped breast
2090
FIG. 10. (Left) Aesthetic results 6 months later. The nipple-areola complex is at the highest
projection of the breast mould. (Right) Adequate upper and lower pole fullness is seen.
with adequate tone and skin tension. The up-
per and lateral fullness, along with the medial
cleavage, can be modeled. The manually cre-
ated breast cone offers the proper position of
the nipple. The dynamic parenchyma imbrica-
tion method can be effectively applied in case
of mastopexy and in planning reduction (if the
reduction is approximately 1000 g). In case of
larger volume resections, the results of the dy-
namic method should be compared with and
controlled by the use of fixed anatomical ref-
erence points. If the intended shape of the
parenchyma is approximated and imitated
manually by a dynamical molding of the
breasts, the marking of the nipples will be sim-
pler and more precise. Nipple dislocation, if it
occurs, will be less than 1 cm. The basic prin-
ciple of plastic surgery regarding the natural
shape and size of the breasts is supported by
Rohrich et al.’s recently articulated opinion:
“The goal of breast reduction should not be to
create a virginal-appearing breast but rather a
mature, slightly pendulous breast that will per-
sist proportional to the patient’s build.”15
Gusztáv Gulyás, M.D., Ph.D.
Hankoczy J. Street 15
Budapest, Hungary 1022
gulyas@oncol.hu
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