Background: The satisfaction after breast augmentation depends upon many factors including the size and symmetrical placement of the implants. The location of the nipple on the newly created breast mound, however, plays an equally important role in the final appearance of the breasts.
Ideally centered on the midportion of the breast mound as an isolated structure, it naturally draws one’s eye to it immediately. Its location, and the symmetry between the two paired nipple locations, impacts one’s perception of the symmetry of the breast augmentation result. I have seen more than one patient who felt their implants were asymmetric when it was the nipples, not the implants, that had asymmetric positions.
For this reason, it is very important in the breast augmentation consultation that the nipple positions are assessed and the horizontal levels between them checked. This is the time to identify any significant nipple asymmetries. Few women have perfectly level nipple positions. But when the differences are more than a ½ or 1 cm, it is likely that the breast augmentation procedure will make that difference even greater. Whether one should have a comcomitant nipple lift (superior crescent mastopoexy) on the lower positioned nipple during the breast augmentation should be considered.
Case Study: A 26 year-old female came in for breast augmentation. She did have some breast tissue with fairly large nipple-areolar complexes. Her left breast hung slightly lower with a 1 cm difference (lower) in the upper edge of the nipple. This was pointed out and a nipple lift discussed. She preferred to wait and see how it looked after surgery and would do a nipple lift in the office under local anesthesia if needed.
Under general anesthesia, saline breast implants were placed through a transaxillary (armpit) incision. A pair of 375cc Mentor moderate plus implants were used and inflated equally to 425ccs. It did not appear that the nipple positions were worsened as the breast mounds got bigger.
In seeing her three weeks after surgery, the implants appeared symmetric and the nipple positions have actually improved. They were nearly level and certainly better than before surgery. Whether they will stay the same as the breast tissues settle and relax remains to be seen.
Pre-existing nipple asymmetry will often be made worse after breast augmentation. In some cases, as in this one, it may actually make it better but this is unusual. If horizontal nipple asymmetry is greater than one centimeter, a nipple lift should be done at the time of breast implants to improve the symmetry of the result. The fine line scar at the top of the nipple heals well and does not pose an aesthetic distraction.
Case Highlights:
1) One of the most important preoperative predictors of asymmetry after breast augmentation is the horizontal level between the two nipples. Consideration needs to be given to a nipple lift done at the same time as breast augmentation for the lower positioned nipple.
2) Usually horizontal nipple asymmetry will become more pronounced, rather than better, after the placement of breast implants.
3) When the nipple asymmetry is small or if it is uncertain whether it will get worse when breast implants are placed, a nipple lift can be deferred to after surgery. Otherwise, it should be done to the lower nipple at the time of breast augmentation.
Dr. Barry Eppley
Indianapolis, Indiana