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Classifying the Postoperative, High-Riding Nipple and its Management
Frank P. Albino, M.D., Ali Al-Attar, M.D., Scott L. Spear, M.D..
Georgetown University Hospital, Washington, DC, USA.

Background: Postoperative nipple malposition is an aesthetically devastating problem for patients and a formidable challenge for surgeons. A high-riding nipple areola complex (NAC) remains a reconstructive problem with limited, suboptimal solutions. Our aim is to identify the surgical procedures leading to high-riding nipples, provide a classification system of the high-riding NAC, and discuss its management.
Methods: A retrospective review of medical records was conducted for patients who presented to the senior surgeon (S.S.) for management of a high NAC over an 8-year period from January 2004 to March 2012. Demographic information, past medical and surgical histories, operative details, and office visit follow-up data were reviewed for each patient. To characterize the severity of NAC displacement, the distance from the NAC to the superior and inferior breast borders was measured. The high- NAC was classified as mild, moderate or severe depending upon whether it was superiorly displaced by 25%, between 25-50%, or greater than 50%.
Results: Twenty-three women met study criteria with thirty-nine breasts determined to have a high-riding NAC. The average patient was 44.2 years of age with a BMI of 22.2 kg/m2. Each patient underwent 2.2+/-0.71 operations prior to the development of a notably high-riding NAC; including, nipple-sparing mastectomy (31%), augmentation/mastopexy (28%), augmentation alone (28%), mastopexy alone (5.2%), reduction mammoplasty (5.2%), and skin-sparing mastectomy (2.5%). Patients were classified as having a mild (43%), moderate (31%), or severe (26%) NAC displacement based upon the nipple distance from the superior and inferior breast boarders. The operation rate for a high NAC was 48.8%; including transposition flap (15.4%), augmentation with mastopexy (12.8%), mastopexy alone (10.4%), augmentation alone (7.7%), or capsulorrhaphy (2.6%). Forty-one percent of patients with a mild NAC displacement, sixty-seven percent classified with a moderate NAC malposition, and forty percent of patients with severely high-riding NACs underwent surgery to correct their nipple position in this population of patients.
Conclusions: A high-riding NAC can develop following a number of surgical procedures. While many patients can be managed conservatively, there are a number of surgical options available that can improve NAC position when selected judiciously.


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