The Ideal Nipple-Areola Complex: A Study on Aesthetic Preferences
Pooja S. Yesantharao, MS1, Erica Lee, MS1, Halley Darrach, MD1, Helen Xun, BS1, Justin M. Sacks, MD MBA2, Kristen P. Broderick, MD1.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
BACKGROUND: Nipple areola complex (NAC) reconstruction is a critical component of post-mastectomy breast reconstruction. This study comparatively investigated the general public’s and plastic surgeons’ aesthetic preferences with regards to the NAC, in terms of size, color, and position on the breast mound. We also determined whether participants’ demographics impacted their preferences. Ultimately, this study aimed to help inform recommendations for NAC reconstruction, a process involving the deliberate placement of the NAC based on aesthetic norms/preferences derived from native, un-reconstructed breasts.
METHODS: This was a cross-sectional study of perceptions on NAC cosmesis. Participants were recruited through Amazon Mechanical Turk, and surgeons were recruited through the American Council of Academic Plastic Surgeons. Participants were queried using postoperative frontal-view NAC images (Figure).
RESULTS: A total of 849 individuals from the general public and 58 surgeons completed surveys. Preferences on NAC position on the breast mound varied between surgeon and non-surgeon participants. While both surgeons and the general public tended to prefer NAC positions lateral to the midpoint horizontally, surgeons preferred NACs at the midpoint vertically while the general public had no clear preference on vertical positioning. Physicians’ preferences on NAC position were significantly more dependent on the underlying shape of the breast mound (Fischer’s exact:p<0.0001) than the general public’s preferences. When stratifying by gender, male participants tended to prefer NAC positions that were more superior to the midpoint vertically and lateral to the midpoint horizontally when compared to female participants (Fischer’s exact:p<0.0001). Physicians preferred greater NAC pigmentation (Fischer’s exact:p<0.0001) when compared to the general public. Upon multivariable regression, physicians and older participants preferred larger NAC diameters (p=0.02 and p=0.003, respectively) while male participants preferred smaller NAC diameters (p=0.001). Amongst all study participants, concordance between the participants’ skin tone and the skin tone of the image they were viewing was significantly associated with a preference for greater degrees of NAC pigmentation (Fischer’s exact:p<0.0001) as well as larger NAC diameter (p=0.001).
CONCLUSIONS: Investigating the general public’s versus plastic surgeons’ opinions on NAC cosmesis can help inform surgeon-patient dialogues. Furthermore, NAC aesthetic preferences can be used to help standardize NAC reconstruction guidelines to optimize cosmesis. We found that NAC aesthetic preferences vary between the general public and physicians, and by factors including race, gender, and breast mound shape. Thus, an individualized approach to NAC reconstruction with detailed discussion of patient preferences as well as a careful examination of provider biases is critical to optimizing patient satisfaction. 
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