Breast asymmetries are common and their management can be difficult and challenging and often requires complex procedures. These asymmetries are classified based on their embryologic and developmental origin [1] or their morphology [2] and have been discussed and reviewed in the literature [3]. Most of these classifications are centred on the shape, size, and volume asymmetries and their management. Nipple-areola complex (NAC) asymmetries are common and are usually documented in regard to shape and size discrepancies. So far the only reported incidence of asymmetrically placed NACs in patients requesting breast augmentation is 53% [4]. However, the article did not mention the axis of the asymmetrically placed NACs. Nipple-areola complexes can be placed asymmetrically in the vertical as well as in the horizontal axis. Vertical asymmetries are known and may require unilateral or, in selected cases, bilateral NAC repositioning when vertical asymmetry is associated with bilateral ptosis. However, asymmetrically placed NAC in the horizontal axis is not described in the literature.

Morphometry was performed in 312 patients who underwent augmentation mammaplasty in 2007 by the author. The results showed that nipples can be placed asymmetrically either in the medial or in the lateral dimension and asymmetry can be unilateral or bilateral in up to 12% of patients. Observation was objective and measurements were done during consultation with patients who proceeded on to surgery. Most of these asymmetries were seen on the right breast as lateralised nipples (Table 1). Most of these patients showed lack of a skin envelope in this dimension, with a borderline significance (P = 0.06). Dissecting an implant pocket close to the midline results in further lateralisation or exaggeration of the NAC. In addition to the poor aesthetic outcome, implants appear medially malpositioned. In the lateralised NAC, the implant pocket is dissected laterally to offset its visual appearance on the breast mound. This also prevents the medially malpositioned appearance of implants.

Table 1 Morphometry of medial and lateral halves of right breasts in normal-looking and right-lateralised nipple-areola complexes
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Materials and Methods

Medial and lateral halves of breasts were measured in 312 mammaplasties performed by the author in 2007. The medial boundary of each breast was measured from the beginning of the medial fold or cleavage to the medial edge of the nipple, and the lateral boundary was measured from the lateral boundary of the breast fold to the lateral edge of the nipple. Nipple positions were classified as normal-looking (control), right-lateralised or medialised, left-lateralised or medialised, or bilaterally lateralised or medialised.

Thirty-nine (12%) patients had asymmetrically placed NACs in the horizontal axis; of these, 29 (9%) were right lateralised, 4 (1.2%) left lateralised, 5 (1.5%) bilaterally lateralised, and 1 (0.3%) was bilaterally medialised. In the more common right-lateralised group (n = 25), the mean medial half measurement was 8.76 ± 22 cm compared with 8.96 cm in the control group (n = 170), with no statistical significance (P = 0.45). However, results in the lateral half measurements in the same group (n = 25) showed 9.06 ± 1.53 cm in the lateralised nipples compared with 9.7 ± 1.67 cm in the control group (n = 169), with a borderline significant value (P = 0.06).

On the affected side, the medial boundary of the breast pocket is marked 0.25–0.5 cm further away from the routine 2.5-cm intermammary distance. The goal is to offset the lateralised NAC and to improve its aesthetic position on an augmented breast.

Technique and Markings

Once the presence of a lateralised nipple is established on visual and measured criteria, marking is performed with the patient in the standing position. Medial boundaries of the two breasts’ pockets are marked with an intermammary distance of 2.5 cm. The nipple is used as the central point, and on the normal breast the distance between the nipple and medial breast fold is measured and used as a template to mark the lateral half of the breast pocket. On the breast with the lateralised nipple, the medial boundary is redrawn 0.25–0.5 cm lateral to the initial medial marking. Measurements are taken from the nipple to the revised and redrawn medial boundary and used as a template to mark the lateral half of the pocket (Fig. 1). The revised marking of the medial boundary on the breast with the lateralised nipple helps to prevent the appearance of a medially malpositioned implant. An implant pocket that is dissected laterally offsets the NAC position and appearance on the breast mound. The NAC position in an augmented breast will appear more central instead of toward the edge of the breast. The lateral quadrant augmentation is aesthetically superior with a more natural look than an uncompensated pocket in similar cases (Fig. 2a, b). Although any plane can be used for pocket dissection, all 312 augmentation mammaplasties in the series were performed using the submuscular muscle-splitting biplane [5].

Fig. 1
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A patient with a right-lateralised nipple. Medial boundary on the right compensated pocket is marked 2 cm lateral to the midline as opposed to 1.2 cm on the left side

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Fig. 2
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a Preoperative view of a patient with lateralised nipples on both breasts. b Postoperative view with implants placed equidistant from the midline. Placement of the implants too close to the midline resulted in further lateralisation of the NAC with an appearance of medially malpositioned implants

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Results

In the majority of the patients in this study, adjustments of pocket dissection gave an aesthetically positioned nipple in patients with lateralised nipples. Lateral quadrant enhancement of the breast was aesthetically superior to uncompensated cases with an aesthetically acceptable intermammary distance. The medialised and lateralised nipple positions in the horizontal axis were compared with respect to the NAC morphometric asymmetry using Student’s t test. A P value of less than 0.05 was considered statistically significant for all the tests (Figs. 3, 4, 5).

Fig. 3
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a, b Preoperative anterior and right lateral views of a patient with right-lateralised nipple. c, d Postoperative views after placing an implant in a compensated lateralised pocket

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Fig. 4
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a, b Preoperative anterior and right lateral views in a patient with right-lateralised nipple. c, d Postoperative views after placing an implant in a laterally dissected pocket

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Fig. 5
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a, b Preoperative anterior and right lateral views in a patient with right-lateralised nipple. c, d Postoperative views after placing an implant in a pocket dissected laterally to offset the lateralised nipple

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Discussion

The aim of an elective aesthetic procedure is to improve and enhance the body’s look and every effort is made to achieve this. Augmentation mammaplasty is one of the most common aesthetic procedures performed today. Proportionate enhancement in all four quadrants is important, and lateral quadrant enhancement in an augmented breast is an integral part of the objective. Breast morphometry has been done and an aesthetic breast has been defined [6, 7]. On the other hand, breast asymmetries are common; in one study, up to 88% of patients requesting breast augmentation had some asymmetry. Asymmetries in NAC size and level are known [4], but NAC asymmetries in the horizontal axis and their potential affect on the aesthetic outcome has not been described in the literature. In their study of 55 normal volunteers, Smith et al. [6] measured the medial half of the breast from the midline to the nipple (mean right = 11.14, mean left = 11.83 cm) and from the nipple to the lateral breast crease (mean right = 9.525, mean left = 9.425). Although the mean measurements showed larger values on the left, suggesting normally larger breasts on the left, overall measurements on both sides had larger values than did the preoperative measurements observed in the current series (Table 1). A morphometric difference between the two groups was also observed by Brown et al. in their study [8] in which the control group had larger measured values than the group requesting augmentation mammaplasties. However, there was no mention of asymmetrically placed NACs in the horizontal axis in either series. Percentage values of asymmetric NAC placement have been described without the mention of the axis [4]. Comparative medial and lateral half morphometry coupled with visual asymmetries revealed that asymmetrically placed NACs are a common occurrence in the horizontal axis. In the current series, measurements of each half of the breast were taken using the nipple as the central point, because the diameters of the NACs vary in up to 24% of the patients [4]. Measurement of the NAC itself was not made in the current study. For reasons unknown, lateralisation is more common than medialisation and right lateralisation predominated. Although pectus carinatum may give an illusion of lateralised nipples, the condition is more commonly due to the lack of a skin envelope in this quadrant or half, or, in other words, these breasts have lateral skin envelope constriction (Table 1).

Lateralised nipples are common and should be kept in mind as an understated and undernoticed form of asymmetry. A pocket dissected laterally on the affected side with the nipple as the central point offsets the lateralised nipple and improves its aesthetic position on an augmented breast. It also prevents the appearance of a medially malpositioned implant with the NAC placed too laterally (Fig. 2a, b).

After marking the lateralised pocket, the procedure can be performed in any plane; however, all the patients in the current series underwent the muscle-splitting biplane technique [5]. An attempt to give or produce close cleavage further deteriorates the lateralisation of nipple. For a handful of patients it is difficult and challenging to improve bilateral lateralisation and it may result in inadequate results (Fig. 6a, b). In an established case of uncompensated pocket dissection, the appearance is of a medial implant malplacement and can be treated using multilayer capsulorrhaphy medially and mirror-image lateral capsulotomies [9, 10]. If the implant was initially placed in the subglandular pocket, then changing the implant pocket to a submuscular plane with lateral capsulotomy is an option. The latter approach does not require medial capsulorrhaphy because the medial attachment of the pectoralis to the lateral border of the sternum acts as the new medial boundary of the prosthesis.

Fig. 6
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a Preoperative view of a patient with extremely lateralised nipples on both breasts. b Good aesthetic results can be difficult to achieve even after dissecting implant pockets a little laterally

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Conclusion

Asymmetrically placed lateralised nipple-areola complexes are not uncommon and the majority of them are on the right breast. A pocket dissected laterally on the involved breast offsets the lateralised NAC and prevents a medially malplaced appearance of the implants.