BACKGROUND

The optimal positioning of the nipple-areola complex (NAC) remains a challenging part of breast surgery, with high-riding NAC (HRNAC) frequently occurring postoperatively. An evidence-based summary of all effective prevention and management strategies is needed for a variety of surgical contexts.

OBJECTIVES

This systematic review aims to explore and summarise the prevention and corrective strategies for HRNAC across aesthetic and reconstructive breast surgeries. The review evaluates their evidence base and summarises the techniques available.

METHODS

A PRISMA compliant search of PubMed/Medline was conducted on November 1st, 2024, and the following search terms were used: "nipple AND high AND riding OR malposition AND breast". Data on demographics, surgical technique, outcomes, and levels of evidence were extracted.

RESULTS

346 articles were screened, yielding 36 after full text screening. Of these, 23 studies included reconstructive surgeries (20 purely reconstructive and 3 mixed), and 13 aesthetic surgeries. For reconstructive surgeries, corrective surgeries included crescent mastopexy, re-draping mastectomy flaps, transposition flaps of various designs, change of implant plane and free nipple grafting. Prevention strategies included suture placement to secure the NAC and implant using various methods, preoperative marking strategies, and maximal filling of the expander. For aesthetic surgeries, preventative strategies also included precise preoperative markings, in addition to intraoperative stabilisation of the envelope and implant pocket. Corrective measures ranged from crescent mastopexy, change in implant plane, local flaps and tissue expansion, amongst others. Outcomes were inconsistently reported and therefore meta-analysis was not possible due to heterogenicity of data. A new evidence-based algorithm is suggested.

CONCLUSIONS

This review highlights the broad range of procedures and prevention strategies for correcting HRNAC, representing the challenging nature of the problem. There is a significant lack of objective and consistent outcome reporting. For the future, standardised reporting including patient-reported outcome measures are required.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .