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. 2025 Sep 2.
doi: 10.1007/s00266-025-05130-1. Online ahead of print.

Management of High-Riding Nipple-Areola Complex: A Systematic Review of Its Prevention and Management

Ross Weale  1 , Muhammad Umair Javed  2
Affiliations

Management of High-Riding Nipple-Areola Complex: A Systematic Review of Its Prevention and Management

Ross Weale et al. Aesthetic Plast Surg. .

Abstract

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 .

Keywords: Areola; Breast reduction; HRNAC; High nipple; High-riding; Mastectomy; Nipple.

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Conflict of interest statement

Declarations. Conflict of interest: The authors declare that they have no conflicts of interest or funding to disclose. Statement of Human and Animal Rights, or Ethical Approval: This article does not contain any studies with human participants or animals performed by any of the authors. Informed Consent: For this type of study, informed consent is not required.

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