SPECIAL TOPIC

The Three Breast Dimensions: Analysis and

Effecting Change
Elizabeth J. Hall-Findlay,
M.D.
Banff, Alberta, Canada
Background: This article reviews the three breast dimensions and how they can
be changed. The first two dimensions constitute the breast footprint. The third
dimension is the shape of the breast on the footprint.
Methods: All four breast footprint borders are reviewed along with the third
dimension, which is the breast shape and how it sits on that footprint. An analysis
of the “normal” position of the footprint and the “normal” shape of the breast
is given. It is important for the surgeon to understand how change in each of
the parameters can be effected. The upper and lateral breast borders are
relatively mobile, but the inferior and medial breast borders are relatively fixed.
All four borders can be changed with certain surgical maneuvers, and these have
been measured and analyzed. The breast is a skin structure that is held in place
by skin/fascial zones of adherence, and the breast itself is mobile over the
pectoralis fascia.
Results: Measurements before and after breast augmentation, breast reduction,
mastopexy, and mastopexy-augmentation have been obtained so that the sur-
geon can better predict results. The change in suprasternal notch–to-nipple
distance and the change in suprasternal notch–to–inframammary fold distance
have been measured.
Conclusion: Being able to explain the issues and the potential changes makes
it easier for a surgeon to manage patients’ expectations. (Plast. Reconstr. Surg.
125: 1632, 2010.)

I
t is important for the surgeon to be able to
analyze the breast in all three dimensions be-
fore explaining to the patient what can and
what cannot be altered. The first two dimensions
are what we call the breast footprint.1 The third
dimension is the shape of the breast that sits on
that footprint. In this article, the variables in the
footprint and the shape are reviewed and the ev-
idence available to show how we as surgeons can
work with the three dimensions to effect change
is discussed.
Plastic surgery is often described as an exercise
in artistic assessment, design, and execution. How-
ever, unless we analyze breast aesthetics in all three
dimensions and then measure what changes can
be made, we will fail as good artists and designers.
THE FIRST TWO DIMENSIONS
The first two dimensions are called the breast
footprint.1 Even though the chest wall is not com-
From The Banff Plastic Surgery Centre.
Received for publication January 12, 2009; accepted July 28,
2009.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181ccdb97
pletely flat (and this aspect does also need to be
considered), it is best to start analyzing the breast
and its four borders: the first two dimensions.
There are two fairly fixed zones of adherence,2
both medially and inferiorly, that limit the slide of
the breast (a subcutaneous structure) on the chest
wall.
Upper Breast Border
Analysis
The upper breast border is the junction be-
tween the flat upper chest wall and the breast itself.
We can move the upper breast border quite
readily during breast examination, and we are all
well aware that the upper breast border is much
more mobile than the lower breast border (the
inframammary fold). The upper breast border
moves easily when a patient is lying down and can
be misleading when a patient is supine on the
operating table.
Disclosure: The author has no financial interest to
declare in relation to the content of this article.

1632 www.PRSJournal.com
Volume 125, Number 6 • The Three Breast Dimensions
Some patients are “high-breasted” and some
are “low-breasted” (Fig. 1). This is an easy way to
explain to patients why they may have a high or low
upper breast border. We need to be able to edu-
cate patients on what we can change, but first we
need to be able to understand ourselves what can
and cannot be changed and what the ideal pa-
rameters of that change are.
Effecting Change
Can we raise or lower the upper breast border?
We can clearly appreciate that removing breast
tissue in the upper pole of the breast can lower the
breast border, but can we raise it? To analyze these
issues we need to make measurements.
Fig. 1. (Above) A high-breasted patient; (below) a low-breasted
patient. It is important to assess the variability in the breast
footprint from one patient to another and understand what
can be altered to make a surgical plan for each patient. The
approach to a breast reduction must be very different in both
of these patients, and an arbitrary distance from the supraster-
nal notch to determine the new nipple position will fail to give
a good result.
Breast implants: When we look at our breast
augmentation patients, we are well aware that we
can raise the upper breast border to some degree.
Where is the ideal upper breast border? Some
patients actually ask us to fill up the anterior chest
wall with an implant, but we know that implants
that are displaced too high appear odd. Why? The
ideal upper breast border is within the dimensions
of the preaxillary fullness. When the implant sits
higher than the preaxillary crease, it appears odd.
When an implant falls below the preaxillary full-
ness, it makes the patient appear low-breasted.
When we look at our normal results, we can
understand what an implant will do (Fig. 2). An
implant will fill up the upper breast border to
some degree, but it will also lower the lower breast
border (the inframammary fold) even when we
believe that we are not violating the fold. An im-
plant will also stretch the skin and lower the nipple
position and lower pole. Measurements were made
from the suprasternal notch to the nipple and from
the sternal notch to the inframammary fold in breast
augmentation patients, mastopexy patients, breast
reduction patients, and mastopexy-augmentation
patients. A sample of 20 patients in each category are
shown in Tables 1 through 4.3,4 When an implant is
used, the nipple dropped an average of 2 cm from
its preoperative level.
When we understand this, we can then explain
to patients that larger and larger implants will not
necessarily give them their desired upper pole
fullness. After a certain point, a larger implant will
Fig. 2. This patient was symmetrical preoperatively, but one of
her saline implants ruptured. This shows that an implant will not
only raise the upper breast border but also drop the nipple po-
sition and the lower pole. Measurements before and after surgery
have shown that the nipple position drops an average of 2 cm in
a breast augmentation patient (Table 1).
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 Plastic and Reconstructive Surgery • June 2010

Table 1. Breast Augmentation Measurements*

Size SSN-N

Follow-Up (mo) Location Right Left Right (cm) Left (cm) SSN-IMF (cm)
48 Subfascial CMH-310 CMH-310 2.5 2
32 Subpectoral CMH-410 CMH-410 1.5 1
29 Subpectoral CMH-365 CMH-365 3 2
18 Subfascial CMH-310 CMH-310 2 2.5
24 Subpectoral 115-222 115-222 0 0.5
16 Subglandular 15-304 15-304 1 1.5
12 Subfascial 15-397 15-397 2 2
12 Subpectoral 15-397 15-397 2 2
9 Subglandular 15-286 15-286 3 3
8 Subglandular 15-265 15-304 1.5 2
7 Subpectoral MPP-250 MPP-250 3 2
12 Subpectoral 15-286 15-304 4.5 5
4 Subpectoral 15-265 15-265 2 3
7 Subpectoral 15-339 15-339 2 2 2
2 Subglandular 15-397 15-339 3 2.5
2 Subpectoral 115-272 115-272 2 2
7 Subglandular 115-322 115-322 2.5 3 2
1 Subglandular MPP-375 MPP-375 2 3 2
1 Subglandular 15-286 15-286 1.5 2 4
1 Subpectoral 115-354 115-354 3 2.5 2.5
Mean 2.2 2.2 2.5
SSN-N, difference in suprasternal notch–to–nipple distance; SSN-IMF, difference in suprasternal notch–to–inframammary fold distance.
*This is a sample of 20 patients in which measurements were made from the suprasternal notch to the nipple position both before and after
surgery. The pocket location (subfascial, subglandular, or subpectoral) is noted, the type of implant (Inamed CML or CMH, Mentor MPP,
or Inamed Style 15 or 115) is noted, and the difference in the suprasternal notch measurement before and after surgery is noted. A quick
review shows that the nipple position drops on average 2 cm even with a short follow-up period.

Table 2. Breast Reduction Measurements*

SSN-N

Follow-Up (mo) Right Breast (g) Left Breast (g) Liposuction (cc) Right (cm) Left (cm) SSN-IMF (cm)
7 270 300 700 1.00 1.00 –1.50
30 1165 950 635 –2.50 –1.50 –1.00
15 290 325 325 1.00 1.00 –1.00
3 730 745 740 1.00 1.00 –1.00
24 245 285 250 0.00 0.50 0.50
12 440 445 750 2.00 2.00 1.00
15 460 435 600 –3.00 –3.00 –1.00
7 330 325 150 0.50 1.00 0.00
7 250 310 300 0.00 0.50 1.00
4 450 385 275 1.00 1.00 1.00
4 480 505 625 1.00 0.50 2.00
6 315 370 500 0.00 1.00 1.00
4 590 535 175 0.50 0.00 1.00
1 550 420 700 –0.50 1.00 –1.00
1 230 340 200 1.50 0.50 0.00
1 340 400 275 1.00 –1.00 –1.00
1 275 305 400 0.00 0.00 0.50
1 310 300 350 1.00 1.00 –1.00
1 985 675 925 –0.50 –1.50 –1.00
3 730 745 740 1.00 1.00 –1.00
Mean 0.3 0.3 –0.1
SSN-N, difference in suprasternal notch–to–nipple distance; SSN-IMF, difference in suprasternal notch–to–inframammary fold distance.
*This is a sample of 20 patients in which measurements were made from the suprasternal notch to the nipple position as drawn preoperatively
and its level postoperatively. The measurements to the inframammary fold are also noted. All patients had a medial pedicle vertical breast
reduction. It can be seen that the nipple position does not change much from the preoperatively designed position. It can also be seen that
the inframammary fold level can be elevated (this is often done intentionally).

no longer raise the upper breast border at all but have seen implants heal in too high a position, and
will continue to drop both the breast footprint and this appears abnormal.
the shape of the breast on that footprint, especially Fat injections: Surgeons have been raising the
in patients with a lax skin envelope. In contrast, we upper breast border for several years using fat

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Volume 125, Number 6 • The Three Breast Dimensions

Table 3. Mastopexy Measurements*

SSN-N Exc SSN-IMF

Follow-Up (mo) Type Right (cm) Left (cm) Right (g) Left (g) SAL (cc) Right (cm) Left (cm)
11 Med ext 1.5 1 125 225 50 0 0
5 Graf 1 1 0 0 0 –0.5 –0.5
6 Graf –0.5 –0.5 240 150 100 0.5 0.5
12 Graf –1.5 –1.5 0 130 600 –2.5 –1
28 Graf 2 1 0 35 0 0 0
12 Graf 1.5 2 0 70 0 0 0
2 Graf 0 0 20 50 0 0 0
12 Graf 0.5 0.5 75 0 50 1 1
11 Graf 1.5 1 27 45 125 1.5 1.5
6 No flap 0.5 1 70 80 0 –0.5 –0.5
10 Graf 1 1.5 30 30 250 1 1
3 Ribeiro 0.5 0.5 130 185 500 2 2
6 Graf 0 1 70 65 390
2 Graf –1 –1 50 68 0
1 Graf –0.5 –0.5 30 10 30 0.5 –0.5
2 Graf 0.5 0.5 61 129 0 3 3
2 Graf 1 1 100 75 0 1 0.5
1 No flap 1.5 1.5 50 46 0 0.5 –0.5
5 Graf 0 –0.1 50 0 0
1 Graf 1 1 210 225 210
Mean 0.5 0.5 0.4 0.4
Med ext, medial extension flap; SSN-N, suprasternal notch–to-nipple distance; SSN-IMF, suprasternal notch–to–inframammary fold distance;
Exc, parenchyma excised in addition to skin excised.
*This is a sample of 20 patients in which measurements were made from the preoperatively designed suprasternal notch-to-nipple position
and its postoperative level. Some measurements were also made to see whether the inframammary fold level changed (minimal). The reference
to “Ribeiro” was a mastopexy where the inferior flap as described by Ribeiro (Ribeiro L. A new technique for reduction mammaplasty. Plast
Reconstr Surg. 1975;55:330 –334) was used;the reference to “Graf” was a mastopexy where the inferior flap was placed under a strip of pectoralis
muscle as popularized by Graf et al. (Graf R, Biggs TM, Steely RL. Breast shape: A technique for better upper pole fullness. Aesthetic Plast Surg.
2000;24:348 –352).

Table 4. Mastopexy-Augmentation Measurements*

Size Exc SSN-N

Follow-Up (mo) Location Right Left Right (g) Left (g) SAL (cc) Right (cm) Left (cm) SSN-IMF (cm)
48 Subpectoral Saline 330 Saline 330 0 0 0 4 3 ?
11 Subpectoral CMH-365 CMH-365 0 0 0 0 0 1
5 Subglandular CML-230 CML-230 0 0 0 2 2 0
38 Subglandular CMH-365 CMH-365 0 0 0 3 3 3
18 Subglandular CML-335 CML-335 20 15 0 2.5 2.5 ?
2 Subfascial CML-335 CML-335 75 75 0 2 2 1
26 Subfascial CML-230 CML-230 75 65 100 1.5 1.5 0
11 Subfascial CMH-410 CMH-410 25 75 20 2 2 0
18 Subfascial 115-378 115-378 0 0 0 2.5 3 1.5
7 Subfascial 15-265 15-265 5 10 0 3 3.5 2
4 Subglandular 15-286 15-286 20 25 0 1.5 2 0.5
5 Subfascial 115-322 115-322 40 45 0 2 2 0.5
4 Subglandular 115-322 115-322 50 50 0 3 3 ?
6 Subglandular 15-213 15-213 0 0 0 2 2 2.5
2 Subglandular MPP-350 MPP-350 25 50 0 3.5 3 1.5
6 Subglandular 115-354 115-354 25 25 0 4.5 4.5 1
3 Subglandular 115-322 115-322 78 79 700 1.5 0.5 2
4 Subpectoral 15-339 15-339 20 21 0 2 3 1
1 Subpectoral MPP-350 MPP-350 12 20 0 2 2 0.5
1 Subglandular 15-339 15-339 15 25 0 3 2 0
Mean 2.4 2.2 1.0
SSN-N, difference in suprasternal notch–to-nipple distance; SSN-IMF, difference in suprasternal notch–to–inframammary fold distance; Exc,
parenchyma excised in addition to skin excised.
*This is a sample of 20 patients in which measurements were made from the suprasternal notch to nipple position before and after surgery.
The suprasternal notch–to–inframammary fold distance was not measured in the initial group of patients. The pocket location (subfascial,
subglandular, or subpectoral) is noted, the type of implant (Inamed CML or CMH, Mentor MPP, or Inamed Style 15 or 115) is noted, and
the difference in the suprasternal notch measurement before and after surgery is noted. The amount of parenchymal excision is also noted.
It is clear that the nipple position drops on average 2 cm in a mastopexy-augmentation, which is similar to an augmentation but in contrast
to either a mastopexy or breast reduction.

1635
 Plastic and Reconstructive Surgery • June 2010

injections.5 Initially, this had been done to smooth
out the upper breast border in patients with breast
reconstruction, but more recently this has also
been done to some degree in patients with breast
implant edge visibility or developmental abnor-
malities. The potential for fat injections to raise
the upper breast border is somewhat limited. The
process is very operator dependent and can be
very time consuming.6
Suture techniques: It is often claimed that un-
dermining the upper pole of the breast and su-
turing breast tissue up higher on the chest wall will
improve upper pole fullness and raise the upper
breast border.7 It is important for surgeons to ac-
tually measure and analyze their results before
making these claims.
I performed a study in 77 patients in my prac-
tice to see whether I could raise the upper breast
border and/or increase upper pole fullness. I un-
dermined the upper pole of the breast up toward
the second rib and folded the freshly cut breast
tissue (above the pedicle opening) and sutured it
up with three sutures on each side to a higher
position on the pectoralis fascia. In 43 patients I
used permanent (3-0 polyester) sutures, and in 34
patients I used permanent (3-0 Ticron; U.S. Sur-
gical Corp., Norwalk, Conn.) sutures. Seventy-two
patients returned for follow-up and were photo-
graphed. The initial improvement did not last more
than a few months in any of the patients (Fig. 3). The
upper breast border returned to its preoperative
position and there was improved projection but no
improvement in upper pole fullness.
The breast is not attached to the pectoralis
fascia, and when scar contracture does occur, we
usually see it as undesirable. If healing actually did
take place with suture fixation, there would be a
lot of breast distortion with muscle movement.
Breast tissue can heal to breast tissue and improve
breast shape, but the breast itself usually stays rel-
atively mobile on the chest wall. There may be a
role for suturing breast tissue to rib periosteum
superiorly in massive weight loss patients8 or su-
turing dermis to rib periosteum9 –12 to elevate an
inframammary fold, but results are not consistent.
Lower Breast Border
Analysis
The inframammary fold is the lower breast
border. When a patient is standing, the inframam-
mary fold does not move inferiorly, but the breast
can be moved upward several centimeters.
The inframammary fold fibers form attach-
ments between the chest wall and the dermis. This
prevents the breast (which is mobile on the chest
wall) from dropping. The breast is a subcutaneous
structure that moves as the skin moves. The breast
is attached to the skin, not the deep fascia. The
Cooper ligaments are not attached to the chest
wall, but they hold the breast attached to the skin.
The inframammary fold fibers are skin/fascial
structures, not breast structures.

Fig. 3. Photographs of this patient show that attempting to raise the upper breast border and increase upper pole fullness by
suturing breast tissue up higher on the chest wall does not last. The patient is shown preoperatively (left), at 10 days after a
medial pedicle vertical breast reduction (center), and again at 20 months postoperatively (right). Seventy-two of 77 patients
studied returned for follow-up, and in none of them did any improvement last beyond a few months. Projection, in contrast,
can be improved.

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Volume 125, Number 6 • The Three Breast Dimensions

The inframammary fold is a zone of adherence
like many other areas of the body where the skin
is attached through fibers (e.g., gluteal crease,
posterior ribs, sacrum). If these fibers did not exist
to hold the skin in place, our skin would form folds
around our ankles. Instead, we form folds in cer-
tain areas, especially as we get older and our skin
loses its elasticity and hangs over the zones of
adherence to varying degrees. The same problem
occurs in the face at it ages: the zones of adherence
are not the problem; the loss of skin elasticity and
the folding and hanging over the areas of adher-
ence are what need to be addressed.
The ideal inframammary fold is at or above the
sixth rib. This lower breast border is actually quite
variable from person to person, and some patients
have a long vertical breast footprint and some have
a very narrow vertical breast footprint (Fig. 4).
Effecting Change
The lower breast border, or inframammary
fold, is a zone of adherence that prevents descent
of the breast caused by gravity. It can be lowered
if the fibers are stretched. This can be seen in
massive weight loss patients when the inframam-
mary fold fibers become stretched and the infra-
mammary fold drops toward the abdomen. If a
weight is placed on the fibers (such as an implant),
the fibers can be stretched and the fold can drop
as the zone of adherence fibers are stretched.
A surgeon will at times purposely drop the
inframammary fold and surgically stretch out the

Fig. 4. These four patients show how variable the upper breast border and inframammary folds can be. The infra-
mammary fold level is marked on the chest wall between the breasts, and the upper breast border is marked with a
dotted line. (Above, left) Patient with a high upper breast border and a low inframammary fold. (Above, right)
Patient with a low upper breast border and a high inframammary fold. (Below, left) Patient with a high upper
breast border and a high inframammary fold. (Below, right) Patient with a low upper breast border and a low
inframammary fold.

1637

fibers so that the fold will drop (Fig. 5). An implant
may be needed to keep the fold lowered, and this
is often the case in a tuberous type of deformity.
It is important for the surgeon to reconstitute the
inframammary fold at closure, or sometimes the
implant can continue to exert force on the skin
attachments and bottom out.
Even when a surgeon attempts not to violate
the inframammary fold fibers when placing a
breast implant, the fold tends to drop. This can be
seen in most patients if the fold position is actually
measured (Tables 1 and 3).
Another form of weight that can exert pres-
sure on the inframammary fold fibers causing
them to stretch is when a breast reduction is per-
formed that not only leaves the weight of the
breast tissue inferiorly but then also compresses
the breast, pushing down even more and stretch-
ing out the inframammary fold fibers. This can be
Fig. 5. Sometimes the surgeon will purposely drop the infra-
mammary fold to achieve symmetry (as in this case) or to bet-
ter “centralize” the nipple on the breast mound in a vertical
direction.
1638
Plastic and Reconstructive Surgery • June 2010
seen postoperatively in some breast reductions using
an inferior pedicle where the inframammary fold
drops out below its original position (Fig. 6). This
may not be as likely to occur if the breast is not
compressed during closure, as can occur when the
surgeon attempts to keep the vertical length at 5 cm.
Can the lower breast border (inframammary
fold) be raised? Because of the design of the in-
framammary fold fibers to keep a zone of adher-
ence stable between the skin and the chest wall,
the only way that the fold could be elevated would
be to remove weight. The inframammary fold can
be elevated (and this elevation measured) in pa-
tients where weight is removed (Fig. 6). In most
breast reductions where an inferior pedicle is used,
the fold will not be elevated. In a breast reduction
where breast tissue is just removed centrally, the
inframammary fold will not be elevated.13 When tis-
sue is actually removed above the inframammary
fold and weight removed (either by direct excision
or liposuction), the fold can be elevated14 (Fig. 7).
Medial Breast Border
Analysis
The medial breast border is relatively immo-
bile because it rests against another zone of ad-
herence between the skin and deeper structures –
in this case the periosteum over the sternum. The
zone of adherence of the inframammary fold is
more like the zone of adherence of the gluteal fold
whereas the medial breast border is more like the
zone of adherence over the sacrum. The breast
tissue itself is mobile but the skin is not. Some
patients have a wide cleavage and the zone of
Fig. 6. This patient underwent an inferior pedicle inverted-T
breast reduction. Even if the surgeon had placed the incision
above the inframammary fold, it is clear that the fold has dropped
well below the scar.
Volume 125, Number 6 • The Three Breast Dimensions
Fig. 7. This patient underwent a medial pedicle vertical breast
reduction, and a vertical wedge of breast tissue was removed
along with both direct excision and liposuction below the Wise
pattern (the Wise pattern is used for what is left behind, not for
what is removed). The fold was initially at the same level as the
upper limit of the abdominal scar, but even with the arms down,
it is clear that the inframammary fold has been raised.
adherence is more widely spaced and other pa-
tients have a narrower cleavage (Fig. 8). It is im-
portant for surgeons to understand this variability
and be able to explain it to patients.
Effecting Change
The medial breast border is limited by the skin
zone of adherence. It can be moved laterally by
removing breast tissue that rests up against it, but
it is harder to narrow the cleavage without dis-
rupting the fibers that hold the skin in place. The
medial breast border is intentionally moved me-
dially in certain situations. This will occur in a
tuberous type of breast when the deep constric-
tion has caused abnormal attachments of the skin
to deep tissues. These need to be released and
prevented from reforming either with an implant
or with fat injections.
Fig. 8. Patient with breast asymmetry showing that the breast
implant was used to fill in both the medial and lateral breast bor-
ders on her right breast. In this case, the base diameter of the
breast is not used to determine the breast implant base diameter,
but instead the breast implant base diameter is used to achieve
the desired result, with an improvement in both the lateral and
medial breast borders.
When a breast is very narrow because of in-
adequate development, there are no abnormal
fibers, but the (potential) space between the existing
breast and the medial breast border attachments
needs to be filled. This is usually filled with an
implant (Fig. 8) but could also be filled with fat
injections.
The medial breast border can be moved lat-
erally in a breast reduction if the base of the breast
medially is narrowed. This occurs in a “vertical”
type approach when the base is narrowed by re-
moving tissue centrally. The base can be widened
in a breast reduction where a horizontal type of
resection is used and the medial breast border is
actually moved medially to some degree. Often,
this medial movement is actually an “apparent”
movement because the actual medial breast bor-
1639

der is not moved but the breast tissue is com-
pressed until the third dimension of the breast
overlaps the border medially.
Lateral Breast Border
Analysis
The lateral breast border is more like the up-
per breast border in that it has more mobility than
either the medial or the inferior breast border.
The breast is a subcutaneous structure that moves
with the skin, and it will slide laterally and supe-
riorly quite easily. This is especially seen in the
supine position, when the normal gravitational
forces are altered from the standing position.
There are no significant skin attachments or zones
of adherence in the lateral breast border except
inferiorly along the inframammary fold.
The lateral breast border can appear wider
than the actual breast tissue because this is an area
of fat accumulation. The lateral breast border is
significantly blunted in an obese patient, but the
true lateral breast border should be at the level of
the anterior axillary line.
Effecting Change
In a breast that is small, the lateral breast bor-
der can be widened with an implant. In this case,
the existing base diameter of the breast should not
be used to determine the base diameter of the
implant, but instead the base diameter of the im-
plant should be used to determine the ideal base
diameter of the new breast (Fig. 8).
The lateral breast border can be narrowed by
removing breast tissue. In some patients, there is
true lateral breast tissue that needs to be removed,
and this will occur in wide-breasted patients who
are not overweight. Some narrowing can occur by
removing breast tissue centrally and narrowing the
breast base, but in some patients direct lateral
excision will still be necessary. In obese patients,
the lateral breast border can be narrowed with
direct excision and complemented by liposuction.
Liposuction is needed to contour the lateral breast
border beyond the true breast to remove fat so that
the actual breast lateral border can be reshaped
(Fig. 9).
THE THIRD DIMENSION
The third dimension is the shape of the breast
that sits on the lateral chest wall. This consists
primarily of the volume and projection of the
breast tissue but is also determined by the slope
and shape of the base of the breast (i.e., the slope
1640
Plastic and Reconstructive Surgery • June 2010
Fig. 9. This patient shows how liposuction (along with direct ex-
cision of the lateral breast tissue) is used to correct the lateral
breast border and create a better curve to the lateral portion of
the inframammary fold.
and shape of the chest wall itself). Both sur-
geons and patients often consider the ideal breast
to be one that is confined within the breast foot-
print and does not extend beyond the borders of
the footprint (Fig. 10, left). This is often the result
that a breast augmentation patient expects, and it
is important for the surgeon be able to explain to
the patient the normal anatomy and what changes
can occur with surgery and what changes occur
with time and gravity. It is essential for patients to
understand that the breast in many procedures
still “hangs” off the footprint to some degree—
much like an awning. An acceptable breast shape
is one where there is some breast skin that sits on
the upper chest wall skin. It is almost impossible
to raise the breast to be completely confined
within the borders of the breast footprint.
A breast shape that drops off the breast foot-
print to some degree can be very acceptable and
aesthetically pleasing (Fig. 10, right). A breast
that does not fit an ideal footprint or a breast
that hangs too much off the footprint can be
unattractive.
The difference between the vertical approach
and the inverted-T approach is not really about the
skin scars. It is more about how the breast is
shaped and what is an acceptable shape as it sits on
the breast footprint. Many of the vertical ap-
proaches narrow the breast base and accept a
more ptotic type of shape with increased projec-
tion. The vertical scar distance needs to be longer
than 5 cm to accommodate that increased projec-
tion. This means that there is more breast skin
sitting on chest wall skin than with many of the
Volume 125, Number 6 • The Three Breast Dimensions

Fig. 10. (Left) Surgeons often think that the ideal breast shape is one similar to that in this breast augmentation
patient, where the breast shape does not extend beyond the borders of the breast footprint. (Right) This medial
pedicle, vertical breast reduction patient shows that a very acceptable result still has the nipple centralized on
the breast mound, but the mound is slightly ptotic and hangs like an awning off the breast footprint. When the
ptosis becomes more severe, the aesthetic result is less pleasing.

inverted-T type procedures. It is when there is too
much “skin-on-skin” or ptosis that the result be-
comes less than satisfactory.
Whether we are performing a breast aug-
mentation, a mastopexy, a mastopexy augmen-
tation, or a reduction, we need to analyze all
four breast borders in relation to the nipple
position. In a breast augmentation, we need to
adapt the mound (and the borders) to the ex-
isting nipple position. In a reduction or mastopexy,
we need to adapt the nipple position to the mound
that we have created.
Measurements in my practice have shown that
the suprasternal notch–to–nipple distance re-
mains relatively unchanged in a breast reduction
and mastopexy, but the nipple position will drop
on average 2 cm in both an augmentation and a
mastopexy-augmentation (Tables 1 through 4).
To make good decisions, we need to understand
what occurs to that mound and what occurs to the
nipple position on that mound. To make good
decisions, we need to measure and analyze.
SUMMARY
It is important for the surgeon to understand
the three dimensions of the breast and how they
can be altered surgically. The first two dimensions
consist of the breast footprint and the third di-
mension consists of the breast shape.
The breast footprint has an upper breast bor-
der, an inferior breast border (inframammary
fold), a medial breast border, and a lateral breast
border. Understanding the anatomy and param-
eters of these borders is key to understanding what
can be changed. The base of the footprint and how
steep the angle of the chest wall is as it slopes away
from the chest wall are important for the surgeon
to visualize.
The breast is a mobile skin structure that is
held in place by zones of adherence, much like the
buttock. The inframammary fold is a relatively
fixed structure like the gluteal fold, and the skin
over the sternum is fixed much like the skin over
the sacrum. When a patient lies on her side, the
upper breast folds over at the medial breast border
and the lower breast slides out laterally. The upper
breast border is mobile but the lower breast bor-
der is adherent at the inframammary fold.
The third dimension is the breast shape. The
actual shape of the breast and how it sits on that
footprint are very important. Breast width, upper
and lower pole fullness, and ptosis all need to be
assessed. Finally, the position of the nipple on the
breast mound gives the final aesthetic result.
The surgeon needs to first assess the foot-
print and the shape of the breast as it exists on
each patient. With an understanding of what
parameters can be changed and an understand-
ing of how the measurements will be affected by
surgery, the surgeon can then explain the plan
to the patient so that she can have reasonable
and realistic expectations.

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 Plastic and Reconstructive Surgery • June 2010

Elizabeth J. Hall-Findlay, M.D.
The Banff Plastic Surgery Centre
340-317 Banff Avenue, Box 2009
Banff, Alberta T1L 1B7, Canada
ehallfindlay@banffplasticsurgery.ca
REFERENCES
1. Blondeel P, Hijjawi J, Depypere H, Roche N, Van Landuyt K.
Shaping the breast in aesthetic and reconstructive breast
surgery: An easy three-step principle. Plast Reconstr Surg. 2009;
123:1–8.
2. Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The
zones of adherence: Role in minimizing and preventing con-
tour deformities in liposuction. Plast Reconstr Surg. 2001;107:
1562–1569.
3. Ribeiro L. A new technique for reduction mammaplasty. Plast
Reconstr Surg. 1975;55:330–334.
4. Graf R, Biggs TM, Steely RL. Breast shape: A technique for
better upper pole fullness. Aesthetic Plast Surg. 2000;24:348–352.
5. Spear SL. Fat for breast: Where are we? Plast Reconstr Surg.
2008;122:983–984.
6. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:
Safety and efficacy. Plast Reconstr Surg. 2007;119:775–785.
7. Hammond D. Personal communication, 2007.
8. Rubin PJ. Mastopexy after massive weight loss: Dermal sus-
pension and total parenchymal reshaping. Aesthet Surg J.
2006;26:214–222.
9. Pennisi VR. Making a definite inframammary fold under a
reconstructed breast. Plast Reconstr Surg. 1977;60:523–525.
10. Ryan JJ. A lower thoracic advancement flap in breast recon-
struction after mastectomy. Plast Reconstr Surg. 1982;70:153–
158.
11. Nava M, Quattrone P, Riggio E. Focus on the breast fascial
system: A new approach for inframammary fold reconstruc-
tion. Plast Reconstr Surg. 1998;102:1034–1045.
12. Muntan CD, Sundine MJ, Rink RD, Acland RD. Inframam-
mary fold: A histologic reappraisal. Plast Reconstr Surg. 2000;
105:549–556.
13. Lassus C. A technique for breast reduction. Int Surg. 1970;
53:69–72.
14. Hall-Findlay EJ. Vertical breast reduction with a medially
based pedicle: Operative strategies. Aesthet Surg J. 2002;22:
185–195.

Contacting the Editorial Office

To reach the Editorial Office, please use the following contact information:
Plastic and Reconstructive Surgery威
Rod J. Rohrich, M.D., Editor-in-Chief
UT Southwestern Medical Center
5909 Harry Hines Boulevard
Room HD1.544
Dallas, Texas 75235-8820
Tel: 214-645-7790
Fax: 847-709-7534
E-mail: rjreditor_prs@plasticsurgery.org

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