Appropriate Location of the Nipple-Areola
Complex in Males
Ori Shulman, M.D., Emanuel Badani, M.D., Yoram Wolf, M.D., and Daniel J. Hauben, M.D.
Petah-Tikva and Tel Aviv, Israel
Gynecomastia is a common deformity encountered by
plastic surgeons. The appropriate location of the nippleareola complex is a major determinant of the aesthetic
success of the procedure.
To study the natural location of the nipple-areola complex in the normally built male, 50 nonobese men with no
evidence of gynecomastia and an average age of 27.9 years
were examined.
Three ratios were calculated and found to be relatively
constant; they were the ratio between the height of the
nipple and the height of the patient, the ratio between the
distance between the nipples and chest circumference,
and the ratio between the suprasternal notch-to-nipple
distance and the height of the patient.
Using these three parameters, a method of locating the
nipple-areola complex on the male chest wall was devised.
The method is advocated as a reliable, simple, and useful
technique. (Plast. Reconstr. Surg. 108: 348, 2001.)
suprasternal-to-pubis distance be the parameter used to determine the nipple plane.8 They
also proposed that chest circumference be the
base for calculating the internipple distance in
the male patient.8
With these two outstanding analyses in mind,
we decided to devise a new, simple, integrated
system for the proper location of the nippleareola complex on the male breast.
PATIENTS
AND
METHODS
A total of 50 nonobese men aged 18 to 40
years with no evidence of gynecomastia were
included in this study.
All patients were photographed, and we then
measured the following parameters (Tables I
and II): height, weight, nipple height measured from the floor, suprasternal notch-tonipple distance, distance between nipples,
chest circumference at the level of the nipples,
areola length, areola width, nipple length, and
nipple width.
Gynecomastia is a common deformity requiring the intervention of the plastic surgeon.
There is a growing awareness of male breast
aesthetic appearance, and patients of all ages
are seeking solutions for their problem. Different surgical approaches have been proposed
for the treatment of male gynecomastia.1–3 Suction-assisted lipoplasty has been introduced as
an adjunct or alternative to surgical management; this procedure has the advantage of minimal scarring.4 – 6
The proper location of the nipple-areola
complex remains the most important factor in
successfully treating the male breast; other important factors are the location and size of the
skin scars. Beckenstein et al.7 stressed the importance of patient height as a fixed parameter
from which nipple location should be calculated. Murphy et al.8 noted that there is a poor
correlation between the midhumeral point
and the nipple plane, and they proposed that
Statistical Analysis
Correlations between the measured anatomical parameters were performed using the
Pearson correlation test with the significance
defined as p ⬍ 0.05. For each anatomical paTABLE I
Patient Data
Parameters
Values
Range
No. of patients
Mean age
Mean height
Mean weight
50
27.9 years
176.3 cm
72.4 kg
18–40 years
158–190 cm
53–100 kg
From the Plastic and Reconstructive Surgery and Burn Unit, Rabin Medical Center, Campus Beilinson, and the Sackler School of Medicine,
Tel Aviv University. Received for publication June 15, 2000; revised October 10, 2000.
348
Vol. 108, No. 2 /
NIPPLE-AREOLA COMPLEX IN MALES
TABLE II
Mean Anatomical Parameters of the Patients
Anatomical Parameters
Mean and Standard Deviation (cm)
Height of nipple
Chest circumference
Distance between nipples
Suprasternal notch–nipple
Areola diameter/length
Nipple diameter/length
Nipple–midclavicle
Suprasternal notch–pubis
Nipple–pubis
Nipple–umbilicus
127 ⫾ 4.9
96.73 ⫾ 7.09
20.6 ⫾ 1.96
18.37 ⫾ 1.57
2.67 ⫾ 0.53/2.08 ⫾ 0.4
0.5 ⫾ 0.09/0.51 ⫾ 0.08
17.2 ⫾ 1.48
52.6 ⫾ 3.31
37.86 ⫾ 2.68
23.06 ⫾ 1.62
349
sented in Figure 3. The Pearson correlation
coefficient was 0.689, with p ⫽ 0.0001. The
mean distance between nipples to chest circumference was 0.213, with a standard deviation of 0.014. The line of correlation is
represented by the following equation: distance between nipples ⫽ (0.190 ⫻ chest circumference) ⫹ 2.192.
Suprasternal Notch-to-Nipple Distance to Patient
Height
rameter, the mean value and standard deviation were calculated.
RESULTS
Mean values and standard deviations of the
measured parameters are presented in Tables I
and II. The mean areola and nipple diameters
were 2.67 cm and 0.5 cm, respectively. Correlations between various parameters were calculated; they are presented in Table III. All correlations were statistically significant (p ⬍
0.05). Three ratios were calculated for later use
in locating the nipple-areola complex (Fig. 1).
Height of the Nipple to Height of the Patient
A scatter diagram and line of correlation
between the nipple height and height of the
patient are presented graphically in Figure 2.
The Pearson correlation coefficient was 0.905,
with p ⫽ 0.0001. The mean nipple height to
patient height was 0.722, with a standard deviation of 0.012. The line of correlation is represented by the following equation: nipple
height ⫽ (0.668 ⫻ height) ⫹ 9.491.
Distance between Nipples to Chest Circumference
A scatter diagram and line of correlation
for the ratio between the nipple distance and
chest circumference are graphically pre-
A scatter diagram and line of correlation
between the suprasternal notch-to-nipple distance and patient height are graphically presented in Figure 4. The Pearson correlation
coefficient was 0.512, with p ⫽ 0.0001. The
mean suprasternal notch-to-nipple distance to
height was 0.104, with a standard deviation of
0.008. The line of correlation is represented by
the following equation: suprasternal notch-tonipple distance ⫽ (0.120 ⫻ height) ⫺ 2.782.
DISCUSSION
Men of all ages suffering from severe gynecomastia go through operations to achieve a better aesthetic chest appearance. It is imperative
to locate the nipple-areola complex in the appropriate location. Murphy et al.8 proposed a
method of determining the site of nipple
placement in patients undergoing a simple
mastectomy and full nipple grafting for severe
gynecomastia. Beckenstein et al.7 also presented the ideal nipple position on the chest
wall and the average areola diameters in men
using ratios according to measured body anatomical parameters. We further clarified these
techniques by emphasizing the importance of
fixed points of measurement, which thus
avoids a surgeon’s subjective point selection.
The following three ratios were defined in
this study for appropriately locating the nippleareola complex in men: the ratio between the
TABLE III
Correlation between Parameters Using Pearson Correlation Test
Parameter
Correlated Parameter
Pearson
Correlation
Coefficient
Height of nipple
Distance between nipples
Suprasternal notch-to-nipple distance
Distance between nipples
Distance between nipples
Midclavicle-to-nipple distance
Distance between nipples
Height
Chest circumference
Height
Height
Suprasternal notch-to-nipple distance
Height
Midclavicle-to-nipple distance
0.905
0.689
0.512
0.508
0.708
0.547
0.630
p
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
0.0001
350
PLASTIC AND RECONSTRUCTIVE SURGERY,
August 2001
FIG. 3. Correlation between distance between nipples
(cm) and chest circumference (cm).
FIG. 1. The following three ratios are used to locate the
nipple-areola complex: (left) the ratio between the height of
the nipple and the height of the patient, (center) the ratio
between the distance between nipples and chest circumference, and (right) the ratio between the suprasternal notchto-nipple distance and height of the patient.
height of the nipple and the height of the
patient, the ratio between the distance between
nipples and the chest circumference, and the
ratio between the suprasternal notch-to-nipple
distance and the height of the patient. These
ratios take into consideration the total body
build in determining the appropriate location
of the nipple-areola complex.
Mathematical accuracy demands using the
equations of the lines of correlation, as presented in the Results section, to predict the
appropriate location of the nipple-areola complex. However, the ratios defined in our study
are relatively constant, as seen by the very low
standard deviations of the mean. In addition,
the lines of correlation pass close to the origin
of the axes, and the practical range of x values,
for surgical applications, is substantially far
from the origin. Thus, the ratios defined in this
study closely approximate the slope of these
graphs and correct for ignoring the constants
of the equations. Therefore, for practical rea-
FIG. 2. Correlation between nipple height (cm) and
height of the patient (cm).
sons, we use the mean ratios as the basis for our
proposed surgical model.
Using the first two parameters (nipple
height:height and distance between nipples:
chest circumference) enables the surgeon to
locate the nipple-areola complex on the male
chest, and the third parameter (suprasternal
notch-to-nipple distance:height) serves as a
control measurement for the correct location.
Because the male obesity pattern involves
mostly the abdominal region, the parameters
of height and chest circumference are relatively unaffected by obesity. The model, which
is based on nonobese patients, can thus be
accurately used for moderately obese patients
as well.
We propose the following technique for nipple-areola complex location in the male patient. Only two parameters should be measured: the height of the patient and the chest
circumference. Preoperative measurements of
patient height should be noted. A horizontal
line at a height of 0.722 of the patient height is
drawn. Chest circumference at this level is measured, and the midsternal vertical line is
marked. Chest circumference is multiplied by
the factor 0.213 to calculate the distance between nipples. Half of this distance is measured
from the midsternal line laterally to both sides,
and the anticipated points of the new nipples
are marked. To verify the correct location of
the nipple-areola complex, patient height is
FIG. 4. Correlation between suprasternal notch-to-nipple
distance (cm) and height of the patient (cm).
Vol. 108, No. 2 /
NIPPLE-AREOLA COMPLEX IN MALES
351
multiplied by the factor 0.104, and the distance
between the suprasternal notch and the new
nipple location is compared with this calculated distance.
The nipple and the areola sizes are then
determined using the sizes noted in Table II.
Mild variations according to patient height and
body build are performed by free hand correction of the calculated nipple-areola complex
location.
In conclusion, we found this three-parameter relative ratio technique for locating the
nipple-areola complex simple and suitable for
the male patient.
Ori Shulman, M.D.
Department of Plastic and Reconstructive Surgery
and Burn Unit
Campus Beilinson
Rabin Medical Center
Petah-Tikva, 49100 Israel
orishon@inter.net.il
1. Letterman, G., and Schurter, M. Surgical correction of
massive gynecomastia. Plast. Reconstr. Surg. 49: 259,
1972.
2. Simon, B. E., Hoffman, S., and Kahn, S. Classification
and surgical correction of gynecomastia. Plast. Reconstr. Surg. 51: 48, 1973.
3. Aiache, A. E. Surgical treatment of gynecomastia in the
body builder. Plast. Reconstr. Surg. 83: 61, 1989.
4. Dolsky, R. L. Gynecomastia: Treatment by liposuction
subcutaneous mastectomy. Dermatol. Clin. 8: 469, 1990.
5. Rosenberg, G. J. Gynecomastia: Suction lipectomy as a
contemporary solution. Plast. Reconstr. Surg. 80: 379,
1987.
6. Courtiss, E. H. Gynecomastia: Analysis of 159 patients
and current recommendations for treatment. Plast.
Reconstr. Surg. 79: 740, 1987.
7. Beckenstein, M. S., Windle, B. H., and Stroup, R. T., Jr.
Anatomical parameters for nipple position and areolar diameter in males. Ann. Plast. Surg. 36: 33, 1996.
8. Murphy, T. P., Ehrlichman, R. J., and Seckel, B. R. Nipple placement in simple mastectomy with free nipple
grafting for severe gynecomastia. Plast. Reconstr. Surg.
94: 818, 1994.
REFERENCES