For thousands of years, the female breast has been a symbol of sexuality, motherhood and nurture and at times it has even been used as a metaphor for the collective responsibility of the nation, during the French Revolution, for example. During the mid-1950s, Penn et al. attempted to define the perfect breast and wrote an article entitled Breast reduction, in which they examined a number of women between 18 and 39 years of age and concluded that the distance between the nipples and the sternal notch should be an equilateral triangle with a distance of 20.63 cm in an attractive breast. This work has been very important in the planning of breast reduction and mastopexy. In 2012, Mallucci et al. wrote the study entitled Concepts in aesthetic breast dimensions: Analysis of the ideal breast, in which they studied pictures of 100 topless women published in the tabloid newspaper, The Sun, and came to the conclusion that the perfect breast should have a 45:55 ratio between the upper and the lower pole of the breast. Mallucci’s study raised another question about breast esthetics: Was there a selection bias? Are the ideal proportions really 45:55 or is it a result of selection by a few people working at the tabloid?

The difficulty when it comes to breast esthetics is that “beauty lies in the eye of the beholder” and the obvious question is whether anyone can say that one breast is superior to another. It does not matter if a breast is small, large, wide or narrow; they can all be perfect, but one detail that may be important in an attractive breast is the location of the nipple-areola complex (NAC). A deflated breast after implant removal can look fantastic if the nipple sits in a position that gives the breast a balanced look, while, on the other hand, a full breast, with or without an implant, may look less esthetically pleasing if the nipple is in an odd position of any kind. After bariatric surgery and massive weight loss, there is often a tendency for the NAC to be medially positioned, giving an unbalanced look.

In the paper entitled The aesthetically ideal position of the nipple-areola complex on the breast, we attempted to isolate the importance of the nipple position by keeping other variables constant. We did not want different breast volumes, different breast shapes or different types of breast to interfere with the analysis of breast esthetics. So we used nine identical illustrations of a female torso and breasts, where only the nipple-areola position differed. The questionnaires were sent randomly to 2000 men and women in the Swedish population, and the results differed compared with Mallucci’s tabloid study. Women and men preferred a 50:50 proportion, but, when it came to the runner-up, there was a difference between men and women. Women preferred 60:40, while men preferred 40:60, which is close to Mallucci’s results.

We now had a gold standard in Sweden for evaluating breast esthetics and were able to start the evaluation of esthetics in plastic surgery of the breast.

We wrote another paper entitled Objective evaluation of nipple position after 336 breast reductions, where we used the conclusions from the previous work as a gold standard and concluded that the NAC is often placed laterally in breast reduction using the superiolateral pedicle. This knowledge helped us plan breast reduction surgery in a different way.

Everyone working in breast reconstruction surgery after breast cancer knows that a misplaced NAC after a fantastic breast reconstruction can ruin the overall look. A breast reconstruction with poor breast shape can look better if the NAC is placed in an effective manner that gives the breast better balance. The same technique of using the 50:50 proportion when planning and evaluating the result could help us achieve better results and more satisfied patients. This can also be used in breast mastopexy, breast augmentations or implant removals.

The obvious difficulty when evaluating breast esthetics is discussed above, and most papers use boards of plastic surgeons, laymen, students, and so on—all with the bias of subjectivity. The search for objective measurements in combination with patient-reported outcome measurements (PROMs) must continue so that the esthetic results after plastic surgery in breasts can be evaluated. Some people may believe that PROMs are good enough, but they are not. It goes without saying that a happy patient is our goal, but the results of PROMs in reconstructive breast surgery or breast reduction surgery are not always consistent with breast esthetics. Other factors, such as social support, expectations and the relief of symptoms, might be more important and will result in enhanced quality of life, regardless of breast esthetics. This is the reason why we need objective measurements combined with PROMs to continue the progress toward improved plastic surgery techniques.