No two breasts are the same, and that's exactly the challenge. The female breast is the most anatomically variable organ in the body. Age, genetics, size, tissue composition. No standardized protocol survives first contact with reality. And that's precisely why so many things can go wrong in mammography positioning.
Stefan Gaisbichler, a freelance radiologic technologist from Austria and certified mammography trainer for the Austrian breast cancer early detection program, laid out years of field experience at Röntgenkongress Digital, the online program running ahead of the German radiology congress in Leipzig.
His premise: the errors are consistent, the fixes are simpler than most assume, and nearly all quality complaints trace back to the same two technical failures.
One fold, most of the problems
Over 20% of all flagged image quality deficiencies under the PGMI criteria come from a single source: the inframammary fold not being visualized. Wrong detector height is the primary culprit for short CC images. Wrong detector angle loses the fold on the MLO. Two adjustments eliminate most standard errors before they happen.
“One can only assess what is on the image," says Stefan Gaisbichler, a freelance radiologic technologist from Austria.Courtesy of Claudia Tschabuschnig
"If you focus on the fold, the pectoralis follows by itself," Gaisbichler said, citing advice from a senior colleague that has held up consistently in practice.
Compression force, once considered critical in the film era, barely registers in digital mammography deficiency lists today, accounting for a fraction of a percent of complaints. The fold dominates. The fix is not complicated: correct detector height for the CC, correct detector angle matched to the patient's body type for the MLO.
"The textbook patient comes once a year"
Forty-five degrees is a default, not a rule. For slender patients, that angle often loses the fold entirely. Adjusting toward 60 degrees, matched to the actual trajectory of the pectoralis, changes the result.
For CC adequacy, the pectoralis–nipple line serves as the measurement tool when the pectoralis muscle itself isn't visible, which happens in roughly 40% of cases. The 15-mm rule for CC length is also more nuanced than often applied: it should be assessed in proportion to breast size, not as a flat cutoff.
Fifteen millimeters missing from a large breast is clinically different from the same gap in a very small one. "The textbook patient comes once a year," Gaisbichler noted. "Everything else is adaptation."
The nipple problem
The nipple in profile accounts for only around 1.2% of quality complaints, far less than the fold, but its clinical significance is disproportionate. Morbus Paget, a rare malignancy, can hide directly behind the nipple. If it appears only as a white patch in the mammogram, assessment is not possible.
Where standard positioning cannot achieve free nipple projection, Gaisbichler recommended a practical fix: make a supplementary exposure targeting the nipple specifically. Where tomosynthesis is available, scrolling through slices can compensate, since at least one layer will pass behind the nipple even if the projection itself isn't ideal.
Austria has already integrated tomosynthesis into its screening program; Germany has not yet reached that point.
When standard doesn't work
For small, firm, or mastopathic breasts, Gaisbichler described a technique that inverts the standard approach entirely: rotating the machine to produce a caudocranial projection, approaching compression from below. The inferior surface of the breast is flat. Compression from below lands on a flat plane, reduces the tendency to push tissue away, and is significantly more comfortable for the patient.
Most major manufacturers include this as a menu option, under names such as reverse projection, caudocranial mode, or from-below. For patients with cervical spine problems, rounded postures, or cardiac devices with lateral lead wires, it offers a practical alternative.
On that last point, Gaisbichler was specific: the device housing itself is not the risk. The lateral lead wires, which run superficially, are. Standard compression can drag them. The caudocranial approach changes where pressure is applied and reduces that exposure.
Funnel chest remains genuinely difficult. Some anatomical situations push against the technical limits of the equipment, and documentation in those cases is not optional. If the image is compromised, the radiologist reading it needs to know why.
Where AI falls short
While AI can support detection, it cannot position the patient and that gap is not closing any time soon. The radiographer's role, reading the person in front of them, adjusting in real time, communicating across a genuinely intimate procedure, remains irreducible.
"Only what is on the image can be assessed," Gaisbichler said. The implication runs in both directions: a missed fold means missed tissue, and missed tissue means missed pathology. The quality of the image is where the diagnostic chain begins.
Rökö 2026, Röntgenkongress Leipzig runs from 13 to 15 May. Full digital program (in German) is available here.
