Difficult breast augmentations

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CHAPTER 56 Difficult breast augmentations

History

When evaluating the breast augmentation patient, one must recognize certain physical abnormalities that could affect the ability to achieve an optimal result. Rohrich in 2003 noted that about 88% of women presenting for breast augmentation had some asymmetries. These included asymmetries in the chest wall, breast parenchyma, inframammary fold, and degree of ptosis. He urged careful preoperative and intraoperative analysis of the patient to achieve an optimal result from breast augmentation. Sometimes the deformities are more extreme and have to be dealt with in specific ways to attain a good result from breast augmentation. The three most common of these abnormalities are tuberous breast deformity, anterior thoracic hypoplasia, and Poland’s syndrome.

Tuberous breast deformity

The tuberous breast deformity was first described by Rees and Aston on 1976. The entity was classified by several authors since then.

Anatomy

The deformity consists of:

• Reduced breast diameter.

• High inframammary fold.

• Breast hypoplasia mostly in the lower pole of the breast that can encompass the entire breast.

• Herniation of the breast through the areola.

• Constricting band around the breast.

• Occasional deficiency in lower pole skin.

The breast is thought to be contained in a fascial envelope. The superficial layer covers the breast parenchyma, and the deeper layer is the fascia below the breast on the pectoralis major and serratus anterior muscles. There is no fascia in the area of the areola. The constricting ring at the periphery of the breast is thought to be from the superficial fascia. This ring prevents the growth of the breast inferiorly. As the breast grows, the parenchyma has no place to go, and therefore pushes through the areola to create the herniation.

The deformity is well described by Grolleau:

Type 1: Lower medial breast deficiency.

Type 2: Deficiency in the entire lower pole of the breast.

Type 3: Deficiency in the entire breast.

Physical evaluation

The key parts of the physical examination include:

• Breast diameter.

• Breast vertical height.

• Diameter of the areola.

• Presence or absence of a constricting band around the periphery of the breast.

• Measurement of the distance from the bottom of the areola to the inframammary fold.

• Assessment of breast volume. This can be accomplished using 3D imaging if available.

Technical steps

The procedure to correct the tuberous breast includes the following options:

• Periareolar mastopexy in most cases.

• Soft tissue parenchymal manipulation to reshape the existing breast tissue.

• Breast augmentation, frequently asymmetric.

• Manipulation and lowering of the inframammary fold.

• Scoring the lower breast skin flap in the lower pole of the breast.

• Possible placement of a tissue expander.

Periareolar mastopexy is almost always a part of any procedure to treat tuberous breasts. After the periareolar skin resection, a lower breast skin flap is elevated. The breast is completely mobilized to the chest wall and then the dissection is continued superiorly until the entire lower breast is mobilized and delivered through the incision. The breast is usually split at the 6 o’clock position and medial and lateral flaps are created. The fibrous ring is divided. Additional cuts are made in the ring if needed. The flaps are sutured together to make a round more normal lower pole of the breast (Fig. 56.1). If the skin of the lower pole of the breast is felt to be deficient, a tissue expander may be inserted. If need for a tissue expander is though to be a possibility, it should be discussed with the patient prior to surgery. In most cases, a tissue expander is not required and the breast is augmented. Usually a subpectoral or dual-plane pocket is created, a sizer is placed, and the appropriate implant is selected. The areola is closed with a permanent purse-string suture (Fig. 56.2).

Fig. 56.1 Diagram of the technique to treat tuberous breast deformity.

Fig. 56.2 A–F, 16-year-old patient with tuberous breast deformity who underwent periareolar mastopexy, internal breast tissue mobilization, transaction and plication, and augmentation.

Postoperative care

Postoperatively, the patient is kept in a surgical bra and upper body exercise is limited for about a month.

Complications

The most common complication associated with tuberous breast surgery is either not recognizing the deformity or underestimating the deformity and only placing a breast implant. This will make the deformity look worse. Without parenchymal manipulation, the chance for an acceptable result is low. Failure to use a permanent suture around the areola could result in areolar spreading. Double-bubble deformity is possible if the inframammary fold is lowered too much or inadequate lower pole skin is present.

Anterior thoracic hypoplasia

The original description of congenital chest wall deformities was described by Froriep in 1839 and then by Poland in 1841. These chest wall deformities could involve the ribs, sternum and muscles as well as the breast and other soft tissues.

Anatomy and physical evaluation

It is important to make sure that any chest wall asymmetries are noted when evaluating a patient for breast augmentation. It is a good idea to take a series of basic chest measurements when examining a breast augmentation patient. These include:

• Breast width.

• Distance from the sternal notch to the nipple.

• Areola diameter.

• Distance from the nipple to the inframammary fold.

Asymmetries in these measurements may tip the surgeon off that a subtle deformity exists and allow this to be explained to the patient prior to surgery. A surgical plan could be developed that will allow possible correction for asymmetry or at least compensation for some of the deformity. The physical examination should also include complete evaluation of the anterior and posterior chest and upper extremities.

Anterior thoracic hypoplasia consists of:

• Posterior positioning of the ribs.

• Hypoplasia of the breast.

• High riding nipple–areola complex.

There is no involvement of the pectoralis major muscle and upper extremity. This distinguishes this condition from Poland’s syndrome which always has involvement of the pectoralis major muscle.

If 3D surface scanning of the breast is available, the breast measurements could be done by the computer and the breast volume could be determined as well. In most cases 3D surface scanning is not available and CT scanning is obtained. The CT scan will allow measurement and visualization of the degree of chest wall depression. 3D reconstruction may be obtained to determine the volume difference between the two breasts.

Technical steps

After the evaluation of the patient is completed, breast augmentation is usually used to correct the chest wall depression and the size of the breast. It is usually better to determine what, if any, surgery is to be performed to the normal breast and then to match the affected breast to the modified normal breast. In most cases, the patient desires augmentation of both breasts. After the implant is selected for unaffected side, the implant is selected for the affected side. The measurements from physical examination and radiologic studies are utilized along with the breast implant manufacturer implant measurement catalogues to determine the most likely implant options. In the operating room, the normal breast surgery is performed first and then a sizer is placed to confirm the size and shape of the implant to be placed on the affected side. Any combination of profile, shape, or size is used to achieve the best result possible. A more natural look is obtained by placing the implants in a submuscular position usually using a variation of the dual-plane technique. In some cases the use of postoperatively adjustable saline implants is indicated. In many cases, there is no way to correct the high-riding nipple–areola complex. This needs to be explained to the patient preoperatively.

In some cases, the chest wall depression is so severe that breast augmentation techniques can not achieve an acceptable result. In these cases the chest wall defect can be dealt with using either a customized silicone implant or autologous tissue. The breast implant could then be placed on top of this reconstruction to obtain the final result.

Poland’s syndrome

The most notable difference in patients with Poland’s syndrome compared to those with anterior thoracic hypoplasia is that patients with Poland’s syndrome always have involvement of the pectoralis major muscle. The syndrome may involve deformities of the breast, unilateral chest, and upper extremity as well. Most cases of Poland’s syndrome occur sporadically and the right side is involved most commonly.

Poland’s syndrome was classified by Hartrampf (Table 56.1). Class 2 and 3 patients are reconstructed with breast reconstruction techniques which are beyond the scope of this chapter. Class 1 patients are reconstructed with techniques that are similar to those used with anterior thoracic hypoplasia. In class 1 patients the pectoralis muscle is hypoplastic and frequently does not need to be separately reconstructed. Since many patients with Poland’s syndrome present in their teenage years, prior to complete breast growth, the first stage of the reconstruction often involves placement of a tissue expander or an adjustable implant. When growth is complete, the implant or tissue expander is replaced with a permanent implant and the unaffected side is modified to match the affected side as best as possible (Fig. 56.3).

Table 56.1 Classification of Poland’s syndrome

Fig. 56.3 A–F, 20-year-old patient with left Poland’s syndrome treated with left breast augmentation alone.

Pearls & pitfalls

Pearls

• More extreme deformities have to be dealt with in specific ways to attain a good result from breast augmentation.

• The tuberous breast may show lower medial breast deficiency; deficiency in the entire lower pole of the breast; deficiency in the entire breast.

• Chest wall deformities may involve the ribs, sternum and muscles as well as the breast and other soft tissues.

• It is important to make sure that any chest wall asymmetries are noted when evaluating a patient for breast augmentation.

• Poland’s syndrome always has involvement of the pectoralis major muscle.

Pitfalls

• The most common complication associated with tuberous breast surgery is either not recognizing the deformity or underestimating the deformity and only placing a breast implant.

• In many cases, there is no way to correct the high-riding nipple–areola complex. This needs to be explained to the patient preoperatively.

• Patients with tuberous breasts, Poland’s syndrome and anterior thoracic hypoplasia need to be cautioned that as they go through the different stages of life (pregnancy, breast feeding, aging), the affected and unaffected breasts will change in different ways. This frequently results in the need for revisional surgery. The patient should be carefully advised of this prior to any surgical procedure.

Summary of steps

Tuberous breast deformity

1. Periareolar mastopexy in most cases.

2. Soft tissue parenchymal manipulation to reshape the existing breast tissue.

3. Breast augmentation, frequently asymmetric.

4. Manipulation and lowering of the inframammary fold.

5. Scoring the lower breast skin flap in the lower pole of the breast.

6. Possible placement of a tissue expander.

Anterior thoracic hypoplasia

1. Breast augmentation is usually used to correct the chest wall depression and the size of the breast.

2. If the chest wall depression is too severe for breast augmentation, the chest wall defect can be dealt with using either a customized silicone implant or autologous tissue.

Poland’s syndrome

1. Class 2 and 3 patients are reconstructed with breast reconstruction techniques.

2. Class 1 patients are reconstructed with techniques that are similar to those used with anterior thoracic hypoplasia.

Further reading

Grolleau JL, Lanfrey E, Lavigne B. Breast base anomalies: Treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg. 1999;104:2040–2048.

Hodgkinson DJ. The management of Anterior chest wall deformity in patients presenting for breast augmentation. Plast Reconstr Surg. 2002;109:1714–1723.

Mandrekas AD, Zambacos GJ, Anastasopoulos A, et al. Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg. 2003;112:1099–1108.

Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg. 1976;3:339–347.

Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast augmentation: A retrospective analysis of 100 patients. Plast Reconstr Surg. 2003;111:1513–1519.

Sadove AM, van Aalst JA. Congenital and acquired pediatric breast anomalies: A review of 20 years experience. Plast Reconstr Surg. 2005;115:1039–1050.

Spear SL, Pelletiere CV, Lee E. Anterior thoracic hypoplasia: A separate entity from Poland’s syndrome. Plast Reconstr Surg. 2004;13:69–77.

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