Difficult breast augmentations

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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CHAPTER 56 Difficult breast augmentations

Nolan Karp

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).

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

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Fig. 56.2 A–F

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