Local Flaps for Tuberous and Asymmetric Breasts

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CHAPTER 38 Local Flaps for Tuberous and Asymmetric Breasts

Key Points

1. Various glandular flaps can be used to treat hypoplastic tuberous breasts.

2. Asymmetry makes correction more difficult.

3. Various flap types are individualized to each patient on each breast.

4. Type I is an inferior glandular flap that is turned down beneath the gland toward and secured at the IMF.

5. Type II is an inferior glandular flap that is turned down beneath the gland to fill out the constricted lower pole.

6. Type III is an inferior glandular flap that is reversed and used beneath the skin to fill out more superficial constrictions.

7. Often breast asymmetry is best treated by removing parenchyma in the larger breast, using appropriate flaps as described and then using similar sized implants.

8. The subglandular pocket is the preferred location for an implant to help expand the lower pole, but a retropectoral pocket may be a necessary choice in a patient with minimal subcutaneous cover.

Summary

Tuberous breast, tubular breast, snoopy breast, nipple breast, and constricted inferior pole, are all different names describing similar congenital deformities that should be considered as different aspects of the same substantial congenital developmental anomaly; although this is still a debated question.

In this chapter I will consider only the ‘heavily hypoplastic tuberous breast.’

This deformity has posed, and continues to pose, many difficulties in trying to surgically correct this malformation. Its solution is considered a real challenge even for the very experienced surgeon.

Such a deformity has a significant psychological impact on young patients, due to its odd and unpleasant appearance. Patients are often quite young when they seek surgical treatment and they have great expectations about the outcome. This therefore makes achieving a good solution very challenging for the surgeon.

Many surgical techniques have been described to best treat these malformations ¹^–²⁰ but none of them, in my opinion, seem to be perfectly applicable to each case and to each different morphological anomaly.

In trying to deal with this difficult surgical dilemma, I would like to introduce a different surgical approach to the problem.

I have developed a new ‘basic idea’ which can be tailored to fit each clinical case.

In order to deal with these variable malformations, it is necessary to apply a flexible approach with a technique that can be modified to fit each particular case.

The preoperative evaluation should include a thorough examination of the patient in standing position in order to have a precise visualization of the deformity. The chest and breast should be measured. The breast shape should be carefully evaluated by observation, palpation of the breast, and pinching of the skin.

This careful examination is necessary to obtain a good ‘manual perception’ of the existing gland and to understand which portion of it must be mobilized and rotated as a flap, in order to redistribute the breast tissue over the breast implant to ensure the best possible result.

The principle is to create a glandular flap, properly shaped and then mobilize it from the relative ‘surplus’ area to the more insufficient part of the breast.

In other words, this means to reshape the breast mound without discarding gland tissue, changing the deformed breast into a quite ‘normal flat hypoplastic breast.’

The flaps need to be long enough to reach the pectoralis muscles once the fibrotic constriction of the breast base is released. This constriction often needs to be released by radial and transverse incisions from the deep surface as described by Aston and Rees,¹⁴ and Maxwell.⁹

Patient Selection and Indications

• Each single flap, described above, can be utilized for selected patients who present different and specific morphological characteristics.

• Flap Type I (Figs 38.3–38.16) and flap Type II (Figs 38.28–38.35) are indicated in cases of minor or major evidence of herniation of the gland into the areolar skin respectively.

• Flap Type III is usually combined with some release incisions of the gland and is indicated in cases with tight, tense and more or less concave inferior pole without defined inframammary fold (Figs 38.46–38.53).

Fig. 38.3 Case 3. A Preoperative view showing hypoplastic tubular breasts with mild asymmetry: left breast is smaller and slightly more ptotic than the right one. This case presents a particular and unusual morphology because the breasts have a wide base with the presence of a double bubble profile and a pseudoherniation of part of the gland into the areola surrounded by a constricted fibrotic ring overlapping a larger flat gland. In order to correct this deformity a flap Type II has been used. B Preoperative oblique view. C Preoperative view showing the periareolar area to be de-epithelialized and the triangular mark on the caudal part of the areola corresponding to the skin excision and the glandular flap that will be prepared. D Preoperative drawing showing the triangular glandular flap. E, F After periareolar de-epithelialization, a triangle of the caudal portion of the areolar skin is excised; the glandular tissue highlighted will be used to create the flap. G The glandular flap tissue is created and elevated. The pedicle is based on the subdermal plexus. H Schematic drawing with triangular flap elevated. I After undermining the central and inferior half of the breast, the rotation of the flap is performed to fill the inferior pole, with the apex of the flap reaching almost the new IMF. The patient is quite thin, therefore a retropectoral pocket is chosen through an inframammary access and an anatomical prosthesis of 250 g is implanted. J Schematic diagram of the procedure in I. K Final front view, a few months after surgery. L Final three-quarter right view, a few months after surgery.

From Muti E; The hypoplastic tuberous breast. In: Spears SL, ed, Surgery of the breast: principles and art Vol 2, 2nd edition: 1444-1457. Lippincott Williams and Wilkins, 2006.

Fig. 38.4 Case 4. A Shows the preoperative markings with the areolar reduction and lifting through the periareolar de-epithelialization. The triangle is drawn in the inferior half of the areola corresponding to the gland flap to be developed with the same technique used in Case 3, with flap Type II. B Lateral view shows the deformity and appearance of typical tuberous breasts, with a constricted and concave inferior pole and an IMF at the level of the inferior limit of the areola. The patient did not want an implant and did not want any modification of her right breast. She only wanted her breasts to be symmetric; she asked for correction of her left breast only. It is much more difficult to achieve symmetry when operating on only one side. C Preoperative view. D Postoperative result 4 years later. E Postoperative view of right breast showing the achieved symmetry, 4 years later. F Postoperative view of left breast showing the achieved symmetry, 4 years later. This case shows the application of the author’s preferred technique: first correcting the deformity, obtaining symmetry and then if desired implanting two equal prostheses.

Fig. 38.5 Case 5. A This picture shows a clearly asymmetric breast with the right breast smaller then left one. The right breast is heavily hypoplastic with a tuberous appearance, a concave inferior pole and a typical cranial IMF. The left IMF is cranial as well. B Preoperative planning with red markings showing the site of inframammary incision chosen as access for the implant, the spotted green markings showing the extension of the pre-pectoral pocket. On the left breast, the yellow and red area defines the glandular resection that should be performed from the base of the gland in order to obtain a volume and shape similar to the right breast. At the left inferior pole, a small glandular flap is harvested, as described in Case 3, to fill the inferior pole. C This three-quarter left side view shows the deformity of the right breast with a cranial IMF and constricted-concave inferior pole. The white line points out the deformity, the concave aspect of the inferior pole as well as the ‘added slight deformity’ immediately caudal to the areola due to a protrusion of a small amount of breast tissue. This minor defect is often missed in the surgical correction and it becomes more evident after the implant of the prosthesis. To correct the constricted inferior pole, sufficient use of several releasing incisions at the inferior pole is necessary. Only then is an appropriate prosthesis implanted. To correct this small added deformity a flap Type III was used. D A schematic side view of the deformity.E This right view shows the residual deformity of the inferior pole after the insertion of the implant through an inframammary access, after performing several releasing vertical and transverse incisions of the breast at the inferior pole that still maintain certain flatness. A small protrusion of breast tissue can be seen caudally behind the areola. F Schematic drawing of the right breast. The red markings show the incision through the gland after subcutaneous undermining behind the caudal portion of the areola. G, H A deeply pedicled glandular flap is created with the protruding tissue and then elevated. I, J The glandular flap is caudally and superficially rotated after subcutaneous undermining of the central part of the inferior pole. K, L Final result showing good symmetry of the breasts after two equal sized implants inserted in the prepectoral pocket through the IMF access, along with correction of the deformity through a deep pedicle and a superficially and caudally rotated glandular flap. Often even a small flap can completely resolve this deformity, clearly changing the profile aspect of the inferior pole.

Fig. 38.6 Case 6. A The preoperative marking of this asymmetric breast with tuberous aspect of the right side shows that the new right IMF should be located in a lower position –XX indicates the cranial IMF. On the left breast the area marked with an ‘A’ indicates the glandular resection needed to achieve shape and size similar to the right one. The ‘B’ area corresponds to the peri- and infra-areolar de-epithelialization; the central flap with the superior pedicle is used for the mastopexy on this side. B Preoperative frontal view of asymmetric breasts with right breast smaller than the left one and a higher IMF. The left breast should undergo reduction with mastopexy to achieve a volume similar to the right one. The right breast presents a cranialized IMF with a constricted and insufficient inferior pole with a slight glandular protrusion caudal to the areola. This corrective surgery has been shown and described for the right breast in Case 5 and treated with the same flap Type III. Following this procedure two equal prostheses are implanted. C Preoperative three-quarter left view showing good correction of the asymmetry ensuring a good result in the long term. D Postoperative result 2 years later. E Postoperative three-quarter left view showing good correction of the asymmetry ensuring a good result in the long term.

Fig. 38.7 Case 7. A Preoperative view of tuberous breasts with the typical pseudoherniated aspect of the areola, tight and very cranialized IMF and a constricted fibrotic periareolar ring. These very small breasts are drooping on the lateral part of the chest wall with a very wide intermammary space. The patient did not want a larger breast therefore a small implant was chosen. There is a defect in the preoperative markings, in fact the distance between the inferior areolar border and the new IMF is shorter on the right side and in addition the inferior pole is less full. This case was treated with the same flap as used for Case 3 (flap Type III) but without adding the incision in the IMF for access to implant the prosthesis. In this case we inserted the prosthesis through the periareolar incision. B Preoperative oblique view. C An unsatisfactory result with persistent small double contour deformity with a residual hemicircular periareolar fibrotic ring. D An unsatisfactory result, oblique view.

Basically I distinguish three different types of flaps that can fit different types of deformities:

Flap Type I

It can be adapted to those cases with a small gland, which is more or less completely herniated into a sort of sac of areolar skin. The areola is usually expanded with a circular constricted base. In those cases the flap can include almost all the herniated gland; the shape of the flap becomes more or less quadrangular. Then the excision of the redundant areolar skin is performed resulting in a periareolar scar, plus a short vertical scar. See Cases 1 and 2.

Flap Type II

It can be adapted to those cases presenting a high and constricted inframammary fold (IMF), a short or missing inferior pole, a quite normal or minor expansion of the areola with a protrusion of the gland only in the inferior half of it.

These are cases in which often a triangle of areolar skin is excised from its inferior half, exposing the protruding gland that will be used as a triangular flap rotated deeply toward the pectoralis plane as for flap Type I. The skin incision around the areola, once sutured, will result in a periareolar scar and a short vertical intra-areolar scar, which is barely noticeable.

In cases like these, I prefer to perform an additional inframammary incision to implant the prosthesis because it gives me a better control of the new IMF. See Cases 3 and 4.

Flap Type III

It can be adapted to those cases presenting with a constricted, tense, flat or concave inferior pole, with a small amount of gland protruding under the inferior half of the areola.

For these cases a different superficial flap is used: after undermining the inferior border of the areolar skin, the upper central part of the tissue is created as a flap. An incision at the superior border of the protruding tissue perpendicularly down to the breast is then performed, leaving the flap attached to the original gland then a rotation of the small flap is performed downward superficially under the skin. See right breast in Cases 5 and 6.

All the cases with tight and firm parenchyma also require radial and/or vertical release incisions from the deep surface till the deep dermal plane as described by Aston and Rees,¹⁴ Maxwell,⁹ and others.

Operative Technique

Markings

These malformations, with so many variables and different morphologies, need specific and individualized preoperative assessment and markings. The skin markings are done with the patient in a standing position.

The fundamental points on the breast are marked as follows:

• The middle thoracic line.

• The new sternal notch–nipple distance: this distance has great variability depending on the patient’s height. Average distance is about 20–22 cm.

• The nipple position should correspond to the central point of the humerus bone between the shoulder and the elbow.

• The existing IMF.

• The desired IMF.

• The distance between nipple and the IMF.

• The new areolar dimension.

• The area to be de-epithelialized and the relative skin excision.

After the preoperative skin markings are drawn, two other important points must be considered:

1. The amount of the gland to be mobilized creating the flap, its shape, its pedicle, and its rotation. All can be assessed by palpating the breast.

2. The selection of the prosthesis, including size, type, and shape is influenced by the morphological appearance of the breast, and when possible by the patient’s desire to choose her new breast shape. At the same time we should select the technique we want to utilize for the implant placement. This procedure varies according to the incision necessary to perform the primary repair of the deformity. Quite often I prefer to add an incision at the level of the new IMF to help enhance its definition.

Intraoperative preparation

The patient is put on the operating table with the arms lying along the body. General anesthesia is usually used.

The operation starts with the patient lying in a flat supine position, but when flap rotation and prosthesis implantation procedure is performed during the final stages of the procedure the patient is put into a sitting position.

Some temporary tacking stitches are usually needed to control the results and the symmetry.

Prosthesis selection and placement plane

The selection of prosthesis dimensions and shape takes into account the patient’s wishes, but more fundamentally the patient’s thoracic measurements.

The shape can be ‘anatomical’ with moderate to high projection, or more often round with moderate to high projection.

The round prosthesis, often softer, is easier to handle with far fewer complications, especially in the postoperative period.

The plane chosen for the implant depends on individual morphological characteristics of the chest wall envelope. It can be prepectoral in patients with good envelope thickness but retropectoral in very thin patients.

I actually prefer, as far as possible, the prepectoral plane because it is an easier and faster procedure and it helps with the redistribution of the glandular tissue.

In those cases with a wide intermammary space and laterally located areolas, the best choice should be an ‘anatomical’ shaped prosthesis with a wider transverse diameter.

The selection of the most appropriate prosthesis is always a challenge, therefore I recommend the use of intraoperative sizers to achieve the best outcome. This must be performed with the patient in a sitting position.

The implant can be introduced through the periareolar incision used to prepare the glandular flaps or through an additional inframammary incision, but, to my experience, this latter selection is often very useful in those asymmetric cases in order to better define the IMF bilaterally.

Surgical steps

The most common steps of the operative technique can be summarized as follows:

• De-epithelialization of the skin following the skin markings.

• Dermal incision at the lateral and medial border of the de-epithelialized area, in those cases where the de-epithelialization also involves the inferior pole.

• In such cases the dermis of the inferior pole is undermined up to the inferior border of the areola.

• The areola is reduced and raised at its new position, fixing it in place with one suture at the 12 o’clock position.

• The shape and size of the glandular flap is then determined and sculptured with perpendicular incisions from the superficial to the deep plane.

• The flap is rotated deeply and downward with the apex towards the new IMF

• The free edge of the flap is fixed in its position on the deep surface of the skin with some sutures and sometimes with through–through sutures.

• The prosthesis is usually implanted in the prepectoral plane, but sometimes in the retropectoral plane, depending on the envelope’s thickness.

• Skin closure: the position and the length of the skin incision line will vary according to the type of deformity and to the amount of skin to be excised during the procedure. If the quantity of skin to be excised is limited, then the skin closure can be localized to the periareolar region. In cases where the area of de-epithelialization is larger, I personally prefer to redistribute the skin closure between the periareolar region and a vertical incision line on the inferior pole, in order to avoid the flattening of the mammary cone. This redistribution of the skin is similar to other techniques but more recently it has been well demonstrated and described as the ‘circumvertical technique’ by Mottura.¹⁰ From a technical point of view the deep dermis is closed with buried, interrupted sutures of resorbable 2-0 material; the superficial dermis is then closed with buried interrupted sutures of 4-0 resorbable material. The superficial, epidermal plane is re-approximated with glue and layers of micropore paper tape.

Hypoplastic tuberous breast deformity (Cases 1–3)

The high morphological complexity of this malformation and its multiple details must be individually considered in approaching surgical repair. This makes it difficult, almost impossible, to describe one complete step-by-step operative sequence for its correction. I have illustrated three different surgical cases presenting different morphological characteristics and the relative intraoperative sequences and drawings (Case 1, Fig. 38.1; Case 2, Fig. 38.2; Case 3, Fig. 38.3).

Fig. 38.1 Case 1. A Bilateral symmetric hypoplastic tuberous breast deformity in a very young patient. The small breast is almost completely covered by the expanded areolar skin. Correction of this deformity presents a high degree of difficulty because it is quite difficult to draw the pre-operative markings and it requires a larger skin resection than ideal, resulting in more skin tension and possible bad scarring. This picture highlights the extreme lateralization of the two small glands on chest wall and a wide intermammary space. B This projection shows clearly the cranialized IMF located at the inferior border of the areola. The preoperative skin mark shows the limits of the de-epithelialization area and the reduction of the areolar dimension. The glandular flap tissue is drawn at the lower half of the areola, outlined in red, within the limit of the dotted black line. The flap will be developed and mobilized, rotated deeply downward with the apex versus the new IMF. The flap’s vascular pedicle is located in the subdermal plexus coming up from the existing IMF. To repair this deformity we used flap Type I. C, D De-epithelialization is performed following the preoperative markings. E, F The new reduced areola is lifted in its new position with some temporary skin sutures. The dermis is incised and freed from the lateral and medial skin border up to the areolar horizontal midline to facilitate the mobilization of the areola, this is important to avoid traction and plication of the dermis that could deform the areola and could strangulate the vascular net of the superior pedicle. The dermis from the inferior pole is then undermined up to the areola inferior border. This maneuver is a common technique I use when performing a mastopexy or breast reduction.G, H The two skin points (a and b in C) are joined together with two hooks, and closed at the 6 o’clock position in the areola. The protruding glandular flap shows the portion of flap that will be developed incising it with full thickness down to the pectoral plane (red line in H). I, J The glandular flap is developed and pulled outward. K, L The deep prepectoral plane has been undermined and the glandular flap is rotated caudally inside. M, N The apex of the glandular flap is positioned downward to the new IMF to repair the deformity. It is then fixed in its new position with some internal or through-and-through skin sutures. At this point the chosen prosthesis is implanted. In this specific case a textured anatomical prosthesis of 210 g was inserted through the existing periareolar access in the prepectoral plane. O Skin closure, in these cases, is distributed partly periareolarly and partly vertically in the inferior pole in order to avoid or reduce the flattening of the areola and to minimize the periareolar scar. P Schematic lateral view showing the glandular flap position and its relation to the prosthesis. Q, S Preoperative aspect. R Postoperative result after 1 month. T Postoperative result after 4 years.

Fig. 38.2 Case 2. A Young female patient aged 17 years presenting highly hypoplastic tuberous breasts and a severe deformity. The small gland is completely covered by the expanded areolar skin. This figure clearly shows lack of dermal-glandular adhesion with absence of Cooper’s ligaments, poor skin quality with skin laxity. The gland has a small round base with a constricted ring around it. B The patient at the age of 13. The breast appears ptotic and hanging down on the more lateral part of the chest wall with a very wide intermammary space. C The patient at the age of 17, demonstrating the worsening of the anatomical features. All these features represent a compendium which explains the complexity that can be encountered in the surgical correction of a hypoplastic tuberous breast. D Postoperative results 10 years later. No sign of residual deformity or recurrence, patient is very pleased with the outcome. To treat this case we used the same procedure as for Case 1. The only difference is that, flap Type I was developed using most of the small existing gland. A textured round high profile prosthesis of 270 g was implanted in the prepectoral plane. E Postoperative lateral view.

Asymmetric tuberous breast deformity (Cases 4–6)

The tuberous breast with asymmetry represents the most difficult deformity to be treated with a single stage operation, as it combines the difficulties of repairing both the tuberous breast anomaly and breast asymmetry.

In this case it is necessary not only to correct the deformity but also at the same time create equal-shaped breasts. It is also necessary to consider the long-term maintenance of the surgical result.

My preferred way to deal with this complex problem, whenever possible, is to attempt the reduction of the larger breast and its reshaping aimed to achieve the same shape and size as the small one.

I have called the following procedure ‘selective subcutaneous gland excision.’

In this procedure, an attempt is made to correct both tuberous breasts in order to use equal-sized prostheses. This complex repair is not always easy to apply and careful attention to detail is essential to reduce the remaining asymmetry and ensure good results.

To better describe my surgical approach to correct this deformity I chose to present three surgical cases with step by step intraoperative description as well as preoperative drawings.

Example of failure of surgical correction of tuberous breast (Case 7)

This case demonstrates the most common type of failure in the surgical correction of tuberous breast deformity (around 1.5%) (Fig. 38.7A–D).

Causes of failure

• Imperfect preoperative drawings.

• Insufficient thickness of the glandular flap.

• Insufficient rotation of the glandular flap.

• Insufficient control of the new IMF.

• Insufficient base dimension of the prosthesis.

Although the above reasons are the result of small mistakes, the result is nevertheless unacceptable.

Fortunately, or unfortunately, the patient in Case 7 was completely satisfied with the outcome and did not want a revision. Today, in cases like these, I strongly recommend a revision by simply performing a lipofilling.

This is a minor surgery that can offer some advantage especially in those patients with unwanted adipose tissue elsewhere in the body.

Postoperative Care

When recovering from breast surgery we ask the patient to refrain from any pectoral activity for the first 2 weeks following prepectoral implant procedure. For retropectoral implants we extend the period to 4 weeks after surgery. Heavy lifting, sports and strenuous activity are accepted after 6 or 8 weeks.

We also ask the patient to sleep in a supine position for 2 months.

We apply a tight bandaging and prescribe medication for at least 3 weeks after surgery we also ask the patient to keep the paper taping on the incision lines for at least 2 months, if not more, in order to prevent or minimize scar visibility.

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Figure Acknowledgement

Figures 38.1A, C, M, Q, T; 38.2A, D, E; 38.3A, B, K, L; 38.4A, D, F; 38.5A, B, C, E, G, I, K; 38.6C; and 38.7A have all previously appeared in Muti E. The Tuberous Breast. SEE Editrice Firenze, 2010 and are reproduced here with kind permission.

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