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

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