Typically, a fully involved tuberous breast deformity will include a superiorly malpositioned inframammary fold that appears high in relation to what would be considered a ‘normal’ breast position. Present along with this is usually a constricted lower pole skin envelope that is likewise tight and unexpanded. As a result, whatever breast parenchyma is present variably protrudes through the areola, creating a ‘pseudoherniation’. It appears as if the embryonic breast bud was restricted to a small area of the anterior chest wall with an abnormally absent peripheral expansion and, as the breast develops during puberty, it has nowhere to go as it grows except forward. Because the areolar dermis is more elastic than the surrounding breast skin, there is a preferential expansion through the areola, which leads to the herniated appearance (Figure 8.1). Anatomically, in severe tuberous breast cases, fibrous bands can be identified along the underside of the breast in association with the constricted breast base diameter (Figure 8.2 A). Once these bands are cut, the entire breast mound can be observed to expand, creating a more normal breast appearance (Figure 8.2 B). Currently, it is not known if these bands are responsible for the deformity or, conversely, are present as a result of the deformity. Either way, it is interesting to postulate what role these bands might have in the development of the condition.

Figure 8.1 (A,B) Preoperative appearance of a 19-year-old woman with a fully developed ‘classic’ tuberous breast deformity. The breast is hypoplastic in general and whatever parenchyma is present is located mainly under the NAC. There does not appear to be normal peripheral expansion of the breast mound. As a result, growth of the constricted breast bud projects through the elastic areolar skin, creating an areolar ‘pseudoherniation’. Along with this is seen a concomitant enlargement of the areolar diameter. As a result of the failure of the breast bud to expand peripherally, the surrounding breast skin remains tight and the IMF that does form is malpositioned superiorly.

Figure 8.2 (A) Appearance of the underside of the breast in a patient with a severe tuberous breast deformity. The breast mound has been dissected free from the pectoralis major muscle and a subglandular pocket has been created. Horizontally oriented fibrous bands can be clearly visualized along the underside of the breast. These bands appear to be restricting peripheral expansion of the breast mound. It may be that these fibrous bands restrict normal breast bud development, resulting in the spectrum of deformity seen in tuberous breast patients. (B) After radial release of these bands, a more normal peripheral expansion of the breast parenchyma can be created. Such a maneuver is central to optimal correction of the tuberous breast.

Further complicating the altered overall appearance of the breast is the fact that asymmetry is a very common finding in patients with this condition. At times this asymmetry can be as dramatic a finding as the basic abnormality itself (Figure 8.3). It is not at all uncommon for one breast to present as a hypoplastic, misshapen mound that contrasts starkly with an enlarged, ptotic and disproportionate opposite breast with a nipple–areola complex (NAC) that appears to be medially translocated. Clearly, adequate surgical treatment must be geared toward artistically reshaping both breasts to maximal advantage in an attempt to restore symmetry.

Figure 8.3 A very common presentation for patients with the tuberous breast deformity includes a smaller hypoplastic breast with a constricted base on one side and a larger and more profoundly ptotic breast on the other. Interestingly, both breasts, despite the size difference tend to exhibit an inframammary fold location that is superiorly malpositioned.

Additionally, the tuberous breast deformity is not an all or none entity and, for any given patient, there can be varying degrees of involvement. As a result, the appearance of the breast can range from a subtle tightening of the inframammary fold all the way to the fully developed deformity with asymmetry as described previously (Figure 8.4). All of these factors combine to make treatment of the tuberous breast one of the most demanding surgical challenges in all of aesthetic breast surgery.

Figure 8.4 (A–E) Although each of these patients presents with differing degrees of deformity, they all demonstrate the basic findings of the tuberous breast, namely a variably constricted breast base with an abnormal medial IMF contour; a high, tight IMF, varying degrees of areolar ‘pseudoherniation’ and asymmetry.

Treatment of the tuberous breast deformity must generally focus on three main areas. First, the constricted skin envelope with the malpositioned inframammary fold must be normalized as much as possible. Second, the anatomic relationships that result in areolar herniation must be remedied. And, finally, any asymmetry in the size or shape of the breasts must be addressed. In most instances, it is necessary to combine these surgical strategies to optimize the final result.

Management of the Constricted Skin Envelope

The tightness of the skin envelope around the breast is perhaps the most difficult feature of the hypoplastic tuberous breast to correct. Not only does this constricted skin envelope interfere with the placement of an appropriately sized breast implant, but the lack development of a normal breast mound fails to stretch the skin appropriately, resulting in an abnormally high and tight inframammary fold. In essence, a new inframammary fold must be created surgically and the deformity or crease associated with the old fold must be overcome to create a smooth lower pole contour. Successful management of this aspect of the tuberous breast deformity will, in large part, determine the quality of the aesthetic result.

It must be emphasized that, even in patients who demonstrate only a mild tendency toward a tuberous breast, the inframammary fold contour can create significant problems in breast shaping. This can become very important in a general breast augmentation practice as the subtly high and mildly tight inframammary fold can escape the notice of the surgeon, only to become a problem later at the time of surgery when the lower pole of the breast appears constricted or the previous fold fails to soften completely as a new and lower fold position is created. These types of patients can be recognized by carefully observing the nature of the medial inframammary fold crease. If there is any convexity or superiorly oriented curving of the medial lower pole contour, a mild tuberous breast can be diagnosed (Figure 8.5). Recognition of this deformity preoperatively can help prepare the surgeon for what is to come at the time of surgery and allow for appropriate preoperative technical planning to be done. Also, the patient can be advised ahead of time as to the nature of her deformity, which then allows reasonable expectations to be set.

Figure 8.5 (A) Preoperative appearance of a 43-year-old woman in preparation for breast augmentation. In addition to the general hypoplasia and moderate ptosis of the NAC, there is a subtle convexity noted at the medial portion of the inframammary fold indicative of a mild degree of constriction in the lower pole of the breast, particularly on the left. This represents a mild form of tuberous breast deformity. Failure to recognize this soft tissue constriction and appropriately release it at the time of implant placement can lead to persistent deformity with asymmetry. (B) Preoperative marks in preparation for augmentation mastopexy. (C) One-year postoperative result demonstrating a smooth and full medial pole contour after vigorous scoring and soft tissue release along the medial inframammary fold.

Perhaps the most difficult determination that must be made by the surgeon is whether or not the constricted inferior pole skin can be expanded enough to allow the primary placement of a breast implant to create a natural contour in the lower pole of the breast. Also, it must be determined whether or not the crease created by the old inframammary fold (IMF) can be overcome by the implant once the new and more inferiorly located fold is created. This is a critical decision point in designing a successful operative strategy as, in fully developed tuberous breast cases, a persistent fold and a flattened and tight lower pole contour will very commonly persist despite aggressive release of the underlying soft tissue support structures. In these patients, better control of the lower pole and the location of the IMF can be afforded with the primary use of a tissue expander. In this fashion, the constricted skin envelope can be stretched sufficiently over time to allow the subsequent placement of an implant and any persistent crease in the old IMF can be softened. Deciding between the primary insertion of an implant versus the use of a staged tissue expander/implant strategy is the major determination that must be made when treating a patient with a tuberous breast deformity. This decision is complicated by other factors. To a certain extent, an old IMF crease that does not completely soften initially may subsequently relax over time due to the influence of the underlying implant. When this old fold will fill out and to what extent will be very patient dependent and is therefore subject to a significant degree of variability. As a result, an early persistent fold that can detract from the overall result after surgical correction may or may not improve over time and in no way can this be predicted with certainty. Added to this is the desire on the part of many patients to accomplish surgical correction in one operation. Besides the basic advantages of needing only one operation on traditional considerations such as operative risk, recovery and time off work, many patients have a financial incentive to effect correction in one stage. Unfortunately, insurance companies very commonly do not extend benefit coverage for tuberous breast correction and the procedure is considered cosmetic. As a result, a great many patients have financial constraints that allow only one procedure. All of this combines to place a fair amount of pressure on the surgeon to provide a one-stage correction.

To this end, several surgical strategies can be employed to maximally expand the skin of the lower pole and accurately lower the IMF. By placing the implant in the subglandular plane, direct force is applied to the skin of the lower pole and any tethering effect created by the pectoralis major muscle can be obviated. Also, by using the subglandular plane, the underside of the breast can be stretched and released as needed. As noted previously, there may be tethering fascial bands running horizontally along the underside of the breast. By radially scoring up into the parenchyma and dividing these bands, a visual and palpable release of the underside of the breast will be noted, resulting in a softer and more compliant breast mound. Taken together, these two maneuvers will allow the soft tissue envelope and the implant to better complement one another, resulting in a smooth and naturally contoured lower pole.

In more severe cases, it may be necessary to completely divide the lower half of the gland in a radial fashion to release fully the soft tissue constriction. These radial releasing incisions can be carried all the way to the dermis as needed to allow the soft tissue envelope maximally to expand. A useful approach that can facilitate a full soft tissue release is to utilize a periareolar incision to access the breast and then develop a dissection plane along the lower hemisphere at the level of the breast capsule. In this fashion, the underside of the breast can be accessed and released as needed and the lower half of the breast mound can also be divided radially to accomplish a complete correction of the soft tissue constriction caused by the breast itself. Also, any tethering bands that remain in the skin flap can be divided in a checkerboard type fashion to complete the release. Particular attention can be directed to the old fold as needed to be certain there are no unrecognized soft tissue attachments that may be contributing to a persistent crease that fails to soften completely. One additional advantage associated with the periareolar approach is that the setting of the new IMF level is more easily accomplished from above rather than through an incision in the IMF. Not only can it be difficult to determine accurately where to place the IMF incision such that it falls directly in the fold, but the technical challenge of trying to set the soft tissue attachments of the new fold through such a closely positioned incision can be difficult. After the overlying soft tissue has been completely released, the only remaining tethering force influencing the shape of the lower pole will be the lower pole breast skin. Therefore, any remaining tightness to the lower pole contour of the breast, or any persistent crease that is present in the region of the old fold, will be due to this unexpanded skin envelope and the only way to overcome such restriction is with the placement of a tissue expander.

Expander versus implant

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