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.

When the areola is excessively large or there is any degree of areolar herniation, a reduction in the diameter of the areola using periareolar techniques is indicated. By combining an outer periareolar incision with an inner areolar incision that ranges from 40 to 44 mm, the excessive and redundant areola can be removed resulting in a smaller areolar diameter. Also, the net effect of this maneuver is to equalize the propensity of the surrounding breast skin and the areolar skin to stretch under the influence of the underlying forces created by the parenchyma and the implant. In essence, the weak spot in the overall breast skin envelope, namely the areola, is repaired with the result being that the pressure from the underlying structures is now evenly dispersed over the entire breast mound. In this fashion, any tendency for the areola to herniate is corrected. It is here, in particular, that the interlocking Gore-Tex technique described previously is particularly useful. By evenly distributing the inevitable tension on the periareolar closure at the superficial dermal level, any tendency for the areola to spread will be minimized. Also, all of the releasing maneuvers described previously are facilitated by the periareolar approach.

When a symmetric tuberous breast deformity is present, the same operative techniques are simply applied from side to side as needed to provide a symmetric result. However, it is very common for the breasts to demonstrate asymmetrically variable deformity in shape and size. One common variant of this clinical presentation is the patient who presents with a fully developed hypoplastic tuberous breast on one side and an enlarged and ptotic breast on the other. It is important to realize that the enlarged breast almost invariably demonstrates many of the attributes of a tuberous breast including a superiorly dislocated IMF and a constricted base diameter. Very often, the breast protrudes over the IMF, creating an exaggerated ptosis with an enlarged areola that tends to be displaced medially. Adequate treatment to provide for a symmetric result must then concentrate not only on the frankly tuberous hypoplastic breast, but the enlarged and ptotic breast as well. From a surgical planning perspective, it is my preference to either reduce or lift the enlarged breast at the same time as the hypoplastic breast is treated with an implant in the hopes of providing the best symmetry possible in one stage. Should a revision subsequently be required, the breasts will display a greater degree of symmetry than they did initially and the revision will be easier to accomplish with greater accuracy.

At the time of surgery, it is recommended to treat the more severely involved breast first as this is the breast where there will be the least amount of control over the final result. Typically, this will be the hypoplastic breast that is released and augmented to the desired size. Once the hypoplastic breast is set, the opposite breast can then be more accurately reduced or lifted to the desired size and shape required to obtain the best symmetry. Although the goal is perfect symmetry, it is best to recognize that the preoperative deformity of many patients is significant and, typically, the breasts present with different anatomic features that make each unique in reference to the other. For this reason, despite considerable effort, it may not be possible to obtain exact symmetry in many cases. Appropriate preoperative counseling can prepare patients for this eventuality and help in setting realistic expectations.

In some patients with a fully developed tuberous breast deformity, there may be enough tissue to allow the breast simply to be re-sculpted without the need for an implant. In these cases, it is possible to utilize a standard mastopexy technique to reshape the breast and lift and reposition the NAC. However, a technique that manages only the skin envelope will not adequately address the deformity as internal dissection and release of the constricted breast base is required to allow the breast to splay out and more anatomically fill out the skin brassiere. My preferred method for doing this is with the short scar periareolar inferior pedicle (SPAIR) technique. Because of the way the breast flaps are developed, an internal release of the constricted base is accomplished that allows the normal dimensions of the breast to be restored. Then, after the inferior pedicle is developed, the underside base of the pedicle can be scored to release completely any deep restraining bands that may be present. Once the breast is reshaped and the widened areola reduced, a standard circumvertical pattern is applied to normalize the skin envelope (Figure 8.6). This same strategy can be used in patients with a tuberous breast deformity that includes any degree of macromastia as a reduction in breast volume can easily be accomplished along with the associated soft tissue release and reshaping of the breast. As with more standard techniques of breast reduction, the advantage of using the SPAIR technique is that an effective method for reshaping the breast and reducing the volume is provided that results in only a circumvertical scar pattern with the inframammary fold scar being eliminated. Because the technique is associated with only a modest settling during the postoperative recovery period, the classical finding of ‘bottoming out’ associated with the Wise pattern inferior pedicle technique is negated and the shape of the breast does not significantly change over time (Figure 8.7). This, along with the fact that the technique can be applied to a wide variety of breast sizes and shapes makes it particularly applicable to the subset of tuberous breast patients who present with asymmetric macromastia (Figure 8.8). Because the shape of the breast is aesthetic immediately, no provision for trying to predict how the breast shape will change over time is required, therefore the breasts can be sculpted with confidence at the initial procedure and very aesthetic results can be obtained.

Figure 8.6 (A,B) Preoperative appearance of a 16-year-old female with a tuberous breast deformity in association with mild macromastia. Note the inward curving of the medial inframammary fold secondary to the constricted breast base. This patient also demonstrates mild areolar herniation with an enlarged areolar diameter along with a mild asymmetry in size and shape. (C) Preoperative marks in preparation for a small reduction and breast reshaping using the SPAIR technique. (D,E) Intraoperative appearance after completing the procedure first on the left breast (D) and then on both breasts (E); 143 grams of tissue were removed from the left breast and 190 grams from the right. As a result of the internal dissection done during flap elevation and creation of the inferior pedicle, the internal soft tissue constriction is released resulting in smooth breast contours. (F,G) Postoperative appearance after 6 months demonstrates a symmetric result with a pleasing shape and an appropriately lifted NAC. The diameter of the NAC is proportionate to the size of the breast.

Figure 8.7 (A,B) Preoperative appearance of a 43-year-old female with a bilateral tuberous breast deformity that presents in conjunction with significant macromastia. The IMF is superiorly displaced causing the enlarged breast to fall over the fold, creating an overly ptotic appearance. (C) Preoperative marks in preparation for bilateral reduction and breast reshaping using the SPAIR technique. (D,E) Postoperative appearance after 3 years demonstrates a symmetric and contoured result along with a properly positioned NAC.

Figure 8.8 (A,B) Preoperative appearance of a 44-year-old female with a tuberous breast deformity variant that includes macromastia in association with a significant asymmetry. (C) Preoperative marks in preparation for a right-sided mastopexy and a left breast reduction. On the right, a skin only circumvertical mastopexy was all that was required to create a contoured breast and there was no need for internal parenchymal release. On the left, a full breast reduction using the SPAIR technique was performed removing 540 grams of tissue. (D,E) Postoperative appearance at 1 year demonstrates improved symmetry in both the size and shape of the breasts as well as in the location of the NAC. The areola is also smaller and an overall aesthetic result has been obtained.

If there is not enough native breast parenchyma to adequately fill out the skin envelope after it has been released, then additional volume must be provided for in the form of an implant. After it has been determined that the soft tissue envelope of the hypoplastic constricted breast is compliant enough to accept a breast implant, planning for the placement of the implant proceeds as it does for any breast augmentation. The three major decisions that must be made, namely implant choice, incision location and pocket selection, are made based on the dictates of the clinical situation. As noted previously, the subglandular plane can afford a practical advantage to shaping the breast in most patients as the skin envelope is more directly filled out by the implant when it is placed on top of the pectoralis major muscle rather than underneath it. In this fashion, any potential tethering effect of the muscle is obviated and the implant can fill out the skin envelope unimpeded by any potential internal constriction. Also, the incision location is optimally situated at either the IMF or around the areola. If there is any degree of areolar herniation or enlargement, a periareolar approach is best used to access the subglandular plane as this will also allow the altered areolar dynamics to be addressed as discussed previously (Figure 8.9). If the areola is not enlarged or does not need repositioning, the IMF incision can provide a direct approach to the underside of the breast and allow soft tissue release and implant insertion (Figures 8.10, 8.11). The transaxillary approach is the least favored approach as direct visualization of the altered and constricted elements of the soft tissue envelope can be difficult at best, even with endoscopic control, and subglandular placement of the implant may be difficult to accomplish through this incision. Finally, implant selection proceeds as with a standard breast augmentation. Essentially, any type of implant can provide an aesthetic result given the types of considerations discussed in the chapter on breast augmentation.

Figure 8.9 (A,B) Preoperative appearance of a 19-year-old woman with a fully involved tuberous breast deformity. Each of the elements that define the tuberous breast are present including breast hypoplasia, a constricted breast base diameter with a high and tight inframammary fold and herniation of the constricted breast volume through the areola. (C,D) Preoperative marks in preparation for bilateral correction with the placement of an implant in the subglandular plane to allow maximal release of the constricted breast base. The peripheral skin envelope will be scored to allow the maximum amount of release possible and an interlocking Gore-Tex periareolar purse string suture will be used to reduce the areolar diameter. (E) Immediate result after the bilateral placement of 325 cc smooth round moderate-profile silicone gel implants in the subglandular plane. (F,G) Postoperative result at 1 year demonstrating improvement in the volume and contour of the breast. Mild spreading of the areolar diameter is present on each side.

Figure 8.10 (A) Preoperative appearance of a 35-year-old woman who presents with a tuberous breast variant consisting of a hypoplastic right breast along with an overly ptotic left breast with a superiorly displaced and tight IMF. Note that the areolar diameter is also slightly widened and the areola itself is slightly translocated medially. (B,C) Preoperative marks in preparation for a right breast augmentation along with a left circumvertical augmentation mastopexy. To correct the medial areolar malposition, an asymmetric periareolar skin excision will be used to try to reposition the areola more laterally (C). (D) Appearance of the patient 3 months after undergoing subglandular placement of a 600 cc high-profile smooth round silicone gel implant on the right along with a 350 cc moderate-profile smooth round silicone gel implant on the left. On both sides, the underside of the breast was scored to accomplish a soft tissue release and allow the comfortable placement of the implants. On the left, a circumvertical skin pattern was used in conjunction with an interlocking Gore-Tex suture. An overall improvement in the symmetry of the size and shape of the breasts, as well as in the position and diameter of the NACs is evident. Because the skin along the inframammary fold on the right was mobile, an implant could be placed primarily on the right thus accomplishing this correction in a single stage.

Figure 8.11 (A,B) Preoperative appearance of a 20-year-old woman who presents with a mild tuberous breast deformity in association with a marked asymmetry. On each side, the inframammary fold is mildly constricted and each breast seems to fold over the inframammary crease in an exaggerated fashion. (C,D) Preoperative marks in preparation for a left single-stage breast augmentation and a right circumvertical inferior pedicle reduction. (E,F) Appearance of the breast after removal of the wedge of tissue from the superior pole within the dimensions marked by the periareolar pattern. By removing the tissue from the area above the NAC, space is made to easily transpose the inferior pedicle carrying the NAC up into the defect without creating a tissue crowding effect (E). The underside of the inferior pedicle is scored to release the soft tissue constriction and allow the breast to expand and fill in the void created by the removal of the tissue (F). (G,H) Postoperative appearance 2 months after undergoing subglandular placement of a 375 cc smooth round moderate profile plus silicone gel implant on the left with lowering of the inframammary fold along with a small circumvertical inferior pedicle reduction/lift on the right. A pleasing shape with reasonable symmetry has been achieved.

In cases where it has been determined that an implant will be required to provide the needed volume in the affected breast, but the soft tissue envelope is too constricted to allow the primary placement of an implant, a tissue expander must then be used to prepare the pocket. The same types of considerations that influence decision making for implant placement also come into play when using a tissue expander. Namely, the optimal plane for insertion of the device is the subglandular plane and the most versatile incision location is periareolar. The only important variable influencing the expander choice relates to the base diameter of the device. It is important to completely fill out the width of the tuberous breast to be certain an appropriate implant can ultimately be inserted into the pocket. For this reason, the same types of considerations that are used in the breast augmentation implant selection are employed in choosing an expander. Essentially, the base diameter of the desired breast is measured and an estimate is made of the medial and lateral soft tissue contribution to this measurement. By subtracting half of the medial and lateral pinch thickness, a starting width for the expander can be determined. It is my preference to choose a base diameter that slightly exceeds this measurement by up to a centimeter as it is much more preferable to have a larger pocket at the time of expander exchange for the implant than a pocket that is not wide enough. Selecting the height of the expander is dependent on surgeon preference. In some cases, it can be advantageous to use a full-height device to ensure that every last portion of the pocket is stretched to make room for the subsequent implant. Candidates for this strategy include those patients who present with a soft tissue envelope that is severely constricted in all directions. Alternatively, it can also be advantageous to use a mid-height device to focus expansion on a tight lower pole. This strategy will limit the magnitude of the deformity created during the expansion process and may be more applicable in those patients in whom the expander will remain in place for 6 months to a year or more.

At surgery, scoring of the overlying soft tissue framework of the breast proceeds as in implant placement and the expander is positioned such that the inferior base is located directly at the proposed level of the new inframammary fold. If the opposite breast is enlarged or ptotic, it is best to perform a primary mastopexy or a reduction as described previously along with placement of the expander. In this fashion, once filling of the expander begins, the opposite breast will provide a stable construct that can guide the adequacy of the expander inflation. Filling of the expander begins approximately 2 weeks after surgery and proceeds as quickly as possible until the desired size and shape of the breast have been created. Because the expander is in the subcutaneous plane, it is very easy to find the fill valve using the magnetic valve finder and filling of the device generally proceeds without difficulty. The device is re-expanded every 2 weeks until the desired volume has been added. A period of 3–4 months is then allowed to pass to allow the soft tissues to settle completely and ensure that any residual edema has resolved.

At times it can be advantageous to plan a long-term expansion process, leaving the expander in place for a year or more. Candidates for this strategy include young girls in their mid- to late teens who present with a tuberous breast on one side and an immature and incompletely developed breast on the other. In such cases, initial reconstruction of the tuberous breast may provide short-term symmetry; however, once the opposite breast reaches full maturity and changes in the size, shape or volume of the breast occur, the symmetry may be lost and a revisionary procedure later in life may become necessary. It can be a better option to insert an expander once the deformity begins to result in a noticeable breast asymmetry and then simply keep the expander in place for up to several years, occasionally inflating the device as needed to keep up with the growth of the opposite breast. Once breast growth appears to have stabilized, the expander can be removed and replaced with an appropriately sized permanent implant (Figure 8.12).

Figure 8.12 (A,B) Preoperative appearance of a 15-year-old girl with a mild tuberous breast deformity on the left in association with a marked asymmetry. (C) Preoperative marks in preparation for placement of a tissue expander on the left. The plan is to allow the device to be left in place for a period of several years until the size and shape of each breast has stabilized to a greater degree. (D,E) Six-month postoperative appearance after placement of a 12 cm wide tissue expander filled to 200 cc in the subglandular plane. Reasonable symmetry has been achieved, enough to allow the patient to wear clothing including bathing suits without feeling self-conscious about her appearance. (F,G) Three-year postoperative result demonstrating acceptable symmetry and a breast size and shape that has remained stable over time. (H,I) At the age of 18, the expander was removed and replaced with a 400 cc moderate profile plus, smooth round silicone gel implant (H). The capsule was scored and released to allow the placement of a slightly larger device to correct the mild asymmetry that was present with the tissue expander. Immediately at the time of implant placement, the overall symmetry appears improved (I). (J,K) Appearance 1 year after replacement of the tissue expander with the permanent implant. Using the delayed, staged approach has allowed the surgical decision making to keep pace with the growth of the patient to optimize the overall quality of the final result.

At the time of expander removal and replacement with the permanent implant, any revisionary procedure required to obtain the best aesthetic result possible can and should be performed. In many instances, such maneuvers can include partial or complete capsulectomy, raising or lowering the inframammary fold, recontouring the lateral chest wall via liposuction, or redoing a mastopexy to create symmetry in the location of the NAC (Figure 8.13). It is for this reason that my personal approach utilizes two distinct devices each managed at a separate operative procedure. This is in contrast to the use of combination expander/implant devices constructed of an internal saline bladder surrounded by an outer silicone gel envelope of varying thickness and volume. The inner bladder is connected to a remote valve via a silicone rubber tube that passes through the outer silicone gel layer. Once the device is inserted and subsequently inflated to the desired volume, the valve and the tubing can be removed from the device by pulling the tubing free from a self-sealing sheath that passes through the implant. This procedure is performed under local anesthesia and involves a small incision located over the location of the remote valve. The advantage of this approach is that only one general anesthetic is required to complete the procedure as the valve removal is easily performed in the office. Also, only one device is required, which can help hold down costs for patients who do not qualify for insurance coverage. The disadvantage is that the dimensions of the expander/implant are fixed and, since the device by default also functions as the permanent implant, any design feature of the device regarding base diameter or projection that does not create the desired result cannot be changed. Also, strict utilization of the expander/implant ‘one-stage’ strategy eliminates the opportunity to revise the soft tissue envelope at the second-stage procedure and can prevent the surgeon from achieving the best result possible. Therefore, although some authors have been able to utilize such combination expander/implant devices to good effect, greater versatility is afforded when the surgeon has the freedom to alter the soft tissue dynamics at a second procedure where the expander is removed and a carefully chosen permanent implant is inserted. In this fashion, strict control over all the variables that combine to determine the quality of the final result is maintained and the surgeon is not locked into the dimensions of the initial expander in terms of base diameter, shape, or projection.

Figure 8.13 (A,B) Preoperative appearance of a 32-year-old woman with a fully involved tuberous breast deformity on the left in association with right-sided macromastia. Although the right breast seems fully developed, the inframammary fold is actually superiorly malpositioned and mildly constricted as evidenced by the slight convexity noted along the lower medial breast border. (C) Preoperative marks in preparation for first-stage placement of a tissue expander through a periareolar incision. (D,E) Postoperative appearance after the subglandular placement of an anatomically shaped tissue expander in the subglandular plane subsequently filled to 1120 cc. Aggressive parenchymal scoring was performed at the time of expander placement. (F) Preoperative marks in preparation for removal of the tissue expander and replacement of the deficient breast volume with a single pedicle completely de-epithelialized TRAM flap along with an opposite right breast mastopexy using the SPAIR technique. The expansion process has prepared the soft tissue envelope of the left breast for the placement of a permanent implant. However, in this case, the patient desired eventually to undergo an abdominoplasty, therefore the TRAM flap technique was utilized to take advantage of the excess soft tissue in the lower abdomen that was destined for ultimate excision and thereby avoid the use of an implant. (G,H) Postoperative appearance 8 months after TRAM flap reconstruction on the left and right-sided mastopexy. In the interim, the left inframammary fold was elevated using an external abdominal advancement flap technique. The final result demonstrates a full and natural contour to the left breast that perhaps would not have been expected given the magnitude of the preoperative deformity.

No matter what the specifics of the expansion strategy may be, the basic design of the expansion approach remains sound and the opportunity to expand the soft tissue envelope over time can greatly enhance the ability of the surgeon to reshape the breast, reposition the inframammary fold and aesthetically reconstruct the size and shape of the resulting breast with a properly chosen permanent implant. By using this staged approach, consistent and aesthetic results can be obtained.