Periareolar Approach for Correction of Bilateral Asymmetric Tuberous Breasts

INTRODUCTION
The tuberous breast is a deformity caused by
mal-development first described by Rees and Aston
in 1976 [1]. Although it usually occurs in young
females, however, it may occur in gynecomastia
[2]. Plastic surgeons should fully understand the
265
developmental and anatomical basis of the deformity.
The superficial fascia is absent under the nippleareolar
complex (NAC). There is a constricting
ring of fibrous tissue at the periphery of NAC
which is denser at lower pole of the breast, restricting
the radial growth of breast parenchyma in one
or all directions [3,4]. Thus, the deformity is characterized
by small mammary base, deficiency of
horizontal and vertical dimensions, hypoplastic
lower mammary quadrants, highly-situated inframammary
crease (IMC), deficient inferior skin
envelope and enlarged herniating NAC through
the constricting ring [1,3,5-8]. In addition to the
common features of the deformity; Dinner and
Dowden 1987 stated that the tuberous breast is
usually ptotic [6]. Also, DeLuca et al., 2005 demonstrated
the strong relation between breast asymmetry,
constricted NAC and tuberous breast [9].
Many authors proposed different classifications
of tuberous breast as regards severity [10-15]. Severity
ranges from mild type with hypoplastic
inferior medial quadrant of the breast to severe
type with major hypoplasia of all four quadrants
with various degrees of herniation of the breast
parenchyma toward the areola.
There are multiple surgical techniques of correction
of the tuberous breast which consider pathology
and severity of each case. Tuberous breast
surgery aims to release the herniated breast parenchyma
through NAC, reposition high inframammary
crease and provide adequate correction of
both horizontal and vertical deficiency. Other
considerations include; normal-size areola and
correction of breast shape and volume. Surgeries
could be designed as one- stage or multi-stage
[15,16,17]. Some techniques used inframammary
crease incision [18], some used periareolar incision
[3,8,19-22] and some used both [5]. Augmentation
of hypoplastic breast could be done by different
methods; glandular flaps and breast reshaping
[8,23,24]; glandular flaps, shaping and implant technique
[3,20,22,25], glandular flaps, shaping, implant
and mesh to provide repositioning of all components
of breast [19,21] and tissue expander [15,17].
There are significant shortcomings associated
with surgical correction of tuberous breast. Poor
results may be caused by inadequate release of the
constricting ring and failure to increase breast base
and inferior pole volume [3,21]. Other complications
include; widening of the areola, flattening of the
breast, poor periareolar scars [26] and irregular
bulges that can be seen through the skin envelope
especially after using glandular flaps.
Patients with tuberous breasts suffer of psychosocial
problems which may be aggravated in cases
of bilateral asymmetric tuberous breasts. That is
why special considerations for bilateral tuberous
breast asymmetry are required as regards; diagnosis,
breast anthropometry and surgical design to achieve
the best possible aesthetic outcome.
MATERIAL AND METHODS
This is a prospective study included 8 female
patients (16 breasts) with tuberous breast from
June 2014 to March 2017. They complained of
small asymmetric abnormal shaped breasts.
None of the authors has a financial interest in
any of the products, devices or drugs mentioned
in this manuscript. An informed consent for participation
in the study was obtained from participants
who also had signed an informed consent
for approval of publication of photographs. This
study was approved by The Ethical Committee of
our University.
History taking, general examination and thorough
local breast and axilla examinations were
done. Breast dimensions in both breasts were measured
including; areola diameter [AD], breast projection
[BP], midclavicular-nipple distance [MN],
areola-inframammary crease distance [A-I],
breast width [BW] and inter-mammary distance
[I-M] (distance between the most medial points of
both breasts).
Ptosis degree (according to Regnault's classification
[27], asymmetry, any chest deformity are
noticed and recorded. We used Von Heimburg
classification system to determine grade of breast
deformity [13]. All patients had bilateral mammography
for two reasons; first to detect any pathological
lesion; and second to measure breast volume
266 Vol. 42, No. 2 / Periareolar Approach for Correction of Bilateral Asymmetric Tuberous Breasts
[BV] using the formula proposed by Kalbhen et
al., in 1999 [28].
Patient interviewing was done to recognize
patient's needs and expectations from her perspective.
The surgical plan was individualized according
to the severity of deformity, presence of ptosis and
degree of asymmetry. Both breasts were operated
upon. Surgery aimed to correct the whole pathology
present and to achieve aesthetic improvement of
breast shape and volume. Table (1) shows the
surgical steps needed to correct the tuberous pathology.
Table (1): Pathology of tuberous breast and surgical corrections.
Pathology
Adherent skin to the underlying
pectoral fascia below
the level of NAC
Constricting ring denser at
lower part of the breast restricts
the radial growth of
the breast parenchyma
Herniating NAC
Enlarged NAC
Deficiency of horizontal and
vertical development of
breast parenchyma (small
mammary base, hypoplastic
lower mammary quadrants,
shortened lower pole)
Highly situated inframammary
crease
Ptosis
Asymmetry
Correction
Sharp release to form lower
pocket
Crisscross scoring for effective
release
Reposition of herniated
parenchyma
Reducing diameter
Expanding by scoring +
implant
Repositioning to a lower
level
Mastopexy
Differential augmentation
Surgical technique:
Preoperative Markings were done in the upright
position. New NAC position and the circum-areolar
pattern designed for mastopexy were marked. The
breast base according to implant size and the preexisting
Inframammary crease were outlined. The
proposed new inframammary crease was marked
at the level of the 5th rib/intercostals space or 6th
rib according to each case.
Circum-areolar deepithelialization was performed
reducing areola diameter to 4.2-5cm according
to the case. The gland was incised horizontally
midway between lower border areola and
skin of lower pole between 4 and 8 O'clock.
The gland was divided obliquely (caudal to
cranial direction) down to pectoral fascia leaving
an appropriate thickness of the gland attached to
the lower skin flap (Fig. 1a). Dissection then
Egypt, J. Plast. Reconstr. Surg., July 2018 267
started in a cephalic direction in the sub-glandular
plane to create the upper pole pocket according
to the predesigned space. The under surface of the
gland was scored in a crisscross fashion using
electrocautery till it is completely and properly
stretched. Then the lower pocket was created by
sharp dissection in the sub-glandular plane and
continued inferiorly till the newly marked IMC.
The undersurface of the lower gland was also
scored in crisscross fashion as the upper gland.
Skin at the old IMC level was sharply dissected
in superficial radial manner to eradicate any residual
memory.
The most caudal part of the stretched lower
gland was then fixed to the inner aspect of the new
IMC to pad the lower pole by three transcutaneous
stitches. Those stitches were applied in a curvilinear
fashion (i.e. medial and lateral sutures lie at the
same level in relation to the rib cage while the
middle one is located at the meridian at a lower
level) to simulate the natural IMC. Each stitch was
tied on small Vaseline gauze rolls (skinífasciaíglandískin).
They were removed three weeks postoperative
to allow adhesion and maintenance of
the newly formed IMC (Fig. 1b).
Purse-string suture of the areola with nonabsorbable
monofilament 3-0 suture was done to
prevent its widening. Then closure of the circumareolar
incision was completed with intradermal
sutures using absorbable monofilament 3-0 suture.
No suction drains were applied in all cases. Vaseline
gauze was applied to NAC and adhesive tapes were
applied along the lateral side and lower pole of the
breast. Patients were advised to wear sports bra
for one week postoperative.
Follow-up was done one week, two weeks, one
month and 6 months postoperative. Patient's satisfaction
was measured after 6 month as regards,
shape, volume, symmetry and scars using (1 to 3)
scale for each item. The whole score indicates
patient's satisfaction; being (0-4): Not satisfied,
(5-8): Satisfied and (9-12): Highly satisfied.
RESULTS
Patients' age ranged between 23 to 35 years
with the mean age being (28.7) years. All patients
gave history of affected breast development during
puberty. All patients presented with bilateral asymmetric
tuberous deformities. No patient had chest
deformity. Preoperative measurements indicate
that all patients had asymmetric breasts as regards,
tuberous type, breast volume, projection, areola
diameter, NAC position and degree of ptosis. Table
(2) shows preoperative measurements of both
breasts in each patient. Table (3) shows tuberous
breast type according to Von Heimburg et al., 2000
classification [13], degree of ptosis and degree of
asymmetry. Patients were followed-up for a mean
duration of 18 months post-operative (6 to 24
months).
Tuberous deformity was corrected in all cases
and naturally looking breasts with good symmetry
was achieved. Postoperatively, all patients showed
increased vertical and horizontal dimensions, areola-
inframammary height, volume and projection.
There was also decreased intermammary distance
and improvement of breast asymmetry (Figs. 2,3).
There were no complications in this study except
for hypertrophic scarring in one case which was
managed conservatively, widening of the scar in
another case which was corrected with scar revision
under local anesthesia and double-bubble deformity
in the right breast of a third case. Seven patients
were highly satisfied (87.5%), while one patient
(12.5%) was only satisfied.
Fig. (1): (A) Circum-areolar deepithelialization to reduce
areolar diameter and then breast gland is divided obliquely
into main upper portion and small lower portion down to the
pectoral fascia (dashed line). (B) The stitch is done through
(skinífasciaíglandískin) and tied on a vaseline gauze, breast
implant was then inserted in sub-glandular plane, the 2 portions
of the gland is the sutured together to cover the implant and
the areola is closed (dotted green lines).
Round, high profile, textured, cohesive gel
implant was placed in the sub-glandular plane after
meticulous hemostasis. Then gland was redraped
and closed using absorbable monofilament 3-0
suture to completely cover the implant and produce
a more natural shape.
(A) (B)
268 Vol. 42, No. 2 / Periareolar Approach for Correction of Bilateral Asymmetric Tuberous Breasts
Fig. (2): 35y old female with bilateral asymmetric tuberous breast. (A,B,C) Show preoperative different views
of type III tuberous right breast and type IV tuberous left breast with bilateral grade III ptosis, (D,E,F)
Show 3 weeks postoperative different views with correction of all the tuberous breast and almost
symmetrical breasts.
(A) (B) (C)
(D) (E) (F)
Fig. (3): 24y old female with bilateral asymmetric tuberous breast. (A,B,C) Show preoperative different views
of type III tuberous right breast and type II tuberous left breast with bilateral grade I ptosis, (D,E,F) Show
4 months postoperative different views with correction of all the tuberous breast and almost symmetrical
breasts.
(A) (B) (C)
(D) (E) (F)
Egypt, J. Plast. Reconstr. Surg., July 2018 269
DISCUSSION
Tuberous breast deformity is considered a stigma
for women. We agree with Dinner and Dowden
1987 [6] and DeLuca et al., 2005 [9] that the tuberous
breast is usually ptotic and asymmetric. Preoperative
breast measurements are crucial for successful
operation. We add intermammary distance because
it is apparently increased in tuberous deformity.
We used mammography not only to exclude breast
lesions, but also to measure breast volume.
Plastic surgeon should well understand the
structural abnormalities. The absent superficial
fascia below the areola [29,30] and the constricting
ring [10] which inhibits breast expansion and causes
breast herniation into NAC.
Mandrekas and Zambacos [31] believed that the
constricting ring represents a thickening of the
superficial fascia. Histological study of this ring
showed large concentrations of arranged longitudinal
collagen and elastic fibers. The constricting
ring exists at the periphery of NAC and it is denser
at the lower part of the breast and does not allow
the developing breast to expand. Also the deficient
superficial layer of the superficial fascia below the
areola caused the breast parenchyma herniation
into NAC.
Thus, severity of tuberous deformity is related
to severity of superficial fascia malformation. Also
the constricted breast base is combined with the
breast tissue deficiency [3], and any attempt to only
augment the hypoplastic tuberous breast would
accentuate the deformity. Any surgical technique
that does not correct the whole existent anatomical
deformity would have poor outcomes.
Asymmetry is common finding in tuberous
breast deformity and it is very much related to
discrepancies as regards; breast volume, shape,
areola size, and degree of ptosis. We agree with
Bach et al., [32] and Chen et al., [33] that breast
symmetry especially breast shape is important and
hard task to achieve.
Table (2): Preoperative breast measurements.
Pt.
1
2
3
4
5
6
7
8
AD
7
9
5
6
6
5
7
6
Rt.
6
7
6
5
7
4.5
6
8
Lt.
BP
5
4
4
5.5
5
3
4
4
Rt.
4
3
5
4.5
6
2.8
3
5
Lt.
M-N
21
26
25
24
21
21
24.5
22
Rt.
20
24
26
21
24
20.5
20
23
Lt.
A-I
4.5
3.8
5
5
3.5
5
4
3.5
Rt.
3.5
3
4.2
4
4
4
3.5
4
Lt.
BW
8
9
11
10
8
9
7
6
Rt.
5
6
9
9
10
8
6.5
10
Lt.
BV
150
170.5
271.1
220
137.4
115
180
115
Rt.
134
108.8
250
140
202
100
120
138
Lt.
8.6
12
6.6
10.1
7.3
7
12.5
11
I-M
AD
BP
M-A
A-I
BW: Breast Width.
BV : Breast Volume.
I-M: Inter-Mammary distance.
: Areola Diameter.
: Breast Projection.
: Midclavicular-Nipple distance.
: Areola-Inframammary crease distance.
Table (3): Tuberous Breast Type according to Von Heimburg et al. 2000 classification, degree of ptosis and degree
of asymmetry.
Pt.
1
2
3
4
5
6
7
8
23
35
32
28
24
27
32
28
Age
I
III
I
I
III
I
II
III
Right Breast
Tuberous breast type
III
IV
II
II
II
II
III
II
Left Breast
II
III
III
III
I
II
III
III
Right Breast
II
III
III
II
I
I
III
II
Left Breast
Degree of ptosis
++
+++
+
+
++
+
++
+
Degree of asymmetry
According to tuberous deformity
We used periareolar mastopexy approach. The
gland was incised midway between lower border
areola and skin of lower pole between 4 and 8
O'clock not along the inferior border of the areola
which adopted by many other authors. We agree
with Kolker and Collins [15] in that the periareolar
approach provides better access for correction of
tuberous breast deformities. While, using inframammary
approach may not easily enable locating the
IMC and correcting the areolar deformity. Also,
the circumareolar scar could be forgiving unlike
the inframammary scar especially if it is malpositioned
[15].
In our study, we divided the gland obliquely
down to the pectoral fascia into upper and lower
glands. Thus, a relatively good portion of the lower
gland was kept attached to the skin to be used in
the coverage of the lower pole of the implant in
the area between the old and newly proposed IMC.
We think that keeping the lower gland attached to
the overlying skin would not compromise vascularity.
This is different of work of Galych et al.,
[34] and Innocenti and Innocenti [35], who separated
the lower gland from the skin and use it to cover
the implant.
We performed extensive crisscross scoring of
the underneath of both gland portions similar to
Galych et al., [34]. This type of scoring was done
for two reasons; to effectively release the constricting
ring and also to expand the sparse glandular
tissues to cover the breast implant. Scoring was
done by many authors with different techniques;
performing radial incisions of mammary base [1],
full-thickness incision through skin, subcutaneous
tissue, and breast [6], horizontal transection of the
constricting ring and using the inferior portion for
auto-augmentation [8], vertical transection of constricting
at 6 O'clock and created two pillars sutured
in a “double-breasted” fashion in the inferior part
of the breast [3,32] or dividing the gland to the
pectoralis fascia and performing radial scorings
[15].
In the present study we lowered the IMC in all
cases to correct its highly-situated position, keeping
it at 6cm below the lower border areola. Thus the
amount of sharp dissection and gaining of more
height is related to the preoperative inframammary
crease deficiency. Also we performed superficial
radial sharp dissection of skin at the level of old
IMC to eradicate any residual memory and we
managed to avoid any double bubble deformity in
all cases except one breast. Kolker and Collins left
gland attached to the lower skin flap and performed
radial scorings in the subcutaneous tissue. They
270 Vol. 42, No. 2 / Periareolar Approach for Correction of Bilateral Asymmetric Tuberous Breasts
assumed that this procedure would release constrictions
and also alleviate the memory of the old
inframammary crease [15].
We added three transcutaneous stitches to stretch
the inferior glandular portion over the implant in
between the old and new IMC (ranged from 1 to
3cm) where the inferior glandular envelope is
usually deficient. Another importance of the stitches
was to fix the new IMC in its natural curvilinear
form not just a straight line. Galych et al., [34] also
used few transcutaneous stitches to cover the implant
with no details about the number or the
fashion.
Discrepancy of volume in both breasts should
be considered in augmentation. We performed
differential augmentation mammaplasty to compensate
for the hypoplastic breast according to the
preoperative measurements. We do not use glandular
flaps neither to augment nor to reshape the
breast as this may end with visible irregularities.
Reberio did not use implants as his patients were
not concerned with large breast volumes [8]. Mandrekas
et al., might add an implant to correct any
volume deficiency [3]. Breast implant size was
decided according to the desired volume. Different
sizes were used in all cases. Persichetti et al.,
recommended use permanent expandable prosthesis
for volume adjustment [36].
Correct placement of the implant with glandular
re-draping could minimize unwanted outcomes
such as recurrence of areola protrusion, doublecrease
of the inframammary crease and “doublebubble”
formation [10]. We inset the implant at the
sub-glandular plane to get a normal shape and
feeling. It could produce natural shape without
being restricted by pectoralis major muscle. We
re-draped the scored expanded upper and lower
portions of the gland over the implant with good
coverage. This helped shaping and avoiding rippling
and double bubble deformity.
Many authors claimed that submuscular augmentation
has many advantages, including; softer,
more natural contour of the upper pole, increased
soft tissue coverage, more durable breast position
and decreased capsular contracture rates [37-41].
Bach et al., have inset the implant submuscular to
provide better soft tissue coverage of the prostheses
that could not be provided by the hypoplastic breast
tissue and to reduce capsular contracture [32].
However they had reported a case with prosthesis
dislocation. Kolker and Collins have put the implant
at subpectoral dual plane as the lower pole requires
the most “expansion” and implant-related shape
definition more than the upper pole [15].
Egypt, J. Plast. Reconstr. Surg., July 2018 271
Non-absorbable circum-areolar purse string
suture is a real secure to avoid postoperative areola
widening. In our series, none of the patients complained
of widening of the peri-areolar scar, regardless
the amount of skin excised. Others had
used GoreTex as Kolker and Collins [15].
Some authors corrected the deformity as multistage
procedure [16,17]. However, Kolker and Collins
put an algorithm for tuberous breast deformity
[15]. They made the decision for two-stage with
tissue expander when a fuller and bigger size is
desired. On the contrary, we managed to correct
all the deformity presented preoperatively as regards;
tuberous shape, ptosis, asymmetry and abnormal
inter-mammary distance along with high
overall patients' satisfaction in one-staged procedure.
Although the sample of patients included in
this study is relatively small and is considered the
main limitation of the current study; we think that
the described technique is readily applicable to all
grades of tuberous breasts.
Conclusion:
Surgical plan for correction of bilateral tuberous
breast asymmetry should be individualized according
to the severity of deformity with special considerations
regarding; diagnosis, breast anthropometry
and surgical design. It is important to correct
all contributing causes of the deformity to achieve
the best possible aesthetic outcome.