Lip Teh

TUBEROUS BREAST

Condition first described in 1976 by Rees and Aston

Definition

Mandrekas definition: tuberous breast is defined as a constricted breast, both in length and width, with herniation of breast tissue into a hypertrophied areola. May or may not be combined with asymmetry or breast hypoplasia.

Epidemiology

  • May be very common
  • DeLuca-Pytell PRS Dec 2005 – found that 81% of women presenting for augmentation or reduction mammaplasty had breast asymmetry. Of those, 88% had tuberous breast using Grolleau’s classification

Clinical Features

1)Deficiency of skin—inferiorly

2)Areolar protrusion-Gland can herniate into areola

3)Enlarged Areola

4)Regional or general hypoplasia- lower pole most affected

5)Constricted base - small circumference, reduced vertical and horizontal dimensions

6)High IMF

7)Ptosis

  • the more severe the tuberous deformity the greater the incidence of areola involvement.

Pathogenesis

  • No anomaly is usually noted prior to puberty.
  • The superficial layer of the superficial fascia is absent in the area underneath the areola, thus invagination of the mammary bud in the mesenchyme.
  • Two theories
  • constricting fibrous ring of superficial fascia
  • This ring, at the level of the periphery of the nipple-areola complex inhibits the normal development of the breast.
  • This constricting ring is denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty.
  • Adherence
  • Strong adherence between the dermis and the muscular plane, which the developing breast cannot divide. This restricts peripheral expansion of the breast, which then preferentially develops forward, giving it is tubular appearance and enlarging the areola
  • The developing breast cannot expand inferiorly, and due to the fact that there is no superficial layer of the superficial fascia under the areola, the breast parenchyma herniates toward the nipple-areola complex.
  • The severity of the deformity depends on the severity of the malformation of the superficial fascia and ranges from slight underdevelopment of the inferior medial quadrant of the breast with near-normal breast volume to major hypoplasia of all four quadrants with various degrees of herniation of the breast parenchyma toward the areola.

Classification

Grolleau (PRS 1999)

type I breasts (minor form) - only the lower medial quadrant is deficient (54%)

type II breasts, both lower quadrants are deficient (26%)

type III breasts, all four quadrants are deficient with breast base constriction vertically and horizontally. (20%)

von Heimburg (BJPS 1996)

Ihypoplastic lower medial pole

IIhypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region

IIIhypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region

IVsevere breast constriction, minimal breast base

Assessment

  1. Degree of constriction of base
  2. Level of IMF
  3. Skin envelope
  4. Breast vol
  5. NAC

Principles of Treatment

Goal: Aesthetically pleasing symmetrical breasts

1. Expansion of constricted base

  • Radial incisions (Rees and Ashton)
  • Division of constricted ring – done during elevation of dermoglandular flaps.

2. Lowering of IMF

  • Dissection inferiorly

3. Increase skin envelope

  • Tissue expansion

4. Augment or redistribute volume

5. Reduction of NAC and herniated breast tissue

  • Periareolar approach

Surgery

Often requires several procedures.

Options

  1. Mastopexy procedures
  2. Augmentation procedures
  3. Combination
  4. Tissue expansion
  5. Alter contralateral breast

General

1)areolar often enlarged thus periareolar incision is an important step

2)normal dimensions of the breast base must be restored.

3)The deficient lower quad subcutaneously undermined so the IMF can be placed in normal level . The undermining is in very adherent tissue which becomes normal when the normal position of the IMF is reached

4)volume of gland harmoniously redistributed

Type I

May have large breast overall but with hypoplastic lower medial pole thus the lateral side appears enlarged

Lower lateral quad is distended, ptotic and has excess skin.

This lateral cutaneous and glandular excess must be put to use to fill the cavity created by the undermining of the lower medial quadrant.

A triangular dermoglandular flap with a lower lateral pedicle is preserved under the area of periareolar deepithelialization and after wide detachment of the gland from the thoracic plane in the lower lateral part the flap slips into the lower medial undermined area and the tip of the flap is secured into the Musc aponeurotic plane. The resulting scar is L shaped

If gland resection is necessary posterior resection of the breast base results

If the lower medial quad isn’t filled it resembles an italic S

Type II

volume is deficient usually, if not then redistribute

If use implant alone—double bubble or second crease will result

Rees and Aston advised using radial incisions at the base of the gland

Puckett (Unfurling technique)

  • periareolar deepithelializationand gland approached from the lower hemiperiareolar portion andundermining of the lower skin and gland down to the new IMF and the gland is then transversely divided
  • Divide the breast from the posterior aspect to create an anteriorly based flap of tissue to fill the inferior aspect of the gland
  • Disadvantage is that it is a difficult dissection

Robeiro

  • Same as above but divide the gland from the anterior aspect to create a posteriorly based pedicle.
  • Advantage is ease of dissection
  • Disadvantage is that if a submuscular implant is required the viability of this flap is questionable
  • Thus if augment planned as well, this technique is not recommended

Type III

breast herniation in 75%

Implant alone= double bubble

Grossly inadequate breast volume with skin shortage in vertical dimension

2 stage correction to avoid skin shortage issues and nipple necrosis.

  • Stage 1 - implant inserted using a lower hemiiareolar approach, radial scoring, lowering IMF and the remaining breast tissue is redistributed.
  • Stage 2 - concentric areola reduction after several months. The periareolar circle is deepithelialized and then subcut undermining is done to bury the nipple. The undermining is limited so not to endanger the nipple

can try tissue expansion—progressive expansion can prevent double bubble but can get areola expansion

Significant asymmetry

Grade I with II/III

  • Stage 1
  • Smaller breast
  • hemiperiarealar incision, undermine down to new IMF, reshape the breast tissue. Subpectoral tissue expander
  • Larger breast
  • If wants to be larger, than implant with base release.
  • Stage 2
  • Larger breast - mammoplasty with a superior pedicle and a lateral dermoglandular flap
  • Smaller breast – implant exchange

Complications

  1. Asymmetry
  2. Recurrence
  3. In many cases, 6 to 12 months after surgery, the areola often again protrudes, and sometimes points outward.
  4. The periareolar approach and the undermining of the skin and breast are again used to recenter the areola and bury the protruding glandular residue.
  5. A second inframammary fold may exist; it requires a small vertical tuck below the area of concentric periareolar skin excision.