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bc
fg
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M. Thomas and J. D’silva
d
e
Fig. 19.11
who has undergone implant based reconstruction of the right breast.
Skin sparing mastectomy was undertaken with excision of the NAC.The
normal breast has ptosis but patient was not interested in undergoing
any procedure for the same. (d, e) Marking of the C-V ap at the most
projected part of the breast along the breast meridian. (f) The ap has
(a–c) Different preprocedure views of a 45-year-old patient
been raised, based inferiorly due to the presence of scar on the superior
aspect. (g, h) The ap has been sutured in place to create the neo-nipple.
There is an 8mm projection of the NAC. (i, j) 3weeks after NAC construction, the length of the nipple is maintained. (k–m) 6months after
NAC construction, the projection is well maintained. Patient has undergone 3D micropigmentation to dene the areola
hi
19 Techniques toReconstruct theNAC
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299
j
l
k
m
Fig. 19.11 (continued)
300
ab
cd
ef
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M. Thomas and J. D’silva
Fig. 19.12
right breast as part of the Poland’s syndrome. (c, d) The rst stage of the
construction involved placing an expander in the submuscular pocket
(muscles were partially absent) and gradual expansion to achieve the
volume of the breast on the other side. (e, f) After complete expansion
of the chest skin, silicon breast implant was placed in the pocket with
(a, b) 21-year-old patient who has congenital absence of
removal of the expander. (g–j) Shows the various steps of the C-V ap
being planned, raised, and sutured to create the nipple. (k, l) The nal
result of the nipple 1 month after nipple reconstruction. This patient
will need three-dimensional tattoo for areola reconstruction at 3months
after nipple reconstruction or later. She should consider mastopexy for
the left breast once she is completed with her family and breastfeeding
gh
kl
19 Techniques toReconstruct theNAC
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ij
301
Fig. 19.12 (continued)
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M. Thomas and J. D’silva
References
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Atiye B, Chahine F. Metrics of the aesthetically perfect breast.
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Brown TP, Ringrose C, Hyland RE, etal. A method of assessing female
breast morphometry and its clinical application. Br J Plast Surg.
1999;52:355–9.
Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheuer
O.Reconstruction of the nipple-areola complex: an update. J Plast
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Hammond DC, Khuthaila D, Kim J.The skate ap pursestring tech-
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tion. Ann Plast Surg. 2003;50(5):510–3.
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ideal position of the nipple-areola complex on the breast. Aesthet
Plast Surg. 2016 Oct;40(5):724–32.
Mallucci P, Branford OA. Concepts in aesthetic breast
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Aesthet Surg. 2012;65(1):8–16. https://doi.org/10.1016/j.
bjps.2011.08.006.
Martinovic ME, Blanchet NP. BFACE: a framework for evaluating
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Shestak KC, Nguyen TD. The double opposing periareolar ap: a
novel concept for nipple-areola reconstruction. Plast Reconstr Surg.
2007;119:473–80.
Swanson E. A measurement system for evaluation of shape changes
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Thomas SV, Gellis MB, Pool R.Nipple reconstruction with a new local
tissue ap. Plast Reconstr Surg. 1996;97:1053–6.
Tuberous Breast Deformity Correction:
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ASimpler Less-Invasive Technique
Using Saline-Inflatable Implants
foraOne-Stage Correction
TedS.Eisenberg
20
20.1 Introduction
Tuberous breasts are a congenital anomaly in which the
breasts fail to develop normally. The characteristics of tuberous breast deformity (TBD) can include hypoplasia, a tubular shape, a superior malposition of the inframammary fold
(IMF), and a herniated nipple areolar complex (NAC).
Over the years, surgeons have developed various techniques to correct this anatomical challenge. A one-stage
approach includes radial scoring of the constricted breast tissue and/or the lowering the IMF (when necessary) before the
breast implants are placed. In a two-stage approach, a tissue
expander is rst placed to break up the constriction, followed
by a second surgery to replace the expander with a permanent saline or silicone breast implant.
This chapter presents a step-by-step guide to a simpler,
less-invasive, one-stage approach to TBD correction with
saline-inatable breast implants. Because the saline implant
acts as a tissue expander to break up the constrictive breast
and stretches the skin of the lower pole of the breast, there is
no need for radial scoring or lowering the IMF.Sometimes,
circumareolar mastopexy is performed to correct the areolar
herniation, and volume asymmetry may be addressed with
implants. The advantages of using saline lled versus silicone gel implants will also be discussed.
20.2 Historical Background ofTBD
Correction
Over the years, since tuberous breast deformity was rst
identied by T.Rees in 1976 (Rees and Aston 1976), surgical
approaches have focused on techniques to re-establish a
more normal shape to the breast, provide lower pole fullness,
address the high-riding inframammary fold (also known as
the inframammary crease or IMC), and when necessary, create a better-shaped nipple-areolar complex.
Rees described the radial scoring of the breast parenchyma to break up the constricted rings of tissue. Later, surgeons advocated moving aps of tissue to the area of
deciency and fat grafting to these areas as well (Maillard
1986; Puckett and Concannon 1990; Ribeiro et al. 1997;
Klinger etal. 2015).
In 1985 Argenta and colleagues (Argenta et al. 1985)
advocated a two-stage tissue expansion in immature tuberous and hypoplastic breasts before full breast development.
In other two-stage procedures, Versaci used a skin expander
before placing a permanent implant (Versaci and Rozzelle
1991), while Kneafsey used a Becker double-lumen perma-
nent implant for his tissue expansion (Kneafsey etal. 1996).
In 2019, T.Eisenberg (the author) published a one-stage
approach for TBD correction that used saline breast implants
as a tissue expander, without the need for radial scoring or
lowering the IMF (Eisenberg 2019) (Fig.20.1).
Supplementary Information The online version contains supplementary material available at
T. S. Eisenberg (*)
Nazareth Hospital, Philadelphia, PA, USA
e-mail: info@lookingnatural.com
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_20
https://doi.org/10.1007/978- 981- 99- 3726- 4_20.
303
304
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Fig. 20.1 Left: traditional
scoring of breast parenchyma.
Right: One-stage expansion
by saline implant
T. S. Eisenberg
Fig. 20.2 Type 1 (a) Preoperative view of a 40-year-old woman with bilateral tuberous breast deformity with ptosis. She is 5 foot 7in. tall, 165
pounds, and received 675cc Mentor smooth saline moderate prole breast implants. (b) Postoperative view at 9months
20.3 Classications ofTuberous Breast
Deformity
Several classications exist for tuberous breast deformity,
which is sometimes called tubular breast deformity. One
classication that is commonly used describes four types
(Von Heimburg etal. 1996).
Type 2: Hypoplasia of the lower medial and lateral quad-
rants with sufcient skin in the subareolar region (Fig.20.3).
Type 3: Hypoplasia of the lower medial and lateral quadrants with a deciency of skin in the subareolar region.
(Fig.20.4).
Type 4: Severe breast constriction with minimal breast
base. (Fig.20.5).
Type 1: Hypoplasia of the lower medial quadrant.
(Fig.20.2).
ab
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a b
Fig. 20.3 Type 2 (a) Preoperative view of a 35-year-old woman with bilateral tuberous breast deformity with ptosis. She is 5 foot 8in. tall, 130
pounds, and received 425cc Mentor smooth saline moderate prole breast implants. (b) Postoperative view at 9months
Fig. 20.4 Type 3 (a) Preoperative view of a 36-year-old woman with bilateral tuberous breast deformity with ptosis. She is 5 foot 7in. tall, 140
pounds, and received 625cc Mentor smooth saline moderate prole breast implants. (b) Postoperative view at 9months
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Fig. 20.5 Type 4 (a) Preoperative view of a 25-year-old woman with bilateral tuberous breast deformity with no ptosis. She is 5 foot 5in. tall, 157
pounds, and received 375cc Mentor smooth saline moderate prole breast implants. (b) Postoperative view at 9months
T. S. Eisenberg
20.4 Common Treatment Options
Radial scoring and ap transfers supplemented with fat
grafting are currently the most commonly used approaches
to treat TBD.The constricting brous ring that occurs at the
level of the nipple-areolar complex is what is thought to keep
the tuberous breast from expanding normally. To address
this, surgeons do radial scoring of the breast parenchyma on
the posterior surface of the breast gland to break up the constricted rings. Another recommended approach is to perform
this scoring of this breast tissue in both the horizontal and
vertical directions (Galych etal. 2016).
Inadequate tissue of the lower pole of the breast and a
high-riding inframammary fold are sometimes xed by lowering the IMF, stretching the skin by expansion, or bringing
aps of tissue (and occasionally fat grafts) to decient areas
of the lower pole distance. Mandrekas and Zambacos
(Mandrekas and Zambacos 2015) state that lowering the
IMF in type 3 deformities without covering the lower pole
may propagate the development of double-bubble
deformities.
As described by Mandrekas etal., there is also a lack of a
supercial layer of fascia just behind the areola (Mandrekas
et al. 2003). As a result, the breast often tends to herniate
toward the nipple-areolar complex during maturation.
The theory of expansion to correct TBD is supported
throughout the literature (Panchapakesan and Brown 2003;
Persichetti and Cagli 2005; Berrino etal. 1998). Kneafsey
and Crawford (Kneafsey etal. 1996) discussed the importance of using tissue expanders in the tuberous breast patient,
stating that in the rst stage, “a tissue expander is placed in
either a subglandular or a submuscular pocket and slowly
expanded to correct the skin deciency at the base of the
breast, which releases the skin tightness at the skin-areola
junction, lowers the position of the inframammary fold, and
increases the breast skin envelope volume.” In the second
stage, the expander is replaced with a saline or silicone breast
implant.
20.5 One-Stage TBD Correction
withSaline-Inatable Implants
The following description pertains to my approach to TBD
correction, which provides a simpler, one-stage, noninvasive
option. This approach is used for mild to severe TBD and can
be used for patients with mild ptosis. Those patients with
more severe ptosis will need a form of mastopexy as well.
This is the same technique that I use for saline breast augmentation: During the U.S. and Canadian moratorium on
silicone breast implants (1992–2006), I placed salineinatable implants in all of my breast augmentation patients.
In breasts that were tuberous, I found that the saline implant
acted as an expander, breaking up the constricted bands and
stretching the lower pole. Patients were satised with the
esthetic result.
I continued to offer my patients saline breast implants
after the moratorium ended in 2006, and I continue to discover advantages. Because the implant is inated after insertion in the submuscular pocket, I can make volume
adjustments for patients who have a small degree of
asymmetry.
20 Tuberous Breast Deformity Correction: A Simpler Less-Invasive Technique Using Saline-Inatable Implants for a One-Stage…
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307
When they are comparing saline and silicone implants,
my patients appreciate that the saline implants require a
smaller incision than the gel. They like the ease of post-op
management: Being able to know if they have a deation
without the need for an MRI or ultrasound. The lower cost of
saline implants is another incentive.
Because silicone gel implants are prelled, there is a limit
to the volume that can t in the subpectoral pocket—dependent upon the breast width diameter (BWD) measurement. A
larger volume can often be accommodated with saline
implants than with silicone gel because the empty saline
implant, when expanded can create a larger submuscular
space.
Recent literature points to other advantages. In its 2021
study, Mentor reported that the Kaplan-Meier estimated
10-year cumulative incidence of silicone gel implant rupture
was 24.2%, with 75% of those ruptures being silent (Caplin
etal. 2021). I have reported that when Mentor moderate prole saline-lled implants are overinated 10–13% beyond
the manufacturer’s recommended maximum ll volume,
deation rates at 8years drop from 4.02% to a statistically
signicant lower rate of 1.83% (Eisenberg 2021). In his 2021
study, Swanson showed that the palpability and visible wrinkling of saline and silicone implants under the skin in breast
augmented patients was statistically similar (Swanson 2020),
thus giving even more evidence that there is no signicant
advantage to using silicone gel implants over saline- inatable
implants.
20.5.1 Consultation Philosophy
One study revealed that 50% of women seeking cosmetic
breast augmentation had some type of tuberous breast deformity (Klinger etal. 2016). Although I might concur with this
nding in my practice, I prefer not to identify TBD during
the examination. Very few women who present with TBD are
aware that they have this congenital anomaly, and I do not
wish to psychologically traumatize them by labeling them
with a “deformity.”
At their initial consultation, if a woman presented with
TBD and requested silicone implants, I would explain that I
would likely have to do some combination of radial scoring,
lowering the IMF, or using aps to expand the constriction
before placing the implants. This approach could increase
morbidity.
I also inform patients that I can achieve an equally good
cosmetic result with my standard saline breast augmentation
technique. This is less-invasive alternative not requiring all
of the above-mentioned tissue manipulation.
I advise women any breast asymmetry can be addressed
with different size implants, and that a herniated areola can
be xed with a circumareolar mastopexy. Most patients with
mild ptosis were satised with the illusion of a breast lift created by augmentation alone and did not seek a mastopexy.
20.5.2 Examination
The following measurements should be taken at the inperson consultation (Fig.20.6).
For each breast, measure the distance from:
• the suprasternal notch to each nipple
• each nipple to the IMF and
• the mid-clavicle to the IMF.
To determine the possible breast implant volume, measure the breast width diameter (BWD). This is the distance
from the medial to the lateral borders across the breast. If the
breasts are larger and displaced laterally, have the woman
raise her arms to get a truer measurement.
Evaluate the laxity of the skin; often more CCS can be
added when the tissues have been stretched from signicant
weight change or the milk that comes in during pregnancy.
Assess breast asymmetry from the sitting or standing
position and then again with the patient in the supine position. Along with any obvious volume difference between the
breasts, rib cage irregularities should also be noted. For
example, if the rib cage is more prominent on one side, additional CCS might need to be added to the other side.
It is possible for tuberous breast deformity grades 1–3 to
have elements of ptosis. Breast ptosis, or sagging, is often
categorized by evaluating the position of the nipple in relation to the inframammary fold (IMF).
To evaluate the grade of ptosis, wrap a measuring tape
around the patient’s rib cage in the crease where the bra band
would rest. Regnault’s classications (Regnault 1966) can be
used to determine the degree of ptosis as follows:
Fig. 20.6 Consultation measurements
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