COSMETIC Tuberous Breast Deformity: Classification and Treatment Strategy for Improving Consistency in Aesthetic Correction Adam R. Kolker, M.D. Background: Tuberous breast deformity is a common congenital anomaly with Meredith S. Collins, M.D. varying degrees of constriction, hypoplasia, skin deficiency, areolar herniation, New York, N.Y. and asymmetry that poses challenges to consistency in aesthetic correction. In this study, the authors classify tuberous breast deformities, and evaluate their techniques used for treatment. Methods: Twenty­six patients (51 breasts) treated from 2008 to 2012 were in­ cluded. Mean patient age was 25 years (range, 18 to 39 years). Cases were clas­ sified using a three­tier system. A periareolar approach and glandular scoring maneuvers were used in all cases. Prosthetic placement (implant or tissue ex­ pander) was subpectoral (dual­plane) in all cases. The selection of one­ versus two­stage correction and mastopexy techniques is presented with reference to the specific deformities in each tier. Results: Mean follow­up was 22 months (range, 8 to 37 months). Twelve type I, 26 type II, and 13 type III deformities were treated. Periareolar incisions only were used in two (4 percent). Circumareolar mastopexy was used in 49 (96 percent), and vertical mastopexy was used in four (8 percent). One­stage cor­ rection was achieved in 47 (92 percent); four (8 percent) were treated in two stages with tissue expansion. The global complication rate for all patients in this study is 7.8 percent—two breasts (3.9 percent) had capsular contracture, and two (3.9 percent) had postoperative malposition. SUPPLEMENTAL DIGITAL CONTENT IS AVAIL- Conclusion: The authors’ experience demonstrates that satisfactory results ABLE IN THE TEXT. can be obtained with appropriate classification and treatment of tuberous breast deformity with periareolar access, glandular scoring, subpectoral im­ plant placement, and mastopexy techniques tailored to the specific deformity type. (Plast. Reconstr. Surg. 135: 73, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. he tuberous breast deformity is a congenital widely variable, often with considerable discrepan­ breast anomaly with widely varying degrees cies between both breasts in the same individual. Tof presentation. Characteristics of the tuber­ The wide range of presentation, in conjunction ous breast deformity include breast base constric­ with frequent asymmetry, poses great challenges tion, parenchymal hypoplasia, inferior breast skin to consistency in aesthetic correction. deficiency, superior malposition of the inframam­ mary fold, areolar herniation, and asymmetry. Disclosure: The authors have no commercial asso- Patients may present with one, several, or all of ciations or financial interest to declare in relation to these anatomical hallmarks. These deformities are the content of this article. No external funding sup- ported this study. From the Department of Surgery, Division of Plastic Surgery, Icahn School of Medicine at Mount Sinai. Supplemental digital content is available for Received for publication November 25, 2013; accepted April this article. A direct URL citation appears in 23, 2014. the text; simply type the URL address into Presented at the 30th Annual Meeting of the Northeastern any Web browser to access this content. Click­ Society of Plastic Surgeons, in Washington, D.C., September able links to the material are provided in the 20 through 22, 2013. Copyright © 2014 by the American Society of Plastic Surgeons HTML text of this article on the Journal’s Web site (www.PRSJournal.com). DOI: 10.1097/PRS.0000000000000823 www.PRSJournal.com 73 Plastic and Reconstructive Surgery • January 2015 Nomenclature and classification are impor­ result. Postoperative results were graded as excel­ tant in the preoperative identification of the pres­ lent, very good, good, or poor. ence and severity of each element, or combination of elements, to assist in achieving more consistent Classification Schema results. There have been several classification sys­ We have used a three­tier classification system4 tems reported to define the spectrum of the tuber­ that facilitated our qualification of the anatomi­ ous breast deformity.1–4 Meara and colleagues have cal considerations and severity of tuberous breast previously described a three­tier classification4 that deformities. With further experience, we have incorporated the specific pathologic hallmarks to updated the classification schema to better define aid in identification of the deformity and to estab­ the deformities and more appropriately tailor our lish a treatment strategy. In this article, we present treatment plans for each individual. To provide an updated tuberous breast deformity classifica­ clarity in stratifying the pathologic condition and tion system that has enabled the formulation of a severity, we have maintained three tiers, but have surgical plan that can be tailored on an individual further aided our approach to these deformities basis to all patients, and review our current prin­ with the added descriptors for areolar herniation ciples and techniques for the aesthetic correction and ptosis. Details of the classification system are of tuberous breast deformity. demonstrated in Table 1. The spectrum of ana­ tomical variations by type is illustrated in Figure 1, PATIENTS AND METHODS and an example of the pathologic features of the Twenty­six patients (51 breasts) with a mean deformity is shown in Figure 2. age of 25 years (range, 18 to 39 years) treated for tuberous breast deformity by the senior author Surgical Technique (A.R.K.) from 2008 to 2012 were included and Figure 3 demonstrates the treatment­planning were reviewed in an institutional review board– algorithm used in this study. All patients are marked approved retrospective study. Data collected preoperatively in the upright position. Pertinent included tuberous breast deformity classification, markings include the existing inframammary techniques used for correction, surgical outcome, folds and the proposed new inframammary fold and complications. Only patients with a mini­ position. The symmetry of these markings is aided mum of 8 months of follow­up were included. As by a vertical­midline “plumb­line” marking, and a measure of patient satisfaction, all patients who an intersecting horizontal line passing through underwent tuberous breast correction were asked the position of the “neo–inframammary fold.” to complete a postoperative BREAST­Q quality­of­ Limits of planned dissection, locations of glandu­ life outcomes questionnaire.5 Patient responses lar scoring, and proposed periareolar/circumare­ to four scales of the BREAST­Q reduction/ olar patterns are marked (Fig. 4). A periareolar mastopexy module were used: satisfaction with incisional approach is used in all cases. Dissection outcome, satisfaction with breasts, psychosocial progresses in a perpendicular fashion through the well­being, and sexual well­being. Patient scores gland directly to the prepectoral fascia. Prefascial were converted into linearized measurements dissection is then carried inferiorly to the limits using the Q­score program6 and presented on a of the premarked new inframammary fold line. scale from 0 to 100. In addition, all patients’ post­ Radial scoring of the gland of the inferior dermo­ operative photographs were graded by an inde­ glandular flap is performed with electrocautery as pendent plastic surgeon. Assessment was based on demonstrated in Figure 5; the endpoint of this dis­ symmetry, breast shape, scar, and overall aesthetic section is the appropriate expansion and release Table 1. Classification of Tuberous Breast Deformities Type Base Inframammary Fold Skin Envelope Breast Volume Ptosis Areola I Minor Normal laterally, Sufficient Minimal deficiency, Mild, moderate, Enlargement constriction minor elevation no deficiency, or or severe medially hypertrophy II Moderate Medial and Inferior Moderate None or mild Normal, mild, constriction lateral elevation insufficiency deficiency or moderate herniation III Severe Elevation of entire Global Severe Mild/moderate Severe constriction fold, or fold insufficiency deficiency herniation absence 74 Volume 135, Number 1 • Treatment of Tuberous Breast Deformity Fig. 1. Classification of tuberous breast deformity. Type I, hypoplasia of the lower medial quadrant; type II, hypoplasia of the lower medial and lateral quadrants; and type III, severe breast constriction and global hypoplasia. then reapproximated in layers. When areolar posi­ tion, shape, or herniation correction is required, or when breast ptosis correction is required, cir­ cumareolar mastopexy is performed with the scor­ ing of concentric circular incisions to include the excess areola, and the intervening areola and skin are deepithelialized. Interlocking purse­string suture with nonabsorbable suture material (CV­3 GoreTex; W. L. Gore and Associates, Inc., Flag­ staff, Ariz.) coapts the concentric incision lines and reduces the areolar surface area and pro­ jection. When ptosis correction with the circum­ areolar mastopexy insufficiently improves breast shape and projection, a vertical mastopexy limb is added. Running intradermal absorbable monofil­ ament suture completes the closure. A short video shows the major surgical steps described. (See Video, Supplemental Digital Content 1, which demonstrates the operative technique for correc­ tion of tuberous breast deformity, http://links.lww. Fig. 2. Anatomical features of tuberous breast deformity.