73 Tuberous/Constricted Breasts

Rafael A. Couto and William P. Adams Jr.

Abstract

Similar to traditional patients, tuberous/constricted breasts follow the four-part breast augmentation process: (1) patient education and informed consent; (2) tissue-based planning; (3) refined surgical technique/fast-track 24-hour recovery, and (4) defined postoperative care regimen; however, the tuberous/constricted breast has distinctive anatomical abnormalities that need to be restored at the time of the augmentation. Herein, we focus in the clinical decision and specific techniques pertaining to the correction of these deformities.

Breast augmentation – dual plane – constricted – High Five Process – tissue-based planning – tuberous – 14-point plan

73 Tuberous/Constricted Breasts

Key Points

The process of breast augmentation consists of four essential parts: (1) patient education and informed consent, (2) tissue-based planning, (3) refined surgical technique, and (4) clear postoperative care regimen. Integration of these four steps optimizes patient outcomes.
The constricted breast requires specific maneuvers to correct the deformity including:
- Using an implant that is wider than the breast width.
- Lowering the inframammary fold (IMF).
- Releasing the horizontal constricting fascia/bands in the lower pole of the breast.
- Using an implant with enhanced gel cohesion and a lower distribution of fill in the breast.
- Correcting pseudoherniation of the areola.
Patients with mild to moderate lower pole constriction are candidates for one-stage procedure, whereas individuals with severe IMF constriction may need a two-stage approach.

73.1 Preoperative Steps

73.1.1 Patient Education and Informed Consent

The more the patient knows, the better the outcome, as well as the satisfaction. During the education and consent phase, key concepts and goals are addressed and reviewed with the patient.
For further details, see Chapter 64 Breast Augmentation.

73.1.2 Tissue-Based Planning

The High Five Process and its corresponding measurements are used for tissue-based planning. Since the breast width is narrower by definition in the constricted breast, the surgeon uses the desired breast width to calculate the optimal fill volume. For further details, see Chapter 64 Breast Augmentation.
A unique planning technique for tuberous/constricted breasts is anterior distraction at the IMF. This maneuver is used to determine the degree of lower pole breast constriction. A patient who has a distractible IMF (mild constriction) is a candidate for a one-stage procedure; whereas, a patient with a fixed IMF (moderate–severe constriction) will need a two-stage approach: tissue expansions, followed by implant placement (Fig. 73.1).
In order to maximize lower pole fullness, we prefer to use either anatomical or round implants with high cohesivity. When using anatomical or round implants, it is important to use an implant that is shorter in height in order to shift the distribution of fill in the lower pole of the breast.
Three-dimensional imaging is a useful tool in these particular cases. It facilitates the surgeon to accurately demonstrate to the patient: (1) a visual simulation of the breasts postoperatively, and (2) an objective assessment of the breast or chest wall.

Fig. 73.1 Anterior distraction of inframammary fold (IMF) tests the degree of lower breast pole constriction. The skin overlying the IMF is pinched and distracted anteriorly. Patients with a mobile IMF (mild constriction) may be candidate for a one-stage procedure, while a patient whose IMF is fixed (moderate–severe constriction) will need a two-stage approach: tissue expansion, followed by implant placement.

73.1.3 Marking the Breasts

The markings utilized for a tuberous/constricted breast augmentation are the same as used for a traditional breast augmentation. See Chapter 64 Breast Augmentation, for a detailed description of the markings.
If the patient requires nipple-areolar complex (NAC) reduction and/or repositioning, a periareolar mastopexy is planned. The appropriate nipple position is first determined by using Pitanguy’s point, and then confirmed with a nipple drop technique. In other words, the nipple is raised superiorly to a level that is aesthetically pleasing, and then it is released and marked where the nipple was located. The top of the marking is planned as the nipple, not the superior border of the areola. Symmetry of both nipples is confirmed with sternal notch to nipple measurements. Often times the nipple level is adequate but the periareolar technique is utilized to improve the areolar fullness. Therefore, patients may not require a periareolar technique if the pseudoherniation is mild.
After determining the new nipple position, the amount of excess skin is estimated and then a periareolar oval shape is marked around the NAC. It is important to keep the periareolar procedure relatively conservative. The flattening that occurs with periareolar procedures is usually a shaping benefit in the constricted breast that is unique to that deformity.
Planning the new IMF location is done as follows:
- The implant volume and new IMF location is determined by applying the estimated new breast width to the High Five Process.
- Because these patients have horizontal and vertical skin envelope deficiency, their breast width and N:IMF distance must be increased.
- It is important to note that constricted/tuberous breasts are the exception to the tissue-based planning rule: the implant will be wider than the current breast width.
- In order to maintain a proper N:IMF distance to breast width ratio, the IMF needs to be lowered. The new IMF location is determined by applying the selected implant volume to the High Five Process.