Perhaps no other condition of the breast presents the same type of surgical challenge as the tuberous breast deformity. Although a wide spectrum of clinical presentations can be encountered, in the most severe of cases, the degree of deformity is significant. Typically all of the elements of the breast are present in that there is a variable amount of breast tissue with a nipple and areola. However, the deranged relationships these structures have with each other and the degree of asymmetry they often demonstrate can create to the inexperienced eye a bizarre breast appearance. Truly the emotional sequelae of dealing with this condition can be devastating to the young women afflicted with any degree of tuberous breast deformity.

The clinical findings associated with the tuberous breast typically include a reduced breast base diameter, a high and variably constricted inframammary fold, breast hypoplasia, and “herniation” or preferential expansion of the growing breast bud through the area of the areola. It is not uncommon for a significant asymmetry to be present with a small and more severely involved breast present on one side, and a larger, more ptotic breast with a tight inframammary fold being present on the other (Fig. 119.1).

Surgical management of the tuberous breast is dictated by the severity of the deformity. Options for treatment range from simple augmentation to reconstruction of the breast skin envelope with tissue expansion. Soft-tissue manipulation invariably includes periareolar mastopexy to manage the herniated areola with or without various internal flaps to reshape the breast. Choosing the most appropriate technique for a given patient requires a considered evaluation of all the elements that describe the preoperative deformity. Once these elements are defined, methods of surgical correction can be identified and a final surgical plan developed.

Perhaps the most important preoperative surgical decision to be made involves whether to use an implant or a tissue expander to manage the lower pole of the breast. In cases of mild constriction of the base of the breast, soft-tissue release with incisions that extend radially away from the nipple toward the breast periphery can result in enough of a release that the implant can smoothly recontour the inferior pole of the breast without any residual clefting being visible. This soft-tissue release typically extends all the way through the breast parenchyma to the level of the dermis (Fig. 119.2). If, however, any residual tightness is present in the lower pole, even after soft tissue release, then placement of a tissue expander may be a better option. In severe cases, the lower pole skin does not physiologically expand, and thus a tissue expander is required to create the smooth, rounded contour of an attractive breast. Determining preoperatively whether a tissue expander will be required can be difficult, and at times this only becomes obvious after a full soft-tissue release does not allow proper recontouring of the lower pole. This decision also has social implications. Unfortunately, some insurance plans do not consider correction of the tuberous breast deformity to be a covered benefit. For this reason, many patients are forced to cover the cost of surgical correction privately and are eager to hold down potential costs as much as possible. This tends to place the plastic surgeon in a difficult position as an emotionally distraught patient and family with high expectations present with a significant deformity and the ability to afford only one operation. Under these circumstances, it is tempting to choose an implant over a tissue expander to avoid a second procedure with the attendant associated additional costs. It is highly advisable to discuss with the patient and family the limitations simple implant placement can have on the ultimate result to avoid postoperative disappointment and allow patients to make informed planning decisions (Fig. 119.3).

A very mild form of the tuberous breast deformity presents as a hypoplastic breast with a subtle constriction of the medial inframammary fold area on one or both sides. If this is not recognized preoperatively, a disappointing flatness to the medial breast after simple breast augmentation will be noted which detracts from the overall shape of the breast. To prevent this deformity from occurring, it is necessary to fully release the soft-tissue attachments in this area with radial incisions extending through the parenchyma to the dermis. It is helpful if the subglandular or partial subpectoral pocket is used because this will prevent the intact muscle in the lower medial corner of the breast from tethering the breast shape. This also will allow access to the breast to facilitate the parenchymal scoring. Usually, with this type of soft-tissue release, a breast implant can then provide the needed volume to fill out the lower pole, and in particular the lower medial pole of the breast, and quality results can be obtained (Fig. 119.4).

A relatively common presentation of the tuberous breast variant is the patient with macromastia associated with a high and relatively constricted inframammary fold. In these cases the breast volume is excessive and the nipple and areola tends to “bend” over the constricted fold to create a very ptotic appearance. In addition, the areola tends to be enlarged. Treatment of these patients is quite straightforward, and any of several breast reductions techniques can be used to correct the misshapen breast along with the macromastia. My preference is the SPAIR (short-scar periareolar inferior pedical reduction) mammaplasty. Here, the internal base constriction is released during the development of the inferior pedicle, the breast reshaped with internal sutures, the breast skin envelope retailored using a circumvertical pattern, and the areolar diameter reduced with a periareolar purse string suture. Taken together, these surgical maneuvers provide particular advantage in this type of tuberous breast patient, and excellent results can be obtained with complete correction of the preoperative deformity (Fig. 119.5).