Tubular breasts

Key points

•

Tubular breast is the most severe and most typical form of the so called ‘breast base anomalies’.
•

Its etiology is an anomaly of the fascia superficialis in the breast.
•

It is difficult to treat and has a tendency to recur.
•

Its treatment is based in the disruption of the constricting ring that is present in the breast.
•

The use of the inferiorly based flap described by the authors allows the disruption of this ring and the redistribution of the breast tissue.

Introduction

Tubular breast is a rare syndrome affecting young women unilaterally or bilaterally. Its real incidence remains unknown. First described in 1976 by Rees and Aston, it received the name of tuberous breast because of its resemblance to a ‘tuberous plant root’ ( ). However, its multiplicity of clinical manifestations has led to great confusion among plastic surgeons, mainly in the nomenclature used. Tubular breasts, tuberous breasts, snoopy breasts, domed nipple, herniated areolar complex, constricted breasts, are some of the names used to describe this deformity. ), consisting of: (1) hypertrophy of the nipple/areola complex; (2) pseudoherniation of the breast content into the areola, producing the very typical Snoopy-dog-nose deformity; (3) hypoplasia with commonly related asymmetry with the contralateral side; (4) vertical constriction with the reduced superior inferior diameter; and (5) a constricted transverse base. It is considered the most severe and most typical form of a group of breast anomalies called ‘breast base anomalies’ and it represents one of the most challenging surgical conditions of the breast because of its tendency to recur.

Etiology

Great controversy exists about its etiology. Recent observations led to the theory of anomalies of the fascia superficialis, in the form of strong adherence between the dermis and the muscular plane or the presence of a constricting fibrous ring as a consequence of a thickening of the superficial fascia ( , ). In both cases, the result is the impairment of the normal development of the breast, restricting its peripheral expansion, with consequent narrowing of the breast base, and preferential forward development into the areolar area, where the fascia superficialis is absent, giving the breast its tubular appearance and enlarging the areola. Clinical observations favor the presence of the constricting fibrous ring and its disruption is the most important step in the treatment of the disorder ( , ).

Classification

The tubular breast is the most typical form of a group of disorders that are characterized by anomalies of the breast base and that generally involve the lower quadrants. Von Heimburg et al classified it in four types: Type I, hypoplasia of the lower medial quadrant; Type II, hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region; Type III, hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar; Type IV, severe breast constriction, minimal breast base ( ).

Treatment

Many techniques developed to treat this condition have yielded poor results. Pushing the mammary gland through the pseudohernia and narrowing the areolar diameter, removing a doughnut-shaped piece of skin, will not correct the deformity. Treatment by simply inserting an implant accentuates the deformity, creating a second crease and dropping the entire gland over the implant. As mentioned earlier, to correct the deformity it is necessary to disrupt the constricting ring, which is achieved by the creation of a dermo-adipose-glandular flap inferiorly based, also called inferior pedicle, that was created by the senior author in 1973 ( ). Another point is the redistribution of the mammary tissue, to allow the filling of the inferior quadrants and enlarge the base of the breast, which is constricted in the great majority of the cases. The procedure is easily performed and may also include implant placement ( , ).

Surgical sequence

In cases of severe hypoplasia, breast implants can be used uni- or bilaterally to reach a better result. The surgery, with or without implants, is quite similar, differing only in the inclusion of the silicone implant and the closure of the space in which it was introduced. The surgery is always performed under general anesthesia.

Pre-operative preparation

With the patient in dorsal decubitus and half-seated position, under general anesthesia, the new areola is drawn with a diameter of 4 cm. The external limit of the areola is also drawn, demarcating the excessive areola to be removed. The submammary sulcus is marked, and this represents the inferior limit of dissection of the inferior flap to be created ( Figure 10.1 ). In cases of highly hypoplastic lower quadrant, we discard the actual position of the sulcus and mark it more inferiorly in a new desired position. It is important to mention that asymmetry is frequently present, so the markings are made independently.

Operative techniques

Surgery without breast implants

The circumareolar region is de-epithelialized ( Figure 10.2 ). The inferior based flap is started by dividing the gland in two halves with an incision in the infraareolar region perpendicular to the thoracic wall and reaching the pectoral fascia ( Figure 10.3 ). This creates the superior hemisphere which keeps the nipple–areola complex and the inferior hemisphere from which the inferior flap will be made. The inferior portion of the gland is freed from its skin with the use of scissors limiting the dissection to the sulcus previ ously marked ( Figure 10.4 ). The lateral and medial prolongations of the gland are resected, with care being taken not to injure the perforating vessels from the fourth and fifth intercostal vessels ( Figure 10.5 ). The creation of this flap will lead to the disruption of the constricting ring which is responsible for the herniation ( Figures 10.6, 10.7 ). Mounting of the breast begins with the fixation of the inferior flap on the thoracic wall. Fix the distal end of the flap inferiorly to its base, bending it over itself, using non-absorbable sutures ( Figures 10.8, 10.9 ). This maneuver is important to fill the inferior quadrants, which generally are hypoplastic ( Figure 10.10 ). The upper portion is left to fall naturally over the inferior flap causing the mammary base to become enlarged ( Figure 10.11 ). The breast is closed using a periareolar suture by the technique of Peled and Benelli performed with 2-0 nylon ( Figures 10.12, 10.13 ) ( , ). The areolar suture is done with separate stitches using 6-0 nylon ( Figure 10.14 ). Suction drains are left for 24 hours. Immobilization of the breast with microporous tape is important and remains for 7 days ( Figure 10.15 ).