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Description Classification and Treatment of the Tuberous or Tubular Breast

Dr. Alejandro Nogueira's clinical description and classification of the tuberous or tubular breast introducing his personal surgical technique for the aesthetic correction of the tuberosity

A large percentage of patients seeking breast surgery mammoplasty with a plastic surgeon have some degree of tuberous or tubular breast, of greater or lesser impact on the technique to be applied. Logically the incidence among the general population is much lower. Patients are increasingly aware of their problem, in fact almost a third of them come with a fairly accurate self-assessment of their anomaly, some even aware of the degree they suffer (thanks to Internet). Another third have never heard of this kind of breasts, but they are aware that their breasts are not like other women's, they know that something is not normal in shape. The rest simply want to enlarge, no more. There are myths and legends about various particular topics connected with tuberous or tubular breast. We will answer the most frequently asked questions on this subject.
WHAT IS A TUBEROUS OR TUBULAR BREAST? It is a type of breast whose shape is atypical and not that corresponding to a normally developed breast. The function of the tuberous or tubular breast is the same as the other women. Patients often refer to the tuberous or tubular breasts as pointy, cornet shaped, fruit shaped, large areolas, herniated areolas, puffy nipples, snoopy breast and others. Generally the patient is not happy with the shape of the breast, does not accept it, whether it has or not the right size.
IS IT A SERIOUS ILLNESS? It is not a disease, neither severe nor mild, the tuberous or tubular breast is a congenital malformation, not necessarily hereditary but with a tendency to family concentration. It is a birth defect such as e.g. cleft lip, cleft palate, the syndactyly, etc. In the same family there may be a single woman with tuberous or tubular breasts, or several may suffer it. Despite being a birth defect, due to its special features affecting a body organ not developing until puberty, you cannot tell if a child is going to suffer it until she starts her reproductive life. It would be therefore a malformation that manifests as an abnormality of development. Functionally the tuberous or tubular breast has perfect ability to breastfeed children and does not have increased incidence of breast diseases or tumours.
WHAT NAMES DOES IT HAVE? It is called in various ways to refer both to its peculiar shape as to the cause of the problem, like tuberous breast due to appear a tubercle, tubular breast for the trend to grow as a cylinder, constricted breast or constricta for their anatomical cause, caprine breasts for the resemblance, and others.
WHY DOES IT OCCUR? The cause of the tuberous or tubular breasts is at their base, exactly at their growth root where they join the pectoral muscle, there exists a fibrous ring, a kind of tendon that prevents its spread throughout the chest occupying what would be its theoretical natural space. This circular ring defines its growth to a small chest area in each hemithorax. At its initial development the breast is strangled by this ring, so it can only grow within it, acquiring its peculiar shape. Outside this ring there exists virtually no breast, as would overall happen in a male chest.
WHAT ARE THE SYMPTOMS OR SIGNS? Symptoms it has not, in its strict sense and not being a breast disease, no symptoms are produced on the patient. It is possible to mention signs, features or components of the tuberous or tubular breast deformity, which are those manifestations that may occur, in whole or in part, more or less intensely, in a woman with tuberous or tubular breasts.
MAIN SIGNS Broadly speaking these are the main features of a tuberous or tubular breast:
Conical, tapered or tubular form: This is greater the more the breast grows, which is logical if we imagine the comparison with a pastry sleeve letting the cream out, if the breast grows little it becomes just button-shaped or a small lump, but if it progresses acquires the only shape that allows the ring through where it does, becoming a more complex and deformed breast the more it can increase. Its internal structure is woven in spiral seams or concentric rings, which makes permanent its peculiar external anatomy.
Large areolas: The areolas become hypertrophic, they can be gigantic up to 4 inches in diameter, even in very young women who have not had children. The explanation is the same logic as above, as growth is only possible within the base ring, and this ring is placed behind the areolas, the entire expansion of skin that needs the gland to grow occurs in the areola, which is forced to increase unusually.
Areolar hernia: This is related to the above, it is that the breast tissue seems to literally go out through the areola. The thin and much enlarged areolar skin is a point of weakness on which the tissue produces a herniation and sometimes a double submammary crease or double-bubble deformity. These cases are the most difficult to solve. Sometimes you may see a double hernia because there is a double ring, a deeper one and the other closer to the areolar skin.
Elevation of the submammary crease: The development limitation is circumferential, which affects all parts of the breast, although this is more problematic in the groove or lower breast crease, where it joins the chest. The inframammary fold is the most important parameter with nipple position, for both the woman and the surgeon's technique, within the normal or pathologic anatomy of the breast. The tuberous or tubular breast is characterized by an abnormally high submammary fold, logically that lower breast area is empty, indeed, it does not even exist and is replaced by abdominal skin. The abdomen gains terrain to the breast, causing the optical effect of short thorax and very long abdomen. The patient feels very uncomfortable with this manifestation, for no brassiere or swimsuit fits properly under the breast, leaving a few inches clearance between the wiring or the brassiere cup and the submammary fold. Logically lingerie manufacturers estimate a normal anatomic position of the submammary fold, which is altered in the tubular or tuberous breast deformity. This is one aspect of greater involvement in the treatment of the anomaly.
Absence of the lower pole: As a direct consequence of having a too high inframammary crease and a short distance between it and the areolar edge, the lower pole of the breast mound is nonexistent and instead replaced by abdominal terrain.
Separation of the breasts: The same restriction that causes the elevation of the submammary crease also causes lack of fullness at the cleavage, extremely separating the breasts.
Empty upper pole: Shares its cause with items above, making the patient dissatisfied with the upper aspect of the cleavage.
Pseudoptosis: Ptosis is a term derived from the Greek meaning droopiness, and pseudo indicates false or apparent, so pseudoptosis is the appearance of droopy breasts which are really not. A breast is low when the nipple is lower than submammary fold, and this is like this as a general rule since the droopy breast nipple descends below the level of the lower breast crease. Extraordinarily the opposite can happen, without actually droopy breast, with a perfectly positioned nipple, the breast may have bogus droopy breast criteria because the submammary fold is very high and higher than the nipple or at least at the same level. It would be the same phenomenon that with the droopy breast but inverted conceptually, is not the nipple descending, it is the submammary fold ascending (not dynamically, we speak of an abnormal position).
Hypoplasia: The tuberous or tubular breasts are usually small or even underdeveloped or hypoplastic. Because of this many women do not detect anything odd about the shape of their breasts, or attribute the peculiar anatomy to not having grown enough breast. In some ways it is preferable that a tuberous or tubular breast does not grow much, the more development it experiences the more it becomes deformed. The vast majority of tuberous or tubular breasts attend consultation also requesting a breast augmentation.
Asymmetry: Very often a complex and very noticeable breast asymmetry between both tuberous or tubular breasts coexists. This can be a size difference, difference of position or birth point, different levels of tuberous or tubular breast deformity, uneven areolas, submammary folds at different heights, etc.
Resistance: It would be one of the few pluses for the woman with tuberous or tubular breasts. Strong pectoral anchors, the usually hard mammary skin and reinforced glandular structure make altogether the tuberous or tubular breast rarely suffer ptosis or droopiness with pregnancy, breastfeeding, weight oscillations or aging. This does not mean the former cannot be produced, everything has a limit, but it is frequently detected tuberous or tubular breast deformity women who after 3-4 pregnancies have breasts in practically the same natural born position.
Gynecomastia: When the tuberous or tubular breast occurs in a man it is the substrate that lies behind the gynecomastia vera, or true glandular development in the thorax of men, with many signs in common with the features suffered by women.
SECONDARY SIGNS There are other secondary features or associated or traits that frequently are part of the clinical findings in women with tuberous or tubular breasts:
Facial traits: With enough clinical experience treating patients with tuberous or tubular breasts one can identify the problem just with a series of anatomical features in the rest of the body that are often associated to it. One is a type of face composed of slanted eyes (slightly higher outer corner than the internal), prominent eyelashes, separated eyebrows, uniform skin, sparse hair, large skeletal features and others. Generally they tend to be women of great canonical beauty.
Digital anomalies: It is also common to find small abnormalities of the shape of the fingers or toes. On hand there may be a little finger bent or shorter, disproportion between thumb and long fingers, short nails with disproportionately small distal phalanges, rotations and others. In the toes may appear sindactilies (mergers), abnormalities in size, arched or flat foot and others.
Lipodystrophy: One of the meanings of lipodystrophy (literally abnormal fat) is a type of fat accumulation which is not intended to accumulate calories and is present since adolescence, as it is part of the anatomy, this means it shapes the body, also called stubborn fat. Tuberous or tubular breasts women often have a fatty flab at lumbar waist level and another plate in the lower abdomen, without thereby necessarily suffering from overweight.
Uniform skin: The skin of the whole body is very similar, there are few differences between the different facial areas, neck, trunk, abdomen and legs.
Other anomalies: Very often tuberous or tubular breast is accompanied by other small anatomical abnormalities to internal organs, very rarely these necessarily showing symptoms or become a problem. The most affected organs are the skeleton and locomotive system, kidney and heart. Some examples can be benign functional heart murmurs, abnormal renal and urogenital tract shape and others. At metabolic level, and probably caused at the liver, there may be an acceleration or delay in drug elimination processes.
From the above described should be insisted that they are not always present in whole or with the same intensity, there is much polymorphism in tuberous or tubular breast so that each woman will have its own peculiarity.
WHAT IS THE TRADITIONAL CLASSIFICATION OF THE TUBEROUS OR TUBULAR BREAST DEFORMITY? There is a traditional and very limited classification, by Grolleau et al, who speaks about three degrees:
Grade I: The lack of development is limited to the inferior-internal quadrant, the areola is deflected downwards and inwards, being the volume of the breast normal or hypertrophic | Grade II: The two lower quadrants are deficient in their development, in these cases the areola is deflected facing downwards | Grade III: All quadrants are affected and are deficient, the mammary base is retracted and the breast has a caprine or tubercle look.
DR. ALEJANDRO NOGUEIRA'S CLASSIFICATION OF THE TUBEROUS OR TUBULAR BREAST DEFORMITY Given the polymorphism of the tuberous or tubular breasts and their different clinical aspects, based on his own personal experience Dr. Alejandro Nogueira proposes a new classification of tuberous or tubular breast he has designed, developed and applied, taking into account the different signs in a more detailed and organized manner, providing a therapeutic-clinical-prognostic approach with medico-legal perspectives.
CLINICAL PARAMETERS In Dr. Alejandro Nogueira's classification the following parameters are taken into account with their corresponding gradation according to the anatomical and clinical features of the tuberous or tubular breast deformity:
Conicity (C): The greater or lesser constriction of the breast cone; C0: none, no constriction, can have tuberous or tubular texture | C1: mild, one constrained quadrant | C2: moderate, two quadrants constrained | C3: severe, three quadrants constrained | C4: extreme, four quadrants constrained.
Areola (A): Hypertrophy suffered by the areolar skin of the largest areola according to the anatomical proportions of the patient, measured as the radius gap between the outer areolar perimeter and the optimal one planned; A0: none, normal or hypoplastic areola | A1: mild, areola hypertrophied 1 cm | A2: moderate, areola hypertrophied 2 cm | A3: severe, areola hypertrophied 3 cm | A4: extreme, areola hypertrophied 4 cm.
Hernia (H): The reducibility and shape memory of the areolar hernia; H0: none, no hernia or only manually provoked | H1: mild, reducible hernia with areolar contraction | H2: moderate, reducible hernia with underwear | H3: severe, manually reducible hernia | H4: extreme, irreducible hernia.
Submammary fold (F): Downwards displacement from the original one the patient was born with necessary to achieve lower pole reconstruction and breast implant centricity; F0: in situ, without displacement, may require descent if there is an implant | F1: mild, displacement lesser than 2 cm | F2: moderate, displacement from 2 to 4 cm | F3: severe, displacement from 4 to 6 cm | F4: extreme, displacement larger than 6 cm.
Skin (S): Neo lower pole, previously upper abdominal terrain, skin firmness; S0: none, flaccid | S1: mild, normal | S2: moderate, hard | S3: severe, very hard | S4: extreme, cuirass.
Associated problems (As): Breast abnormalities, problems or issues, other than lack of development or breast hypoplasia, which require surgical correction at the same time than the tuberous or tubular breast deformity like pathological breast asymmetry, breast droopiness or mammary ptosis, breast hypertrophy or gigantomastia, previous breast surgeries, failed attempts of tuberous correction, presence of failed or ruptured breast implants and others; As0: none, no increase of complexity | As1: 1, mild increase of complexity | AS2: 2, moderate increase of complexity | As3: 3, severe increase of complexity | AS4: 4 or more, extreme increase of complexity.
GRADATION OF TUBEROSITY Based on the previously classified clinical parameters the prognostic gradation and severity of the tuberous or tubular breast deformity is defined, combining them in different degrees of tuberous or tubular breast:
Tuberous or tubular breast grade 0 (trait): C0 + A0/1 + H0/1 + F0 + S0/1 | Tuberous or tubular breast grade I (mild): any combination with C1 or A2 or H2 or F1 | Tuberous or tubular breast grade II (moderate): any combination with C2 or A3 or H3 or F2 or S2 | Tuberous or tubular breast grade III (severe): any combination with C3 or A4 or H4 or F3 or S3 | Tuberous or tubular breast grade IV (extreme): any combination C4 or F4 or S4 | Complicated tuberous or tubular breast (X): any grade with As1/2/3/4.
SURGICAL RISK OF TUBEROSITY A generic treatment prognosis criterion is concluded from this classification in terms of rates of complications and likelihood of a reoperation. These are overall percentages in an ideal scenario safe from the typical surgical complications, involving highly adherent implants, enjoying a well trained surgeon and done on strictly collaborative patients:
Very low risk (5%): grade 0 | Low risk (10%): grades I and II | Medium risk (15%): grade III or grades 0/I/II-X | High risk (20%): grade IV or grade III-X | Very high risk (25%): grade IV-X.
To these percentages has to be added another 25% probability of poor result and reintervention when poorly adherent implants are used and an additional 25% in case the surgeon is not experienced in tuberous or tubular breast treatment techniques. An extra 10% risk would source from any usual postoperative complication, including non compliant patient of postoperative immobility.
WHAT IS THE TREATMENT OF THE TUBEROUS OR TUBULAR BREAST DEFORMITY? As we are neither facing an illness nor present or future risk, the decision to undergo corrective surgery of the tuberous or tubular breast deformity is entirely at the discretion of the patient herself. In the sense of dissatisfaction due to its shape, often aggravated by the small size, the patient decides to undergo voluntarily the intervention, once deemed fully informed and understanding that he has found the right professional. In the days before the advent of breast implants the treatment state of the art was totally different. There were a number of techniques, complex, with uncertain outcome and generally not very rewarding. This changed when combining breast augmentation with simultaneous treatment of the tuberous or tubular breast deformity. Implants provide the solution to some of the signs of tuberous or tubular breast deformity, as is the absence of lower pole.
PRINCIPLES OF TREATMENT Today practically 100% of operated tuberous or tubular breasts are also made a breast augmentation, so here will be depicted what is done on the tissue itself, it is not the subject of this text talking extensively about breast augmentation. Indeed we will go into the interaction between the tuberous or tubular breast and the implants, let’s see how they affect each other.
Never a standalone augmentation: A well done breast augmentation but on an untreated tuberous or tubular breast gives a disastrous result, it causes a double-crease or double-bubble deformity, literally you can see two breasts on each side. The tuberous or tubular breast is very rebellious and does not adapt to the implant if it has not received its corresponding and specific treatment. A normal breast adapts to the prosthesis within 4 to 8 weeks on average, this never ever happens if the glandular structure is tubular. To avoid this issue glandular tailoring techniques are applied which somehow facilitate its adaptation. As much as some surgeons insist, just inserting an implant does not make the tuberous or tubular breast deformity disappear.
Submammary fold must be lowered: As a concept the point of maximum projection of an implant must correspond as closely as possible to the level of the nipple. By doing this on a normal breast should always lower 0 to rarely more than 2-4 cm the position of the submammary fold, since when the breast does grow it is in every spatial axis, also inferiorly, and the failure to do so would lead to too high riding implants. This general concept becomes more important and more extreme in a context of tuberous or tubular breast deformity, in which exists an abnormal elevation of the submammary fold and absence of the lower breast pole. The necessary descent ranges normally from 4 to 8 cm, which is huge in breast surgery. In other words, if the tuberous or tubular submammary crease is respected the implants would be very high, almost at the collarbones, so that the nipples would look downwards and the lower pole would be relatively even emptier. The problem is given by the skin we gain to the abdomen, with the submammary fold lowering the implant is largely placed under the thick abdominal skin, skin furthermore scarcely expandable, and not the usually thin breast skin. For this texture discrepancy phenomenon it may occur a slow and inexorable postoperative elevation of the implant, although it has been placed correctly, due to the contour-shape memory of the skin, or that abdominal skin is not expanding enough then creating a lower pole dual-texture.
Wide implants: You have to occupy the space not covered by the mammary gland in the upper pole, at the cleavage and interiorly, so it is common to use implants with broad base dimension.
Generous implants: Although tuberous or tubular breasts are often small, the patient has the feeling that has more volume than there actually is. That is because the little or much glandular tissue is concentrated in a very small area, bounded by the tuberous or tubular ring, making it bulge forwardly. When the tuberous or tubular breast deformity is tailored the breast ends in almost nothing left, because it expands horizontally and occupies the whole thorax and not because the gland is trimmed away, appreciating to its full extent the hypoplasia laying behind the abnormality. Therefore it is common that the surgeon underestimates the real volume deficiency of the patient choosing small nominal size and dimensions implants.
No matter the composition of the implant filler: Although today the recommended golden standard is cohesive or highly cohesive silicone gel as best implant filler for all cases, there are other alternatives which, being disappointing and outdated for breast augmentation, do not change the prognosis of tuberous or tubular breast deformity treatment.
No matter the profile: The anatomical or round profile, high or low projection, all give good results if well selected, the successful treatment of the tuberous or tubular breast deformity lies on the excellence in managing and tailoring the gland, not in the type of implant profile.
No matter the plane of placement: Within the valid options, preferably subfascial, nothing will change the success of the outcome by the aforementioned.
Matters, and much, the insertion way: The only way by which you can make the glandular tailoring and a complete treatment of the tuberous or tubular breast is via the areola, which is also the most generally recommended in standard breast augmentation. The problem comes when we meet tuberous or tubular breast deformity and small or hypoplastic areolas. This combination is absolutely exceptional, as one of the features of the tubular or tuberous development is excessively large areolas. Would that happen then an extra-areolar access of any kind should be turn to, for neither by submammary way or other approaches the glandular tailoring surgery would be possible.
Matters, and much, the implant surface: The appropriate surfaces are the highly adherent textured one and especially the ideal is the polyurethane-coated implant with bio-velcro adhesion properties. The reasons we have them coming up next.
Migration tendency: Due to the thin mammary and thick abdominal skin texture interface beared by the implant in the lower pole, the prosthesis can migrate in superior and lateral directions, towards the collar bone and armpit, very little by little, week by week, despite of all measures or massaging carried out. Implant surfaces with higher adhesion properties are the most suitable in these cases, being optimal those with textured surface and superiorly the polyurethane-coated implant which is the one with strongest fixation, resistance to displacement and both mechanical and biological adhesion features. The polyurethane-coated implant has one of its main indications in the tuberous or tubular breast deformity correction surgery, for this reason and that explained next.
Increased risk of encapsulation: It is a known fact the increased risk of occurrence of capsular contracture in cases of tuberous or tubular breasts. It is due to the bigger mechanical pressure exerted by the skin on the capsule during its formation process, hence the recommendation to use anti-encapsulation implants in all cases of tuberous or tubular breast deformity, being the best indications those textured and the specially featured against capsular contracture polyurethane-coated implants.
TREATMENT OF THE TUBEROUS DEFORMITIES Entering what would be itself the treatment of the tuberous or tubular breast deformity, apart from the always beneficial effect of well selected implants, the treatment of the tubular breast will be explained based on its main clinical aspects.
Treatment of the shape: There are different techniques with better or worse results, having all the common goal of eliminating the basal ring, detach the breast, tailor the tissue to eradicate the conicity of the breast mound by a series of planned and controlled cuts, sometimes glandular flaps are made and others. This stage, well done, does not ever fail and does not require repetition; the traditional techniques and Dr. Alejandro Nogueira's personal technique will be explained later below. However, it is to be noted that the glandular plasty techniques do exclusively produce reshaping effects on the breast tissue and no one of the surgical procedures to correct the tuberosity may void the requirement of using breast implants to fill up the underdeveloped breast areas.
Large areolas: Areola reduction is carried out removing a ring or donut of intra-areolar skin. This detail is very important, talking of eliminating skin of the areola, from within, not externally to it. The extra-areolar removal is seldom necessary or desirable, it may be indicated in some cases of double submammary crease due the double texture of skin in that area. It may be necessary to repeat the resection of intra or extra-areolar skin in many subsequent surgical times. There is a maximum limit of skin which is removable around the areola without leading to deformities like wide or keloid periareolar scars, puckering around the areola and periareolar rippling.
Areolar hernia: The treatment, in addition to reducing the glandular prominence by internal tailoring, is also achieved by reducing the areola, which creates an effect of contour flattering. By the same principle is explained tuberous or tubular patients notice significant cosmetic improvement when the areolar muscle contracts.
Elevation of the submammary crease: Lowering it to host the breast implant under nipple centricity is an absolutely required yet technically simple gesture without limitations, despite which as previously noted it is a very important part of the treatment and may need further surgery to lower again the submammary fold partial or totally to its desired position in case the lower pole skin displaced the implant.
Absence of the lower pole: After lowering the submammary crease breast implants do reconstruct the typically absent crescent of breast tissue between the new lower breast border and the original one the patient was born with; no one surgical methods replaces the mammary prostheses role regarding this essential goal.
Separation of the breasts: The same constriction ring that causes the elevation of the submammary fold also causes absence of fullness in the cleavage, separating the breasts to the maximum; again breast implants are required here.
Empty upper pole: Shares causes with the aforementioned, the patient is not satisfied with the upper breast fullness regardless the tuberosity correction applied, thus requiring breast implants.
Pseudoptosis: As previously mentioned the treatment consists in properly positioning the submammary crease.
Real breast ptosis: If there is actual breast ptosis or droopiness associated with the tuberous or tubular breast deformity, rare though possible, a breast lift or mastopexy can be applied along with the rest of the treatment. However the mastopexies in the tuberous or tubular breast deformity are more problematic, which does not mean they cannot be or should not be performed, because the areola can be so large that intersect the incision lines of the mastopexy, for which small areola remains could be left next to the mastopexy scars and in the future may require easy removal touch up; also healing is impaired for the greater strain caused by moulding rebellious tissues, therefore the wounds may present widening, opening and other issues during the postoperative; finally the almost exclusively admitted technique is the vertical or lollipop or Lejour pattern scars with horizontal only skin removal, since the inverted T, anchor or Wise pattern scars, featured with both horizontal and vertical skin removal, applied on breasts typically suffering a massive vertical shortfall of skin on their lower pole would lead to serious complications and deformities on both, the mastopexy and the prosthesis used, it is senseless and pointless applying an horizontal cut to remove skin in vertical fashion on an area severely affected by lack of skin cover due to the tuberous or tubular breast constriction and elevation of the submammary crease; should a tuberous or tubular breast be droopy then the excessive skin on the lower pole would be exclusively or mainly on an horizontal fashion and this is addressed by the vertical-only incision mastopexy.
Breast hypertrophy: In spite it is not a common circumstance some patients develop gigantomastia within tuberous or tubular breast deformity context lead to an aberrant breast shape with a peculiar angle downwards due to the constriction ring at the lower pole; a customized technique of breast reduction has to be applied, with suitable tweaks adapting the procedure to the congenital breast deformity; this reduction mammoplasty exercises a total demolition of the tuberosity therefore neither any specific glandular plasty technique nor breast implants are necessary, the reduction surgery itself eradicates any trace of tuberous or tubular shape.
Hypoplasia: The use of implants is indicated to compensate it.
Asymmetry: Its treatment may be palliative, can be improved but never entirely eliminated. For this purpose breast implants, cutaneous maneuvers and glandular tailoring can play their role.
WHY TUBEROUS OR TUBULAR BREAST SHOULD BE OPERATED MORE THAN ONCE? We are facing a complex congenital malformation that alters the normal external as well as internal anatomy of tissues, predisposing to suffer complications or undesirable phenomena, especially when other treatments are to be associated. These are some of the reasons for tuberous or tubular breasts cases reoperation: encapsulation or capsular contracture of implants, implants displacement, implants of insufficient volume, lower pole double texture, scars of poor aesthetic quality, scar retractions or adherences, improvement of the complementary techniques (mastopexy, asymmetries, and others).
DOES IT MAKE UP UNDERGOING SURGERY? Certainly it does, this is one of the most rewarding breast interventions for the patients and the one they are the most grateful to their surgeon about. However, women with tuberous or tubular breast deformity should be fully informed of the problem, the involved difficulties to the surgeon and the chances of needing another operation. In the Dr. Alejandro Nogueira's hands all the patients do successfully complete their treatment process, either in one or eventually needing more surgical stages.
WHY ANATOMICAL PROFILE IMPLANTS? Because they are natural looking and the most beautiful in the subfascial plane in general for any breast augmentation and particularly for tuberous or tubular breasts. You certainly cannot say that the round profile implant is a bad implant or ends "ugly"; all implants can be good, bad or average according to the skill and experience of the surgeon as well as the anatomy of the woman. No prosthesis is guarantee of results as breast implants are only one element within the surgical procedure, which is not to say that all models give the same result. Essentially the anatomical implant is superior to round profile ones in two aspects.
It is more effective filling breast upper pole; the round implant is not able to fill the top of the breast and leaves an empty space, which does not happen with the anatomical which does reach where a natural breast begins.
Its upper part progressively decreases in form of natural slope that replicates the natural shape of a breast avoiding the "ball" or "balloon" effect, while the round profile implant forms an abrupt step at the top and provides a rounded result which is less natural, even artificial.
These advantages or differences between the round and the anatomical shaped implants are greater the lesser breast adds the patient herself, the bigger is the implant to be used and the slimmer the woman is. Let’s take two extreme cases; first let’s imagine an extremely slim or skinny woman as per her constitution, suffering from hypoplasia or a total or subtotal lack of breast development (quasi-male chest), and who wishes a large breast volume, in such case the difference between a round implant and other anatomical is dramatic, as much as the round implant will give a grotesque and utterly unnatural result as a "coconut", while the anatomical one will provide a natural breast reconstruction; now let's assume one plump fleshy woman with middle sized breasts, and also not wanting a too large increase of her mammary volume, in this patient the difference between anatomical and round, yet existing, is negligible or at least barely detectable, since the prosthesis is much covered by the tissues of the patient and also the implant is slightly projected or prominent thus will have little impact on the external form; between these two extremes imagine an infinite number of intermediate situations.
90% of patients operated of simple augmentation mammoplasty prefer the anatomical implant, although the round one may offer similar degree of satisfaction to patients seeking them and duly informed of the limitations or poor results that will occur.
When handling cases of tuberous or tubular breasts the use of round implants is not contemplated, but not because either model might have any influence on the treatment of the tuberous or tubular breast deformity. No matter at all the use of anatomical or round profiles to achieve tuberous or tubular breast deformity correction as its eradication depends on the correct glandular plasty and other technical and surgical gestures not connected with the shape of the implant (see text above). This is a purely conceptual question, therefore no minor, when it comes to understanding what a woman suffering tuberous or tubular malformation is seeking. The patient who comes to an office wishing treatment for tuberous or tubular breasts is looking for the best, quality, naturalness and finally having in her body a breast as has been dreaming of for years, and that sought breast must be of the highest beauty and naturalness possible, which is only obtained using anatomical shape implants (if we talk about subfascial technique, it would not be so in other planes of placement). A patient of tuberous or tubular breasts does not admit a suboptimal result if it can be avoided by choosing the most advanced implant today.
WHY HIGH ADHERENCE IMPLANTS? Here we will particularize in the pathology that concerns us. The main problem of the tuberous or tubular breast (read the text above) is reconstructing the lower mammary pole and lowering the submammary fold to the anatomically correct position. It is a constant that all tuberous or tubular breasts suffer from an abnormally high submammary crease, in a moderate or severe grade, due to the constriction suffered from birth. This submammary fold and its location are inadmissible because they would oblige to place cephalically eccentric or too high riding breast implants and prevent building the absent lower breast pole.
The descent of the submammary fold poses no particular technical difficulty for the surgeon, not so its proper planning which is only possible in very experienced hands and for surgeons with a greatly developed abstract spatial thinking. Such fold must necessarily be lowered as much as was meticulously planned, but in doing so we are occupying abdominal territory. What we are really doing is recovering breast territory that was unduly invaded by the abdomen in the absence of breast development; literally there is no breast below the lower limit of the tuberous or tubular constriction, since the abdomen begins there. The surgeon strives to recover that territory stealing it from the abdomen and recovering it as lower mammary pole cover that is reconstructed with the prosthesis.
It happens that the surgeon wins the battle but not the war; the abdominal skin, which after tuberous or tubular breast deformity surgery covers the lower 30-50% of the implant, becomes part of the mammary territory in practical terms, but not from a biological or genetic point of view. That skin remains an abdominal one, thick and with shape memory, tends to concavity and resists to the protruding convexity of the implant. In other words, the skin intends to return to its place and pushes upward the prosthesis with great force; the larger the territory gained to the abdomen and the harder the abdominal skin the greater the upward implant push and the pressure of the abdominal skin to return all or in part to its original location.
During 4-6 months the abdominal skin applies great pressure on the underlying prosthesis, mobilizing it and making it dislocate upward and even toward other directions, and there is nothing that the surgeon can do to minimize such skin push, in a greater or lesser grade all the cases of tuberous or tubular breast deformity are affected by this cutaneous conflict between the lower pole vs. prosthesis. If implant migration might happen one or more surgeries would be necessary to reposition the prosthesis until taming such rebellious skin.
Nevertheless we can do, and much, to prevent migration of the prosthesis in the tuberous or tubular breasts; using implants with the greatest adherence possible and firmest fixation to tissues. Here is the answer to the question that heads this section; the undisputable #1 implant among all the models available in the market in terms of adherence to tissues and resistance to displacement is the polyurethane-coated implant. As an estimate out of large series of tuberous or tubular breast patients treated and with non homogeneous grades of the deformity, it can be roughly speaking said implants featuring low adherence to tissues (smooth shell) have 50-70% of reoperation due to migration when used in tuberous or tubular breast, medium adherence ones (microtextured shell) have 30-50%, high adherence ones (macrotextured shell) 10-30% and the ultra-adherent polyurethane-coated implants have as low as only 1-10% of migrations by skin push in tuberous or tubular breasts, reason that makes the latter the best performing ones and virtually indispensable within the technical portfolio of the surgeon who handles tuberous or tubular breasts for both their mechanical (adherent rough surface) and biological (the capsular tissue of the patient penetrates the reticulated foam of the polyurethane shell creating a bio-velcro effect) fixation properties.
WHY SUBFASCIAL PLACEMENT PLANE? Because it is less aggressive, in general for any breast augmentation, whether or not in tuberous or tubular breasts. The trend today is to phase out the submuscular techniques, which Dr. Alejandro Nogueira has practiced himself for many years and he has quit also many others ago. The use of muscular techniques is not synonymous of malpractice or proscribed scientifically, much less, as long as they are done properly (partial submuscular or dual plane) are appropriate and very correct, muscle techniques are nowadays simply unnecessary and outdated as a general primary indication for uncomplicated augmentation mammoplasty. Although in Dr. Alejandro Nogueira’s practice and in that of many of his colleagues the subfascial technique has set as dominant choice, remains few exceptions to the norm in which the muscular technique might be appropriate.
The subfascial plane placement offers the following advantages compared to other technical options: faster surgery; lesser surgical aggressiveness; lesser anesthetic drugs interventionism; aspirative postoperative drainage tubes are not necessary; it allows early discharge allowance as day case hospital regime; lower rate of complications (hematomas, infections and others); reduces costs for patients; muscular dynamism or dynamic double-bubble deformity and animation deformity or flex deformity or elevator breast deformity are impossible; much less postoperative pain; much faster postoperative recovery; equal or lower rate of capsular contracture; much more satisfying overall surgical experience for the patient; equal or better aesthetic results if anatomical implants are used; same or longer duration of implants lifetime; same efficiency in early detection of disease in mammary imaging tests; same possibilities of pregnancy and lactation; same evolution of women’s breasts with the passage of time and aging.
WHAT IS DR. ALEJANDRO NOGUEIRA’S 4 FLAPS GLANDULAR PLASTY TECHNIQUE? The technique Dr. Alejandro Nogueira designed is not something really radical or revolutionary new, since it is the personal evolution that he has been developed from some of the technical concepts already existing before, which have been endowed with greater efficiency and improved the aesthetic outcome. Let's do some historical summary.
REDISTRIBUTION TECHNIQUES Treatment of tuberous or tubular breasts in the era before the advent of breast implants was really disappointing, the results were, at best, mediocre and often disastrous. The techniques were intended to replace or reconstruct the lower breast pole, a key element within the treatment of tuberous or tubular breasts. Not being that possible with breast implants the aim was cutting the mammary gland for a better distribution of breast parenchyma or glandular tissue, with the purpose of taking a portion of the central and upper gland to transfer it to the lower pole, so that there were not only tissue within the constriction ring but outside of that limit and more homogeneously distributed.
Ribeiro's technique: Some classic examples of redistribution techniques are those which, after undermining the skin off the lower breast pole, a portion of breast parenchyma or glandular tissue is sectioned all along its axis, and then flipping that glandular flap to insert it in the pole lower, in order to rebuild it and achieve better distributed breast. The oldest developed in the 1960s and the pioneer is Ribeiro’s simple technique, characterized by a direct flow from the body into the periphery and therefore vascularly reliable long glandular flap, but hardly foldable in a high percentage of cases and therefore unfeasible; this technique gained great popularity among surgeons for two decades.
Puckett's technique: Also ancient but more recently developed in the 1990s than the former is Puckett’s technique, which is the one growing in use over the past 20 years although it is more difficult technically; in it the glandular flap is of reverse flow from the periphery to the body which together with the great length of the flap makes little vascularly reliable with high incidence of necrosis, although its advantage is that it is more foldable and can be applied to more cases, although not to all or with the necessary efficacy, allowing better adaptation to breast implants.
These two techniques, equivalent in terms of their surgical concept, have gained great popularity among surgeons and are preferred by many doctors in combination with breast implants, especially Puckett’s since it is better suited to the use of prosthesis, although they are not techniques specifically designed for this purpose or produce as brilliant results as would be desirable. Although sometimes redistribution techniques achieve good tissue distribution and elimination of the conicity, the fundamental limitation of these redistribution techniques is, precisely, that the tuberous or tubular breasts are most commonly characterized by being small, featuring low or very low glandular volume. Needless to say, when there is little to distribute little fullness is accomplished, no matter the strong will that is laid down.
Moreover, not in few cases the tuberous or tubular breast is such rebellious and reinforced glandular structure in concentric spiral that it is impossible to fold as the technique was designed to be turned on itself, technique which becomes simply unfeasible as we meet a reinforced structure breast, something not uncommon; the actual and real tissues in the operating room surgery sometimes are not as manageable as they are painted in medical illustrations.They are neither effective procedures decompressing the lower pole or the upper, making no action on the tuberous or tubular constriction ring. Indirectly they exert a certain relaxing effect for the sake of dividing the entire breast, but do not address in a direct form to the fibrous ring of the tuberous or tubular breast deformity.
Finally and worse, the high number of glandular necrosis as serious complication in those very long and tubular tuberous or tubular breasts, where the irrigation at the end of the flap tailored to fill the lower pole is insufficient, so that it "dies" by devascularization.
Without denying that in some selected cases of medium-large sized and flexible breasts redistribution techniques can achieve a good result, Dr. Alejandro Nogueira does not think are optimal for widespread use with breast implants, for reconstruction of the lower breast pole is performed precisely inserting implants; in fact there are technical descriptions of surgeons who have even used expander prostheses in the lower pole identical to those used in post-mastectomy patients for reconstruction of the former in tuberosities, without redistributing or decompressing the tuberous or tubular breast deformity. While there has been no spread in the international scientific community, the expanders are popular among USA surgeons who treat tuberous or tubular breasts, despite requiring operate at least twice on absolutely all patients, which is today totally unnecessary and in Dr. Alejandro Nogueira’s opinion hardly acceptable.
In other words, redistribution techniques have as its main goal the filling and reconstructing of the lower pole, but with the advent of implants they become meaningless lacking indication.
DECOMPRESSION AND DEMOLITION TECHNIQUES There exists another group of techniques indeed designed for their use in conjunction with breast implants, furthermore, their use is inconceivable without associating underlying prosthesis. They are glandular plasty or modification techniques seeking to eliminate the conicity, release the breast from its constriction, allowing the gland to embrace the breast implant and favor the prosthesis becoming the one to rebuild and fill the lower pole, without redistributing the gland; they simply decompressed the breast inferiorly without redistributing it, although the expansion of the glandular tissue indirectly provides some peripheral fullness, and allow the conicity to "collapse" as would a building losing its support pillars.
Rees and Aston's Technique: The most popular techniques of this group have been designed by means of radial tailoring type like "in umbrella" or "parasol" but applied only or mainly to the lower pole, as the pioneer described by Rees and Aston in the 1970s.
Palacín's technique: In the recent era decade some authors describe interesting horizontal transversal tailoring like Palacín.
These decompression techniques do walk the logical path for their combination with prostheses; the glandular tailoring eliminates the conicity as it decompresses the breast and its constriction ring, and simultaneously performs the demolition of the tuberous or tubular circular pillars of the gland allowing the structure collapse and to behave as would a normal non-tuberous or tubular breast, i.e., adapting without any resistance to the presence of an underlying implant. In not doing so, if the tuberous or tubular breast deformity is not decompressed and demolished, the breast remains in identical shape without undergoing changes by the mere fact that you have inserted an implant behind, creating a grotesque double breast deformity.
Non-tuberous or tubular as correctly treated tuberous or tubular breast should slide and adapt without difficulties on the surface of the inserted breast implant, preventing external deformities and the aforementioned double-bubble, not to be mistaken with the persistence of a remainder of the submammary fold being the skin very thick or having a double cutaneous texture.
As a surgeon Dr. Alejandro Nogueira’s is in favor of this group of decompression and demolition techniques together with the use of implants to rebuild the lower pole, however there are many criticisms that can be made to these procedures based on the limitations that he has found in them: overall they do not effectively treat the upper pole, sometimes not even the central, of the breast, so the glandular and tuberous or tubular constriction ring decompression is not complete, leaving traces of tuberous or tubular breast deformity; some are described as tuberous or tubular breast deformity plasties with little separated many tailorings or radial sections of the gland, leaving devascularized areas and, therefore, often producing areas of necrosis, not massive but very problematic; they are technical or excessively conservative, only glandular sections that merely affect the ring at the base and barely a few glandular millimetres, or too aggressive with multiple massive slices of the gland; sometimes they do not produce glandular expansion in all directions and generally do not favor good skin expansion at the lower pole.
REDISTRIBUTION + DECOMPRESSION AND DEMOLITION TECHNIQUES: There is an excellent decompression technique also adding a significant degree of redistribution, which has served to Dr. Alejandro Nogueira as a basis to develop his own surgical procedure, it is the Mandrekas’ technique of decompression and glandular plasty of the lower pole with 2 flaps, released in 2000s and developed over a decade. Essentially the skin is separated from the gland at the lower pole, to following divide the lower pole breast parenchyma or glandular tissue into two major portions that bisect the breast vertically, forming two large reverse flow independent flaps, while at the same time the tuberous or tubular constriction ring is severed.
While it is a technique of certain vascular risk given the length of the flaps, the reverse flow and the absence of skin inflow, it is a plasty allowing the maximum possible expansion of the lower pole, the decompression of the tuberous or tubular constriction ring and a remarkable tissue contribution to the constricted area which will be supplemented by the additional volume of the breast implant. Despite its effectiveness, reliability and simplicity this is not a technique that has been popular in the community of surgeons, probably because their authors are not Americans or Brazilians. On the negative side Dr. Alejandro Nogueira must say the Mandrekas procedure does not envision treatment of the upper pole or to the laterals of the tuberous or tubular breast deformity.
DR. ALEJANDRO NOGUEIRA’S 4 FLAPS GLANDULAR PLASTY TECHNIQUE Derived from Mandrekas’ glandular bisection technical principle and in order to solve the limitations of other procedures Dr. Alejandro Nogueira has developed a personal technique for the treatment of tuberous or tubular breasts which he has been applying and perfecting for 15 years and publicly describes in this article. It is a procedure that has predominantly decompression and demolition effect of the tuberous or tubular breast deformity, but also at the same time homogeneously redistributes the parenchyma or glandular tissue all over the breast.
It consists always and necessarily of an areolar approach with or without periareolar skin resection to reduce areolar hernia in order to access the peak of the tuberous or tubular breast deformity or apex of the conicity, continuing vertically, without detachment or separation of skin and parenchyma or glandular tissue, towards the depth and from there completely separate whole breast from the pectoralis major muscle, releasing the gland from all anchor that could perpetuate the tuberous or tubular breast deformity, to finally make a glandular plasty in 4 short flaps or portions which resemble 4 petals of a blossom. Tuberous or tubular breast would be a cocoon or closed blossom opening when is tailored down to 4 petals or glandular flaps to embrace the underlying breast implant.
The glandular section is subtotal in those 4 short portions, persisting only 1-2 cm of tissue attached to the skin as blood supply carrier pedicle, without having experienced any tissue necrosis due to ischemia or lack of blood supply up to date and having operated hundreds of cases. Cutting work is made from the above peak to depth or cone base down to cut the constriction tuberous or tubular ring, first by means of a horizontal bisection from 3:00 to 9:00 which also serves as cavity access channel and then a vertical bisection is practiced separately on the lower pole at 6:00 and finally on the upper pole at 12.00.
Thus 4 reverse flow glandular flaps are delimited receiving nourishment from mammary tangential vascularity and not from the perpendicular perforators, with contribution of the cutaneous inflow. These flaps are completely separated from the pectoral muscle and float on the implant allowing the glandular tissue a smooth and natural prosthetic adaptation in a homogeneous way evenly across all breast quadrants.
ADVANTAGES OF DR. ALEJANDRO NOGUEIRA'S TECHNIQUE FOR THE TREATMENT OF THE TUBEROUS OR TUBULAR BREAST Several are the advantages of Dr. Alejandro Nogueira's 4 flaps glandular plasty technique, tested and proven over the years on a huge casuistic and long-term follow ups:
It is a deep glandular tailoring but fewly repeated, only 2 full bisections or what is the same, 4 quadrant bisections, combining a necessary invasiveness and the greatest possible respect towards breast tissue.
Total demolition of the tuberous or tubular cone, which collapses completely making the conicity to disappear.
Total eradication of the tuberous or tubular breast deformity by decompression in all breast quadrants homogeneously.
Complete glandular adaptation to of the presence of breast implant, with smooth transition between the gland and the abdominal territory gained at the lower pole.
Total elimination of the tuberous or tubular constriction allowing lower pole complete expansion as much as the upper one or the lateral breast.
It allows the maximum cutaneous expansion possible in the lower pole as much as the upper one or the lateral breast, since no area persists without severing or decompressing that might impede the skin growth; the 4 flaps are entirely separate from each other and the pectoral muscle; this significantly reduces the risk of upward migration of breast implant.
It produces a remarkable degree of homogeneous redistribution of breast parenchyma or glandular tissue, not just to the lower pole which is massively occupied by the implant, but also in the upper pole and lateral breast, creating an effect of absolutely natural breast without tuberous or tubular breast deformity trace.
Excellent vascularization of the flaps delimited by the glandular tailoring, without necrosis even in medium-large size breasts requiring very long flaps.
Universal technique as it can be applied in all cases of tuberous or tubular breast deformity, including rigid structure breasts, it is not a technique based on glandular portions folding or their mobilization, and small-sized ones; there exists no tuberous or tubular breast in which it cannot be applied.
Technical simplicity accessible to surgeons with different levels of experience and excellence.
Allows breastfeeding in the future and actually many of Dr. Alejandro Nogueira’s tuberous or tubular deformity correction surgery patients have been happy mothers have breastfed their children.
Does not produce any specific interference in breast diseases diagnostic imaging tests.