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BACKGROUND Herniated or pseudoherniated nipple-areolar complex (NAC), also called protuberant or "domed nipple," is an entity that can be present both in males and females and represents a therapeutic challenge. It can be an isolated deformity, but in most cases is found within another breast deformity, such as tuberous breast or can appear following pregnancy. Its diagnosis and appropriate treatment become important when patients search for correctional breast surgery. OBJECTIVE To review some common techniques for the treatment of tuberous breasts that address the nipple-areola problem as well, but also to present our experience with some newer and less invasive surgical techniques that could be useful for isolated treatment of herniated or pseudoherniated nipple. METHOD We performed a retrospective study that included all patients operated from December 2013 to December 2018. We reviewed existing techniques which in addition to our personal experience helped us to create an algorithm to assist surgeons in this matter. RESULTS A total of 125 patients with herniated or pseudoherniated NAC were treated. There were 87 women and 38 men. The average age of the patients was 30, 8 ± 8.1 years (ranging from 20 to 63). We analyzed the results of four following techniques: periareolar mastopexy (52 patients), release of fibrous tissue in combination with lipofilling (19 patients), resection of herniated breast tissue (23 patients) or controlled electrocoagulation of relaxed erectile muscle (31 patients). The minimum follow-up for all cases was 4 months. CONCLUSION The achievement of a successful aesthetic result is possible in a single-stage procedure with initial surgery. It depends on careful individual preoperative evaluation of anatomical features and a surgical approach chosen accordingly. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

In the surgical correction of tuberous breast deformity, implants and regional flaps play a prominent role. Lately, fat grafting has been used as an alternative, but there is evidence that patient satisfaction is higher after correction with implants compared with lipofilling. We report a tuberous breasts correction series of ten cases, enrolled between 2015 and 2018. Percutaneous fasciotomies and fat grafting were performed by the Body-Jet technique. Analysis of outcomes was undertaken with BREAST-Q surveys. The breast satisfaction scores increased from 0 to 75 (p < 0.01), the psychological well-being scores from 20 to 70 (p < 0.01) and the sexual well-being scores from 18.5 to 58 (p = 0.02), while the physical well-being scores remained stable (from 68 to 63, p = 0.2). The median outcome satisfaction score was 86. Scores of patient-reported outcomes after lipofilling can reach and even exceed those of patients corrected with implants, at the cost of more interventions. Fat grafting is beginning to establish itself as a true alternative in the treatment of tuberous breast deformity in patients with the appropriate fat deposits. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Tuberous breasts are a congenital anomaly in which the breasts fail to develop normally. This abnormality may include hypoplasia, a tubular appearance, a higher inframammary fold (IMF), and sometimes a herniated nipple-areolar complex. Correction of tuberous breast deformity (TBD) is traditionally done with a 1-stage breast augmentation with radial scoring of the constricted breast tissue and/or the lowering of the IMF. An alternative 2-stage approach first uses a tissue expander to correct the deformity; the expander is later replaced with a permanent breast implant. Sixteen patients are presented in which a 1-stage correction of TBD was successfully accomplished with saline implants acting as tissue expanders. In all cases, the expansion remedied the deformity without the need for radial scoring of the breast tissue or lowering of the IMF. This approach has not been reported in the literature. Sixteen women (32 breasts) were treated, with TBD ranging from mild to severe. All patients had a breast augmentation with round, smooth saline implants placed through an IMF incision in the dual plane (partially subpectoral and partially submammary). Implants ranged in size from 225 cc to 675 cc. The IMF was never lowered and the breast parenchyma was never radially scored. Three patients had asymmetry requiring breast implants of different sizes, and one had a circumareolar mastopexy to repair a herniated areolar complex. Representative case examples are provided. The average follow-up time was 9 months. All deformities were corrected, and the patients expressed satisfaction with their results. There were no occurrences of hematoma, infection, capsular contracture, or malposition. This review has shown that saline breast implants alone, with their inherent expansion capability, can correct TBD without the increased morbidity associated with radial scoring and lowering the IMF. For patients who choose saline implants, this single-stage, less invasive surgical approach can provide a good aesthetic result.

Background: Periareolar augmentation mastopexy is one of the most demanded operations at Plastic Surgery clinics. Nevertheless, it is one of the leads of malpractice claims in United States caused by the high patient expectations and the standard surgical techniques which may result in common complications. The aim of this report is to present a new surgical approach to solve these complications. Methods: After establishing a working hypothesis, we performed a revision study of our patients and we came to the following conclusion: in order to perform a periareolar mastopexy for ptosis correction, breast has to be tuberous at any level and to have abnormally short inferior pole. These findings may explain the main complications from periareolar augmentation mastopexy with the standard surgical techniques. Consequently, we started a prospective observational study including 56 patients following a new surgical technique which deals the cases as tuberous breasts. Results: During three years, fifty-six periareolar mastopexies were performed with this new surgical approach with one year follow-up. No major complications were observed and 40 of the patients (71%) described the results as very positive. Conclusion: “If a periareolar mastopexy can be performed, then it must be a tuberous breast”. According to this, a new surgical technique for periareolar augmentation mastopexy has been developed obtaining an improvement in our surgical results and achieving a totally different view on this pathology, which has not been reported in literature yet.

Las mamas tuberosas, denominadas así por Rees y Aston, y también llamadas hernias del complejo areolar (Bass), Snoopy deformity (Gruber), mamas tubulares (Williams), hipoplasia del polo inferior (Brink) o mamas de base estrecha (Puckett), son una malformacion en el desarrollo del volumen mamario en los cuadrantes inferiores con hernia areolar secundaria (placa areolar y músculo mamilar débiles), areola ancha y protruida (en la mitad de los casos), ascenso del surco submamario, mamas hipotróficas y raramente hipertróficas, con asimetrías en las dos terceras partes de las pacientes. Presentamos la estrategia quirúrgica adecuada para resolver esta patología utilizando solo implantes anatómicos de gel cohesivo sin necesidad de tallar colgajos glandulares. De esta manera, disminuimos la morbilidad quirúrgica, ofreciendo resultados estables y con alta satisfaccion por parte de las pacientes.

Introduction: Tuberous breast is a rare malformation that has negative physical and psychological impacts during puberty. A range of surgical techniques has been used to correct breast shape and volume in this context, including a combination of skin plasty and mammary gland remodeling, as well as prostheses and locoregional flaps. The authors have used fat grafting as a complementary technique to correct tuberous breasts since 1998. Objectives: The authors discuss application of their lipomodeling technique for correction of tuberous breast deformity. Methods: The charts of tuberous breast patients treated consecutively over an 11-year period (n = 31) solely with fat grafting (ie, without using an implant) were retrospectively reviewed. Each breast deformation was graded according to the Grolleau classification. The number of sessions and the mean transfer of fat volume by lipomodeling session were recorded. Patient and surgeon satisfaction were evaluated. Results: Of the 31 patients in this series, 18 had bilateral formations and 13 had unilateral malformations. The mean patient age was 23 years, and the mean body mass index was 21.9. A single session (mean transfer volume, 158 mL; range, 90–253 mL) was required in 14 (45%) cases. A second session (mean transfer volume, 226 mL; range, 100–316 mL) was necessary in the remaining 55% of cases. Mean follow-up period after the last fat transfer session was 6.5 years (range, 1.5–11 years). Patients were very satisfied in 94% of cases (n = 29) and satisfied in 6% (n = 2). The surgical team rated 94% of cases as being successful or very successful. No complications were observed. One patient developed hypertrophy of the treated breast following weight gain and thus required breast reduction. Imaging performed preoperatively and 1 year postoperatively did not reveal any anomalies other than oil cysts. Conclusion: Fat grafting is a reliable technique that produces excellent results and high levels of patient satisfaction for the treatment of tuberous breast. The aesthetic outcome is natural, implant free, and long lasting. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Treatment of tuberous breasts types 1 and 2 must deal with the problem of the pseudo-double bubble in the primitive inframammary fold and also must release the constrictive ring. Two techniques currently are used to overcome these problems, but neither is entirely satisfactory. The first technique, in which the approach is via the primitive inframammary fold, leaves significant scarring when the lower poles expand. The second technique, in which the approach is periareolar, considerably reduces the area's sensitivity. This report presents a new endoscopically assisted technique with an axillary approach designed to solve these problems.Between 2005 and 2010, 68 patients (ages 18-42 years) underwent surgery. The intervention was bilateral in 57 and unilateral in 11 of these patients. All cases involved tuberous breasts types 1 and 2 (Grolleau's classification). The augmentation involves a transaxillary subfascial endoscopic approach, opening of the fascia at the primitive inframammary fold, and releasing of the constricting ring to enable the breast to expand, followed by implantation of an anatomic prosthesis to add volume to the lower quadrants. If the pseudo-double bubble appears, fat grafting is applied during the same surgical procedure.The results were reported to be highly satisfactory both by the patients and by the independent medical team. For six patients (8.82 %), fat grafting had to be repeated in the double bubble. No major complications were reported.The endoscopically assisted subfascial breast augmentation technique obtains highly satisfactory results in tuberous breasts types 1 and 2 (Grolleau's classification). The single scar is concealed in the axillary fold.This journal requires that authors assign a level of evidence to each article.

Developmental breast asymmetry (DBA) can affect psychosocial well-being in the young female. Correction of breast asymmetry may present a reconstructive challenge, especially in tuberous breasts. Fifty-two cases of DBA treated between January 2002 and January 2006 were reviewed. Preoperative clinical assessment of the specific anatomical deformity, subsequent surgical treatment modalities, esthetic outcome, and patient's satisfaction were evaluated. Surgical modalities used in our series include augmentation mammaplasty with or without tissue expansion, parenchymal scoring, nipple areola complex reduction, glanduloplasty techniques, mastopexy and reduction mammaplasty. The mean age of DBA presentation was 21 years; 69% (36/52) patients had tuberous breasts, of which 67% (24/36) were unilateral and 33% (12/36) were bilateral deformities. Patients with tuberous breast deformity presented consistently under the age of 25 years. Esthetic outcome was rated "good" in 75% (39/52), and symmetry rated as "good" in 58% (30/52) by professional evaluation. Surgical treatment is tailored to the affected esthetic units of the individual breast. In our experience, symmetry is the hardest parameter to achieve, particularly in tuberous breasts. Operative treatment is of great value to the psychosocial well-being of the patient. A conceptual approach in the assessment and treatment of DBA is emphasized by this series.

Background/Aim. There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. Methods. We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). Results. During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, 'pubertal' (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, 'pubertal' asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achieve satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. Conclusion. Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

Breast reshaping surgery for tuberous breast, breast reduction, and mastopexy procedures aim to keep the gained shape for a long time. In breast reduction, the surgeon must avoid loss of fullness in the upper pole, descent of the breast mass known as secondary dropout, and relapsed shape of the repaired tuberous breasts. As described in their clinical report, the authors use a caudally based thoracic wall flap to avoid these problems. The blood supply to the breast comes from two main sources: the mammary internal and lateral arteries. Because of vessels constantly perforating the pectoralis major muscle, it is possible to isolate a caudally based thoracic wall flap. These vessels originate from intercostal arteries as anteromedial intercostal perforators, and from the thoracoacromial artery as in the skin paddle of the pectoralis major muscle flap. This flap is long enough to reach every part of the breast where it is needed. Between January 2002 and June 2005, 64 patients underwent procedures in which the caudally based thoracic wall flap was used.

Since the original descriptions by Gonzales-Ulloa in 1960 and Regnault in 1966, breast augmentation in combination with mastopexy has remained a difficult, and often polarizing, topic in plastic surgery, not only because of its results but also because of its litany of potential complications. Over the past few years, there has been an increase in the discussion of one-stage augmentation combined with mastopexy throughout the literature. However, a critical analysis of the aesthetic results, as well as patient satisfaction with the procedure, continues to be absent. Because there have not been any reported studies on the aesthetic results or patient satisfaction with augmentation and mastopexy, we undertook this retrospective review in an attempt answer a fundamental question: is one-stage breast augmentation combined with mastopexy aesthetically and functionally worthwhile for both the physician and patient? All 34 patients reviewed for this retrospective study underwent bilateral, one-stage breast augmentation and mastopexy between April 1996 and December 2002. Patient charts were reviewed for a number of parameters including previous breast surgery, degree of preoperative ptosis, type of mastopexy used, size and type of implants placed, implant position, postoperative complications, and any revision surgeries performed. Patient photographs were evaluated by observers blinded to the study, and patients were asked to complete a satisfaction questionnaire. Ptosis was graded according to the Regnault classification. As a result, 14 women had grade 1 ptosis (41%), fourteen had grade 2 ptosis (41%), one had grade 3 ptosis (3%), two had pseudoptosis (6%), and two had tuberous breasts (6%). The grade of ptosis in one patient was not defined. The patient complication rate was 8.8% (3 patients). For the aesthetic rating scale, preoperative and postoperative photographs taken after more than 1 year were evaluated. On the scale of 1 (poor) to 4 (excellent), overall ptosis correction was rated as 3.4, asymmetry correction as 3.4, postoperative breast symmetry as 3.2, scar quality as 3.3, breast shape as 3.1, nipple/areola size as 2.9, and overall result as 3. Only 13 of the 34 patients were available for completion of the satisfaction survey. Evaluation of the 13 patient satisfaction surveys showed that, on the average, the patients were satisfied with the various aspects of their surgery. The average overall result and surgical goals both were 3.1. However, 54% of the patients (n = 7) desired revision surgery for various reasons, the most common being a desire for more breast lift. A review of the patients and results, brought a number of issues to light. First, aesthetic results for augmentation and mastopexy truly depend on a number of different factors that must work in harmony to yield an excellent result. Second, what is aesthetically pleasing to the surgeon may not be pleasing to the patient, and vice versa. Third, although the patient aesthetic results were good, they were not consistently rated as excellent, nor were the patients totally satisfied with their outcomes. This perhaps reflects the more complex nature of both the patient's problems and the surgical procedure itself. Finally, although the overall results of one-stage breast augmentation and mastopexy are good, and the patients generally are satisfied, this study raises the question whether staging the surgery by performing the mastopexy first may not yield significantly better results than the combined simultaneous procedure.

The authors make a historical summary of the pathologic condition of tuberous breast and describe a new procedure for its correction. The method involves a periareolar approach, dividing the breast in two portions to disrupt the constricting ring, and making an inferiorly based flap or pedicle, as described and used by the senior author since 1969, with publication in 1973. The main goal is to correct the deformity at a one-stage operation, resulting in a periareolar scar only, without the use of alloplastic elements such as prostheses, mesh, or tissue expanders. The authors emphasize that Brazilian patients prefer having small breasts rather than large ones, even though the procedure allows the implantation of pre- or retromuscular implants through the periareolar incision.

A corrective surgical technique is described for a newly defined deformity: hypoplasia of the lower medial quadrant of the breast. It involves reducing the usually enlarged nipple-areola complex and reshaping the breast by turning a glandular pedicled flap from the fairly large upper two quadrants on a medial base into the underdeveloped site of the medial lower quadrant. The method proved uniformly successful in 11 cases and 17 breasts involved.

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue "herniation" is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recommend use of the combination expander/implant.

The tuberous breast deformity is a rare entity affecting young women bilaterally or unilaterally. The deformity is characterized by a constricting ring at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast parenchyma toward the nipple-areola complex and areola enlargement. Several methods have been put forward to correct the deformity, but most of these fail to address the issue of the constricting ring and subsequently yield results that are not aesthetically satisfactory. A new approach to the treatment of the deformity is presented, which consists of a periareolar approach and rearrangement of the inferior part of the breast parenchyma by division of the constricting ring, thus creating two breast pillars. These pillars are allowed to redrape, and in cases of volume deficiency, a silicone breast implant is placed in a subglandular pocket. The procedure is completed by a donut-type excision to address the size of the nipple-areola complex. The technique has used on 11 patients (21 breasts) with excellent aesthetic results.

We read with great interest the article published by Cannistra et al. [1] about gynecomastia with severe ptosis and its treatment. We would like to point out that some forms of gynecomastia do not match properly the existing classifications [2–4]. Tuberous breast deformity can be associated with gynecomastia, with the same features as the corresponding condition in females. We suggest considering this a separate entity in male patients and we propose a specific surgical procedure. From January 2005 to January 2008 we treated six patients with gynecomastia and tuberous breasts using our technique. We combined traditional liposuction by the tumescent technique, standard maneuvers to reduce skin and gland excess, and gland redraping. About 50 ml of saline solution and 10 ml mepivacaine 2% with epinephrine 1:100,000 was injected via a 2-mm incision in the inferoexternal quadrant. Liposuction using a 2-mm blunt cannula was performed beneath the entire mammary region. A concentric circle entirely around the areola was deepithelized. A semicircular, infra-areolar incision of the dermis was made, leaving a superior dermal pedicle to the nipple-areola complex. A cone-shaped mass of breast tissue beneath the areola was resected. As with female tuberous breasts, the constricted base was released with electrocautery and radial incisions of the residual breast fibrous tissue beneath the areola were made. After hemostasis, a suction drain was placed laterally. An intradermal purse-string peripheral suture allowed areolar repositioning. Compressive elastic dressing was used to prevent seroma or hematoma. Elastic garments were kept on for 2 weeks postoperatively. At 1-year follow-up the cosmetic appearance was excellent in all patients (Fig. 1). Appropriate diagnosis is essential for treatment. Our studies on tuberous breasts in female patients suggest that

A surgical method for treatment of the extremely hypoplastic tuberous breast is described. It is based on turning differently shaped glandular flaps to correct the deformity, followed by insertion of a prosthesis, and, where necessary, correction of areola size and position and adjustment of the skin of the inferior pole. The results so far have afforded total and recurrence-free aesthetic correction of the usual deformities. The underlying aim of the operation is to transform a hypoplastic tuberous breast into a simple hypoplasia without discarding gland tissue which can be used to thicken the most deficient mammary area.

Routine subpectoral or subglandular mammary augmentation in women with a small breast (particularly lower pole deficiency) often results in poor late results with the appearance of a double-bubble deformity. We describe our experience with a technique of unfurling the breast tissue at augmentation in an effort to avoid this complication and improve the long-term results.

Two-stage correction of tuberous breasts is illustrated and probably indicated to attain a more aesthetically pleasing result in this unusual deformity. Routine augmentation mammaplasty corrects the base defects of vertical and horizontal contraction treating an appropriately placed breast mound. However, ptosis of the nipple-areola complex becomes obvious, and correction with creation of a new skin brassiere is necessary. Merely telescoping the breast tissue into the nipple-areola complex has not always produced a satisfactory long-lasting result. Subsequently, a true ptosis procedure on that breast deformity after augmentation mammaplasty has yielded the most aesthetically pleasing long-term results.