Dr. Linder's Blog
I evaluated a female patient who expressed that she wanted to lift the shape of the breast as well as increase the volume. During her examination, we discussed her slight tubular deformity and grade 3 ptosis. Grade 3 ptosis is where the nipples lie below the inframammary fold and point downward (see the pre-op photo to the left). After setting her expectation, we scheduled her breast augmentation. During her surgery, we placed 350 cc high-profile saline breast implants under the pectoral muscle.
The post-op photo to the far right is 4 weeks out, and she is extremely happy with the shape and fullness of her breasts.
This patient presents with severe congenital breast asymmetry. Preoperative photograph shows right breast is a 36DD, left breast 36C. Patient desired implants for reconstruction purposes as well as a breast reduction lift on the right. She is one-week postop. Notice the symmetry of the nipple areolar complex. There is some upper pole fullness to the right breast which should come down over the next 5 to 6 weeks. Severe breast asymmetry such as the following is most easily correctable with high profile saline implants in which 250 cc placed on the right and a 420 on the left. The right formal mastopexy using the inferior pedicle Wise-pattern technique was necessary in order to bring the nipple up to the even position. Notice the inframammary folds are now even as well. The patient will have sutures removed in 10 days and will continue with dry dressing changes twice a day for the next 10 days.
Severe congenital breast asymmetry comes in many forms. This is an excellent example of a left tubular breast with a right severe grade 3 ptotic hypertrophic breast requiring different size volume implants with a full breast lift on the right.
The patient presents with severe tubular breast deformity. Notice her preoperative photographs showing conical appearance to the breast, poorly defined inframammary folds, flattening to the bottom of her breast (left greater than right) and pseudo-herniation of the nipple areolar complex. The patient is an exceptionally good candidate for tubular breast augmentation/reconstruction with high profile saline implants placed in the dual plane technique with radial striation of the lower poles of her breast.
The second photograph shows the markings that have been placed with 490 cc of high profile saline on the right and 505 cc on the left to regain symmetry. She had partial resection of the retroareolar tissue with dual plane augmentation mammoplasty procedure as well as formal radial striation of the breast without any form of breast lift. Her postoperative photograph shows a one-year postoperative result. She has good symmetry, softening of the breast, excellent cleavage, inframammary folds are quite even and the nipple areolar complexes are quite symmetric. Patient is extremely happy with the results of her tubular breast reconstruction.
Patients present to my practice with tubular breasts weekly. I enjoy fixing this difficult problem, as only Board Certified Plastic and Reconstructive Surgeons specializing in breast augmentation and revisions should.
TUBULAR BREAST DEFORMITY
BREAST ASYMMETRY – SEVERE
The below case is a patient who is 20 years old, presenting with severe tubular breast deformity on the left with severe breast asymmetry and right breast ptosis. To reconstruct this young lady’s breasts in order to create a normal appearance, requires both different volume implants as well as a formal mastopexy on the right as well as release of the tubular breast deformity on the left. This patient underwent augmentation mammoplasty procedure with 160 cc high profile saline implant placement on the right and 280 cc high profile saline implant placed on the left. An inframammary release of the pectoralis major fascia was performed on the left in order to reduce the tubular breast appearance. She also underwent formal mastopexy using the inferior pedicle Wise-pattern technique on the right to recreate a symmetric nipple areolar position and reduce the grade 3 ptosis.
The patient is now at three weeks postop, sutures have been removed today, the nipple areolar complex positions are even and the size is quite good. The inframammary folds are even and the swelling is reduced greatly.
Only Board Certified Plastic and Reconstructive Surgeons should be performing these very difficult operations of tubular breast deformity with conical shaped breasts as well as breast asymmetry and ptosis.
Patients present to us with severe congenital breast deformities. The next example shows a patient with severe breast asymmetry, and tubular breast deformity. Notice on the right breast there is minimal breast tissue with pseudo-herniation of the breast tissue into the nipple areolar complex, no inframammary fold and blunting along the lower pole of her breast. The left breast has a conical tubular-like shape and is significantly larger in size. In order to recreate normalcy to her breasts, two different size implants will be used in the dual plane (two-thirds under the muscle, one-third over the muscle) and tissue will be removed under the nipple areolar complex along the periareolar incision in order to smooth out the nipple areolar complex. Postoperatively, the patient required six weeks of upper pole compression band in order to allow for inferior displacement of the implants and elevation of the nipple areolar complex as well as to maintain a rounding out shape along the lower pole of the breast. Her after photos show good symmetry with smoothing out of the nipple areolar complex, reduction of the conical and protuberant shape of the breasts and a well-defined inframammary fold along the right breast.
Operations for tubular breast deformity with breast asymmetry are tricky, requiring a skilled, experienced, Board Certified Plastic Surgeon. Although these are challenging cases, they are exceptionally rewarding when the results can improve the self-esteem of a woman for the rest of her life.
Patients who present with tubular breast deformity are often very unhappy, not with just the size of their breasts, but actually with the shape. The components of a tubular breast deformity include No.1, a poorly defined inframammary fold. In other words, there is no fold along the bottom of the breast or it is not defined well. No. 2, is a flattening or blunting of the lower pole of the breast in which there is no round shape to the lower breast causing a conical or tubular shape, almost a triangular shape, on an oblique or side view. Finally, there is also a pseudo-herniation of breast tissue into the nipple areolar complex. This means that the glandular thick or fatty tissue actually pushes the nipple areolar complex out performing a protrusion that does not look pleasing to the patients.
It is highly recommended that these patients undergo augmentation mammoplasty procedure either through saline or silicone implants under the muscle with the dual plane technique if it’s a minimal tubular breast. If it’s an endomorphic thick barrel chest, then we often place the implants above the muscle or subglandular or retromammary plane. We also release along the inframammary fold in a radial striated fashion in order to round out the lower pole of the breast. We see patients with tubular breast deformity each and every week, if not several a week, who are really distraught and frustrated with not only the size of the breast, again with a conical tubular shape of the breast, which can be corrected. Now postsurgically, it is very important that patients maintain a sports bra, athletic bra for approximately six weeks. They can be fitted into the new Dr. Linder Bra which allows for support, but will not allow the inframammary fold to end up too high. We also have an upper pole compression band that pushes down on the implants and the muscle and it relaxes the implant and displaces it inferiorly so that 1) it allows rounding out of the lower portion of the breast pocket; and 2) it does not allow the implants to settle into a too superior position. In other words, the implants don’t end up too high. So, it is apparent that tubular breast deformities are significant in the population and at least two to three percent of my patients for breast augmentation will present with this. We can correct this in a useful manner that is predictable as long as the implants are placed correctly, the fold is released, there is release along the lower pole of the breast fascia and a band is used for a significant period of time in order to maintain the lowering of the position of the implants.
Stuart. A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.
Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery (ABPS).