CHAPTER 38 – Local Flaps for Tuberous and Asymmetric Breasts

Tuberous breast, tubular breast, snoopy breast, nipple breast, and constricted inferior pole, are all different names describing similar congenital deformities that should be considered as different aspects of the same substantial congenital developmental anomaly; although this is still a debated question. In this chapter I will consider only the ‘heavily hypoplastic tuberous breast.’ This deformity has posed, and continues to pose, many difficulties in trying to surgically correct this malformation. Its solution is considered a real challenge even for the very experienced surgeon. Such a deformity has a significant psychological impact on young patients, due to its odd and unpleasant appearance. Patients are often quite young when they seek surgical treatment and they have great expectations about the outcome. This therefore makes achieving a good solution very challenging for the surgeon. Many surgical techniques have been described to best treat these malformations [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19] and [20] but none of them, in my opinion, seem to be perfectly applicable to each case and to each different morphological anomaly. In trying to deal with this difficult surgical dilemma, I would like to introduce a different surgical approach to the problem. I have developed a new ‘basic idea’ which can be tailored to fit each clinical case. In order to deal with these variable malformations, it is necessary to apply a flexible approach with a technique that can be modified to fit each particular case. The preoperative evaluation should include a thorough examination of the patient in standing position in order to have a precise visualization of the deformity. The chest and breast should be measured. The breast shape should be carefully evaluated by observation, palpation of the breast, and pinching of the skin. This careful examination is necessary to obtain a good ‘manual perception’ of the existing gland and to understand which portion of it must be mobilized and rotated as a flap, in order to redistribute the breast tissue over the breast implant to ensure the best possible result. The principle is to create a glandular flap, properly shaped and then mobilize it from the relative ‘surplus’ area to the more insufficient part of the breast. In other words, this means to reshape the breast mound without discarding gland tissue, changing the deformed breast into a quite ‘normal flat hypoplastic breast.’ The flaps need to be long enough to reach the pectoralis muscles once the fibrotic constriction of the breast base is released. This constriction often needs to be released by radial and transverse incisions from the deep surface as described by Aston and Rees,14 and Maxwell.9