Complications were identified in 4 patients: hematoma in 1 patient, which was drained 4 hours after operation; circumareolar scarring in 1 patient; and mild “double-bubble” deformity in 2 patients, who initially had stiff submammary folds. But there was no evidence of capsular contracture, implant displacement, or palpation. These patients underwent surgery to correct minor aesthetic outcomes. Correction of circumareolar scarring using an interlocking suture was performed, and double-bubble deformity was corrected by fat grafting according to the technique of Tonnard et al.11 After correction, aesthetically pleasing results with good sensation were obtained in all 17 patients. Two patients, who delivered after surgery, had no feeding problems.
Morphological studies have shown that vascular bed of glandular flap of the tubular breast has a polymorphous structure and has capillaries, separate arterial and venous vessels of different diameters, and dysplastic vascular formations. Polymorphism of the vascular bed in the tissue of affected quadrants of the breast is expressed by sites of microangiomatosis, local areas of hemorrhagic leakage with a few sinusoidal and dysplastic vessels, and nonvascular areas without any capillaries; such areas with hemorrhagic leakage and individual vessels are clear signs of underdevelopment of the vascular bed, immaturity of capillaries, and congestive processes in those zones. Under surgical stress, these zones can be both the cause of bleeding and source of vascular bed restoration. There are also certain groups of vessels with normal ratio of arteries and veins (1:2), which can provide blood supply to individual lobules of the gland. But studies also revealed in these zones the absence of an important intermediate segment of vascular network, indicating the congenital nature of this pathology.
Locally, arteries and veins of small diameter were observed, which, based on their peculiar structure, ratio of diameters, state of endothelium, and signs of arteriovenous shunts, could be classified as minor malformation (Fig. 5). This indicates the adequate proliferative capacity of blood network to restore and enhance blood supply in areas of trauma, hypoxia, or ischemia. So, even when a large glandular flap is mobilized, the risk of its necrosis is less.
Tubular breast represents a significant psychological problem in women. In general, the pathology becomes apparent in puberty and is characterized by narrow breast base, bulging of mega-areola, asymmetry, etc. Our morphological studies have found signs that confirm the congenital nature of this pathology, and our results are in agreement with those of the previous studies.6,12,13
Since the correction of type II deformity has a large number of problems, it cannot be classified as a reconstructive surgery. In the majority of cases, a satisfactory contouring of tubular breast could be obtained by widening its base, moving the inframammary fold down with creation of a lower pole using tissue or implant, and reshaping the areolar complex.
To create lower pole of the breast, some authors used anatomical implants for extending the base of the tubular breast.14 In our previous studies in patients with augmentation mammoplasty and patients with tubular breast type I, we noted the ability of the highly cohesive shaped implants to expand the skin of lower pole of the breast. So, it was logical to try them in patients with tubular breast type II as well. But it did not work in all cases, especially in patients with a stiff submammary fold. Textured shaped implants in patients with tubular breast type II were associated with increased rates of palpable and visible implant margins and double-bubble deformity. Using an implant is very important for achieving proper contour of the lower pole. Therefore, many methods are suggested to solve this problem. Hence, we used shaped implants in combination with mobilized and scored glandular flaps and achieved favorable results. Although we have used shaped implants in our study, the use of round implants should be considered, and their use needs to be studied further.
For patients who had sufficient volume of their own breast or did not want to increase their breasts’ volume, Ribeiro (1998) proposed to cut the breast horizontally into 2 flaps. The lower flap, bigger than the upper one, was folded down for creating the volume of lower pole.8 The technique provides good aesthetic results, but patients often wish to increase their breast volume.
In small-volume breasts, Puckett and Concannon9 proposed a high prepectoral dissection of the breast, cutting it in the posterior surface into 2 halves. On the one hand, it allows the formation of a glandular flap to cover the lower pole of the implants, but on the other hand, it increases the risk of circulatory disturbances in the flap, followed by its atrophy or scarring in the postoperative period. In such cases, contour irregularities in the lower pole of breast could be observed.
Kolker and Collins6 performed dissection in a perpendicular fashion through lower pole of the gland directly to the prepectoral fascia. Prefascial dissection was then carried out inferiorly to the limit of new inframammary fold, and radial scoring of the inferior dermoglandular flap was performed with electrocautery. From our point of view, this approach increases the risk for possible decrease in blood supply of the inferior dermoglandular flap, scarring, and contour irregularities of the lower pole.
Mandrekas et al10 dissected the breast parenchyma from the deep pectoral fascia, leaving only the superior part of the breast attached. Breast parenchyma was exteriorized through the periareolar opening and was transected with vertical incision along the middle, dividing fibrous ring and creating 2 breast pillars that allow breast parenchyma to redrape implant, but often the flap is too short to cover the lower pole of the implant. Therefore, in the postoperative period, it can be reduced, leading to contour irregularities of the lower pole of the breast.
Our method is different from other methods and has several advantages. It allows mobilization of the extended glandular flap from the central part of the breast by vertical and horizontal incisions to form the flap like a chessboard. This technique does not disturb blood supply to the flap. The entire breast is not damaged as in high prepectoral dissection, making it possible for the women to breastfeed after the surgery.
The method allows full coverage of the implant with the glandular flap without any tension and prevents reduction. Thanks to stitches, new submammary folds can be better accented.
We preferred textured, anatomical, highly cohesive gel implants. In all cases, we fixed them in the subglandular plane. This maneuver provided better aesthetic effects in postoperative periods because the dense skin of lower pole stretches better, and contour of the breast has a natural look.
One of the problems with tubular breast correction in follow-up, according to many authors, is the double-bubble deformity. This occurs because in some cases, the fibrous constricting ring and previous inframammary fold cannot be completely released.
Some authors use lipofilling to correct this complication.15,16 We also noted a beneficial effect of lipofilling in double-bubble correction. We obtained good aesthetic results using method of Tonnard et al.11
Correcting tubular breast type II is a challenge for plastic surgeons. To achieve aesthetically pleasing results, an adequate surgical approach is required. Our technique is simple and easy to perform.
Morphological studies have confirmed that tubular breast tissue has increased vascularity because of the vessels with a characteristic minor malformation and because of the high restorative potential of vascular bed. Therefore, an extended glandular flap could be freely mobilized without damaging its blood supply. In most cases, this allows covering of the implant completely, achieving good aesthetic results.
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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.
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