Category: Breast Revision
If breasts are narrow at the bottom and protruding out like snoopy’s nose they are what is classified as Tuberous breasts. This type of breast shape is reported in 5% of patients but the exact incidence isn’t known. Tubular breast deformity can occur in men and women. Originally classified in three grades of severity a few typical characteristics are present. First like the name states the breast has elongated tubular appearance. Most often this is due to a shortage and tightness to the tissues only the lower half of the breast. This is why tubular breasts are also called “constricted” breast for the tighter lower portion of the breast narrows to the base of the breast. This constriction tends to make for a higher inframammary crease which is where the breast joins the chest wall. Typically the distance from the nipple to the inframammary crease (IMC) is shorter than normal. Also, this constriction of breast tissue leaves a wider than normal spacing between the two breasts. The patients Areola and nipple may look like its being pushed out from the breast and frequently it may a bit large relative to the rest of the breast. Patients with constricted breast deformities may have a lower chance to breast feed than the general population, but this has not been formally studied.
So what can be done to assist the patient in managing the tubular breast? Breast Augmentation with tissue scarring is the mainstay of addressing tubular breast deformity. Tissue “scarring” means the surgeon will make some cuts into the breast tissue to allow it to relax and stretch quicker with the breast augmentation. How much “scarring” depends on the tightness of the native breast.
As mentioned earlier tuberous/tubular breasts can have an enlarged areola that is pushing out from the breast. To create a better contour to the breast a “donut” mastopexy might be needed as well as the breast tissue scarring. A donut mastopexy or some variant means we remove a donut shape of the extra areola skin to make it an appropriate size. Also, releasing the breast from the overlying skin permits I to push the herniating breast/areola tissue back in so it doesn’t look like snoopy’s nose anymore. If the tubular deformity is mild it might be suggested to hold off on the mastopexy to see if after augmentation is even needed. Frequently a donut mastopexy can be done under local anesthesia down the road if needed.
Occasionally a patient might have a severe enough deformity that a tissue expander could be suggested. Tissue expanders allow the surgeon to stretch out your breast tissue over time by adding salt water (saline) solution into a type of breast implant expander made for this purpose. Tissue expanders are commonly used in breast cancer reconstruction. The need for the expander is rare for tuberous breast issues. There are expandable implants that can serve as your expander and a final implant. However in my opinion, in the very rare patient that an expander is utilized the end result is better & the expander is changed out for a more standard implant after the expansion process is finished. We hope this sheds some light on tuberous/tubular breast deformity. Feel free to contact us at 520-575-8400 for an appointment for a personal assessment.
First let’s define what Capsular Contracture (C.C.) is vs. simply a capsule around a breast implant. Anyone who gets a breast implant will form a capsule of natural tissue around that implant. A capsule is your body laying down a thin layer of collagen and cells around the object. Any medical device placed in the body will get this capsule made around it. Pacemakers have capsules, joint replacements have some capsule, and internal insulin pumps have capsules. The formation of thin scar tissue around the scar around the implanted object is pretty normal. So every patient with an implant has a capsule, but most patients don’t have a “Capsular Contracture”(C.C.). The contracture part of the equation is the piece we wish to avoid. Contracture means the capsule is getting stiffer, thicker or hard enough to distort the breast. Years ago Dr. Baker gave a simple grading scale on how to access how firm a capsular contracture (C.C.) was. Baker’s Class goes form I to IV. A Baker’s class I means a soft normal feeling breast without evidence of C.C. A class II looks normal, but on palpitation the surgeon or patient can tell the breast is firmer than normal. Class III typically has more hardening and perhaps some visual distortion of the breast. Baker’s class IV has even more hardening, distortion and possibly even pain in the breast or pain with palpitation. This classification scheme is not very detailed or scientific, but it is a standard way to follow and grade the degree of C.C. a patient has.
So what causes capsular contracture? Why do some people get it and some people don’t. Also why does it happen to one breast and not the other? The reality is we don’t have definitive proof of one single cause, there appears to be several potential culprits leading to capsular contracture. The underlying process that leads to C.C. is anything that increases inflammatory reactions in the breast space around the implant. The likely contributors can be extra blood around the implant at time of surgery, any extra foreign body like surgical glove powder, cellular debris, serum, or bacteria in the space that generate inflammation, but not infection.
As surgeons have become more aware and sophisticated with our performance of breast augmentation the occurrence of C.C. has decreased over the years. First you want your surgeon to be very meticulous about the dissection decreasing the risk of extra blood or serum getting in the space around the implant. If there is extra blood the body has to generate more inflammation to clear it just like absorbing a bruise over time. More inflammation can lead to more capsular reaction and then contracture. Also extra blood or serum can act like culture medium if there are bacteria in the space around the implant. For the last 25 years better studies have been done looking at bacteria as a reason people might get a capsular contracture. Bacteria do live normally on our skin, there are bacteria in the air around us and even the most sterile environment can have a few bacteria hanging around. While a true implant infection is extremely rare in breast augmentation the chance of some bacteria getting on the implant is real. This risk of bacteria getting on an implant is one reason we prefer not to use incision around the areola as much as we used to. Breast tissue and glands have bacteria in them naturally, and there is the hypothetical chance of periareolar incisions causing more chance of bacteria coming in contact with implant. This is not a proven hard scientific fact, but it does make sense.
The position and surface style of an implant also changes the capsular contracture risks. Smooth implants above the muscle (subglandular placement) in most studies have a higher C.C. rate than if the implant was placed under the pectoral muscle (submuscular placement). However a textured (rough surface) implant placed above the muscle doesn’t have as much C.C. risk as the smooth implant. The belief is the textured surface can break up the alignment of scar tissue so it can’t organize in one direction to pull on the surface of the implant. The understanding of this is not precisely understood for both smooth and textured implants under the muscle have fairly low capsular contracture rates. Its implants placed above the muscle that seems to make a bigger difference here. Studies will be going on for many years before we have a better and more complete understanding of capsular contracture and how to prevent it. For now a key way I keep capsular contracture as low as possible is to not open an implant until right before it goes into the patient. The moment we open an implant it is immersed in antibiotic solution to make it hard for a bacteria to even land on the implant. My surgical gloves are changed to new gloves and washed with antibacterial solution. No one but me ever touches the implant to decrease chance of contamination. I irrigate the space for the implant with antibiotic solution also. These and other sterility maneuvers have been documented to have lower C.C. rates with breast augmentation.
Capsular Contracture will continue to be an area of active research and as of yet we don’t have all the answers, but we keep getting the incidence lower and lower so C.C. are much lower than several decades ago. If you wish greater details on this topic give us a call and set up an appointment to fill in any gaps in your understanding of this component of breast surgery.
As Plastic Surgeons we are always looking to refine techniques and find answersto make results better. “Photo Shopping” out minor defects or irregularities in the breast with fat injections is a good example. I wish I could clain the term “Photo Shopping” but I picked that up from collegues using the term over the last few years at meetings. The concept is a simple one really. For many years we just excepted, for example, that mastectomy patients would have to accept ripples or contour irregularities of the breast. Now we can offer fat injections into these defects to smooth out irregularities or “Photo Shop” the breast . You have to love the term it gives a great visual.
Typically I will liposuction some tummy or medial thigh fat from the patient to use for grafting. The fat is cleaned of blood and free oils and injected into the breast where needed. Insurance does not always cover this, but frequently may. These tequniques are not only used for breast reconstruction, but can also be used in cosmetic breast surgery contour problems.
Like all forms of fat injection procedures I can’t guarantee complete fat graft take so we go for a little over correction expecting to loose a hint of the result. As you might expect age, tissue quality and thickness all play into the results. If someone smokes, is diabetic or has significant vascular disease their results are not as reliable as the healthy patient with no medical issues. Still “Photo Shopping” the breast with precision fat graft placement is a nice new procedure to take our breast surgery results to the next level.
Breast Augmentation is one of the most common aesthetic surgeries Plastic Surgeons perform. While breast augmentation is a very safe and reliable proceedure, patients can require revisional surgeries over the many years they have implants. Some revisions may be needed due to aging of the breast tissues, breast feeding, weight changes,rippling, broken implants, capsule formation around the implant, or malposition of the original implant. It has become more frequent to use acellular dermal matrices (ADMs) to correct some of these breast issues. What is an ADM exactly? The tissues that make up skin are very strong and dermis is the main strength component of skin. Some ADMs come from human sources and some are porcine (pig) skin derived. Pig skin is biochemically and structurally very similar to human skin. The cells are all removed from the collagen and other components that make up the dermis. This leaves a sheet that can be placed in the body and used to reinforce weak tissue in the breast. These sheets of dermis can help resolve ripping in the breast, reinforce areas where the weight of an implant over time has stretched out breast tissue, or improve control of implants that might be too medially placed (symmastia).
If a patient has very little native breast tissue and over the years forms a thick capsule around an implant we may need to remove all of that capsular scar tissue which may now leave weakened thin breast tissue that had been a bit stretched by the implants over the years. This patients may benefit from the addition of an ADM to give thicker coverage and better internal support to the implant. Multiple manufactures market ADMs and there is no consensus that one is superior than another. These products come in different thicknesses and sizes also so the surgeon will decide what type or thickness of product they prefer. We continue to look scientifically at these dermal products to see if some hold up better than others and try to balance the benefits against the cost or any down sides to the products.
Of course, the cost of ADMs is a significant concern to our patients so they are not necessarily indicated for all patients. Many revisional breast surgeries, if not most, do not require ADMs to fix the problem. That being said however, if a patient has had a revision failure for the same problem it is more likely that an ADM will be suggested or required to fix the issue. The added expense of the ADM product may be well worth it in those cases. As we refine the science of these products maybe someday we can have a readily available one generated by a 3-dimensional biologic printer for nominal expense to our patients. Now that would be fabulous, let’s hope the future is not to far off. For now we will use the best science we have on hand to assist patients with there breast surgery needs.