Challenging Surgery

By: Philip Turton
Created on 05th October 2010

A relatively common condition that no one likes to talk about: tuberous breasts. Leading breast specialist Mr Philip Turton explains how he tackles this demanding but rewarding surgery

Named because the breasts are shaped like tubes, tuberous or tubular breasts is a condition that can make a woman feel self-conscious and insecure about her appearance.

Usually caused by a lack of development in the breast tissue during puberty, it leads to a malformation that can see the breasts grow asymmetrically as well as appear droopy and unusually far apart.

Not all surgeons who perform breast surgery have the expertise to detect or deal with asymmetry or developmental breast problems. It is an area of expertise that comes with caseload, experience, technical skill and a desire to achieve the best for patients.

What exactly are tuberous breasts?

The normal growth of the breast during puberty has been partially incomplete. It is as if one particular part of the breast has just decided not to mature whereas the neighboring part does so as normal.

The result is a distortion of the shape. Some of these can be so marked that the breast looks more like a sausage or the areola develops a puffed-out appearance on a small breast base.

There is no known recognized cause for tuberous breast abnormality but it is very much treatable by the correct specialist. It may occur just in one breast, in both, or to varying degrees in each breast.

The embarrassment to the affected women is of course profound and I have found that I am very often the first person with whom these women have discussed their problem.

Stage one: mild

The more mild form of tuberous breast deformity is often referred to as a grade one constricted breast abnormality. This is apparent when the crease under your breast is notably higher on one side.

In addition, the shape of the fold is more of a diagonal line toward the sternum rather than a sweeping curve.The breast will usually appear to be slightly smaller.

Between one and five per cent of patients requesting breast enlargement surgery will have these subtle differences and simple breast enlargement can cause surprisingly awful results if the wrong technique is used.

This is why patients with any asymmetries should see a surgeon who is a specialist in breast surgery, reconstructive surgery and cosmetic breast surgery who can readily discuss their experience in dealing with these sort of cases.

A typical error is for a patient with a mild constricted breast to be augmented with a tear drop style breast implant, usually with a partially behind the muscle approach. This can readily lead to a marked double-bubble deformity on the under surface of the breast.

If the constriction had been spotted and the correct technique applied this would have been predicted and dealt with. The more minor variants of tuberous breast abnormality can look remarkably normal, but the asymmetry is made more obvious after breast enlargement if it hasn’t been addressed.

In some cases an even more abnormal shape can result with a high riding implant, a double-bubble and obvious discrepancies of nipple position.

Grade two: moderate

The grade two tuberous breast has a more marked abnormal appearance with an obvious size difference to normal, as well as a raised level to the inframammary fold.

There is a wider gap between the breasts as the inner part of the breast extending from the edge of the breast bone to the undersurface of the breast is flattened, having never matured.

There is often a degree of breast elongation, such that the nipple is lower on the more affected side, sometimes causing a ‘beak-like’ appearance of the breast. The areola may be more fleshy and pouting.

Grade three: severe

Grade three is the most severe form. It is very uncommon and most GPs will never see a case. Patients should always see a specialist breast surgeon with extra experience in this area.

The constricted development relates to a much bigger area affecting the under-surface, inner side, and upper part of the breast. This leaves a very narrow base to the breast and as the growth of the breast only occurs from this part it causes a very unsightly protuberance.

This may be short in length with a broadly puffed out areola or long and sausage-like. There is often a degree of droop present.

The surgery

Simple breast augmentation cannot correct tuberous breast abnormality and it needs to be combined with additional steps during the operation. The cost of surgery is higher and may vary from £5,000 to £12,000 depending on what is required.

In addition to placing the appropriate type and shape of implant, the more minor grades of constriction are addressed by releasing the constricted tissue internally using a series of radial cuts placed within the breast tissue. These will not leave any additional scars on the outside and I perform this through a cosmetic breast augmentation incision in the crease.

Where there is an obvious discrepancy of nipple height, a partial mastopexy is required. It is normally possible to use a single additional incision around the areola to achieve this, which produces the most inconspicuous scar possible.

For those grade two to three cases where there is a marked distortion of shape, the correction will require a combination approach, of constriction release, mastopexy, areola reduction, areola resizing, and breast augmentation.

If there is insufficient space for an implant a temporary tissue expander may be required and a second operation would then be needed to swap this for a silicone implant once the tissue has stretched adequately.

Treating tuberous breasts is the most technically challenging area of cosmetic breast surgery and requires considerable expertise in all aspects, from assessment to aesthetics and reconstruction.

It is also one of the most rewarding areas to work in, as the improvement makes such a difference.