Comment to: Tuberous Breasts Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation

Dear Editors, We read with great interest the article titled “Tuberous Breast Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation.” By Ioppolo et al. 1 We congratulate with the Authors for the presentation of a very interesting case of asymmetric Tuberous Breast (TB) with chest wall deformity, treated using a hybrid technique, but we have some elements to discuss. Tuberous breast deformity is a congenital malformation appearing during puberty, uni-or-bilaterally, with a wide spectrum of anatomical presentations. The deformity is widely variable among the affected patients, showing very different clinical appearances but despite this, wider intermammary space, breast base constriction, cranialization of the inframammary fold (IMF) and areola’s disorders are always present as common hallmarks. TB may also appear in male patients affected from gynecomastia.2-3 Furthermore, asymmetry may also be observed. Tuberous Breast disorder represents a real challenge, in particular in the presence of breast asymmetries and chest wall deformity. The simple introduction of a prosthesis does not allow a satisfactory outcome in volume correction of TB hypoplasia since the fibrous constriction at the mammary base does not consent to the parenchyma, confined above the native sulcus, to slide down to cover the distal edge of the outer surface of the breast implant. The difference in thickness of the tissue overlying the breast implant will create a coverage discontinuity between above and below the native sulcus, producing a double bubble deformity. Several surgical techniques have been previously described in the literature to address this congenital malformation performed in one or multiple surgical steps. Although the difference between anatomical versus round implant is particularly evident in the presence of large breast prosthesis, whose employ could be difficult in TB correction, round shape implants could benefit from sub muscular placement of the upper edge of prosthesis in order to obtain more optimal result. In fact, in the presence of soft gel silicone, the muscular resistance of the cranial part of the device displaces the gel downward, in the lower part of prosthesis producing a natural result, very similar to anatomical devices. Moreover, sub-muscular location of the implant reduces the incidence of capsular contraction and guarantees a more valid coverage of the implant rather than the gland, which became atrophic both for the presence of the breast implant itself and for the natural aging process. 4-8 Although the presence of chest deformity or muscular disorder, sub fascial or sub glandular implant could be the suitable solution, the final outcome could be benefit from anatomical rather than round shape prosthesis. Moreover, the supra muscular location of anatomical devices, strongly reduce the risk of implant rotation, allowing a better projection of the lower mammary pole. 9-10 To ensure more stable long lasting result, in the presence of sensitive asymmetry, volume assessment through a reduction of the bigger breast could be useful to reduce less different implants.11 Did the Authors consider this issue?