Tuberous breast correction

A tuberous breast is a structural difference that arises while the breast is developing. It is not a single appearance but a spectrum made up of varying combinations of separate findings. This article covers which findings make up a tuberous breast, what the examination looks at, how correction is planned, which risks are involved, what carrying an implant involves and what is known about breastfeeding.

What is a tuberous breast?

A tuberous breast is not a disease but a difference in how the breast has developed. It is counted among the congenital breast differences and usually becomes apparent in adolescence.¹

The findings gathered under this heading are:¹

• Narrowing in one or more parts of the base of the breast
• Underdevelopment of the breast tissue
• The fold beneath the breast sitting higher than it should
• Widening of the areola
• Breast tissue bulging into the areola (herniation)
• A difference between the two breasts

The essential point is this: one person may have only one of these findings, several of them, or all of them, in one breast or in both.¹ Another review that examined the degree of the deformity adds ptosis and skin deficiency to the picture.²

A tuberous breast is therefore not the same thing as a "small breast" or a "drooping breast". Breast volume may be low, it may be normal, and it may even be large. Mild forms have also been described in which only the areola bulges and the base of the breast remains of normal width.¹

What the operation is not matters as well. Correcting a tuberous breast is not simply an operation that adds volume. Releasing the narrowing, widening the lower pole and correcting the bulge at the areola are the essential parts of the work. Placing an implant while disregarding the narrowing can leave a persistent second fold line in the lower pole, the double-bubble appearance.¹

Why does it develop?

Breast tissue sits inside a covering of fascia. In a tuberous breast the superficial layer of that covering has been described as thickened, forming a tighter ring particularly in the lower part of the breast. Examination of samples taken from within and around this ring has shown increased collagen and elastic fibres.¹

The explanation attached to this structure is as follows. In adolescence the breast tissue finds no room to expand outwards and so grows in the direction of least resistance, that is, towards the areola. The result is a breast that is cylindrical rather than conical.¹

The explanation makes the findings easier to understand. Why the ring forms, however, has not been established. Nor is it known how common a tuberous breast is in the population; published rates lie far apart from one another.¹

Who does it suit?

People usually present after adolescence. In a systematic review pooling 897 patients from 38 studies, the mean age was 24 and the range 13 to 53.³

Timing is not set by chronological age alone. The opinion of the American College of Obstetricians and Gynecologists (ACOG) on breast surgery in adolescents asks that physical maturity and emotional readiness be assessed together and that the individual be screened for body dysmorphic disorder, with referral to a mental health professional where it is suspected.⁴ To this are added the stabilising of breast development and volume, the decision resting on the person's own wish, and expectations being realistic.

In some situations the operation may be delayed, or the underlying problem should be treated first:

• Breast development not yet complete
• Pregnancy and breastfeeding
• An active infection anywhere in the body
• A finding in the breast tissue that has not been assessed or fully treated
• Smoking. The interval needed for stopping is set out below

The condition may not be limited to appearance. An article reviewing the benefits of aesthetic breast surgery reports that correcting a tuberous breast has a positive effect on body image and psychological well-being.⁵ That is a narrative review; it rests on summarising published work rather than on comparative measurement. So the burden a marked difference can place on a person is not dismissed, but the benefit of early surgery cannot be presented as a proven outcome.

Where an implant is to be used there is one further criterion. The person is expected to know from the outset that they will attend regular follow-up and that a corrective operation may be needed later.

What does the examination look at?

The examination begins with expectations. What the person wants, how long they have wanted it and what has been considered before are all asked about.

Measurement and assessment follow. Each of these headings is looked at separately:

• The width of the base of the breast and which part the narrowing affects
• The capacity of the lower pole to expand
• The position of the fold beneath the breast and the difference between the two sides
• Breast volume
• The thickness of the breast tissue and how much soft tissue is available to cover an implant
• The amount of skin and how tight it is
• Whether there is ptosis
• The diameter of the areola
• The degree of bulging at the areola
• The position of the nipple
• The shape of the chest wall and any curvature of the spine
• Which of these headings the difference between the two breasts falls under

This distinction matters, because the two breasts being affected to different degrees is common and each breast is planned separately according to its own findings.

Smoking, diabetes, blood pressure, current medication and previous operations are asked about. Breast imaging may be requested depending on your age and history. If you are planning a pregnancy or breastfeeding, that needs to be said.

What are the classifications for?

More than one classification has been described for the tuberous breast. The most widely used is the Grolleau classification, which has three tiers: in type 1 the lower inner quadrant is affected, in type 2 both lower quadrants, and in type 3 all four quadrants of the breast. A type 0 was later added for the mild form in which the base of the breast is of normal width and only the areola bulges.¹

These systems establish a common language, but they do not determine treatment on their own. In the same review, of 27 studies screened, 14 used the Grolleau classification, 4 the Von Heimburg classification and 3 the version with type 0 added, while 3 devised their own system and 3 followed no classification at all.¹ Different studies using different systems makes the reported rates difficult to compare directly.

Planning is therefore built not on a type number but on which findings that person actually has. That no consensus exists on the optimal technique is the shared conclusion of the reviews in this field.¹²

How is the operation planned?

Planning is not the selection of a single technique. It is the answering of several separate questions according to which findings are present: how the narrowing will be released, where the fold beneath the breast will sit, whether the areola and any ptosis will be addressed, whether volume will be added and where the incision will be made. To these are added the person's preferences about scars, implants, fat transfer and staged treatment, along with the surgeon's experience.

How are the narrow base and lower pole widened?

The tight ring of tissue that creates the narrowing is released by scoring or cutting it. This is called glandular scoring and can be done through the edge of the areola or with a cannula or needle passed beneath the skin.¹

How extensive the work needs to be varies with the degree of narrowing. In mild cases, separating the breast tissue from the skin above and the muscle beneath has been found sufficient on its own.¹ In more marked cases, raising a flap from the breast tissue itself and folding it to fill the lower pole, or redistributing the tissue, has been described.¹

So extensive release is not needed in every patient. The options range from limited release to redistribution of the tissue, and how much is done can also change during the operation according to how the tissue behaves.

Where does the fold beneath the breast sit?

The fold sitting high is a consequence of the narrowing at the base. Where the fold is to be brought down, dissection proceeds towards the new level and the ring is released in the lower pole, where the narrowing is most marked.¹

The position of the new fold is not chosen arbitrarily. In one-sided cases it is set against the opposite breast, and in two-sided cases the rib line is taken as the landmark.¹ To this are added the shape of the chest wall and the planned height of the lower pole.

This step carries risk in both directions. If the old fold is not released sufficiently, a second line appears in the lower pole, the double-bubble appearance.¹ Placing the fold lower than necessary, or supporting it insufficiently, can contribute to the implant sliding downwards and to asymmetry in the lower pole.

The fold does not need to be brought down in every patient. In some cases widening the lower pole shifts its position on its own.¹

How are the areola and ptosis addressed?

A widened areola and breast tissue bulging into the areola are separate findings. Either can be present without the other.

The diameter of the areola is reduced by lifting the upper layer of skin in a ring around it and closing the remaining opening by gathering it. The bulging is dealt with by rearranging the breast tissue and, where necessary, removing part of it.¹ In most mild cases there is no bulging towards the areola and the priority is keeping the scar small.¹

Where there is ptosis, excess skin or a large breast volume, a breast lift may be added to the shape correction. In a series of 26 patients covering 51 breasts, a lift around the areola was reported in 49 breasts and a vertical lift in 4; these are not two mutually exclusive groups.⁶ Where volume is large, shape correction together with breast reduction may also be considered.

Working around the areola has its own gains and limits. The scar stays at the colour border of the areola, the diameter of the areola can be reduced and the bulging can be corrected through the same incision. Against this, the scar can widen over time, the areola can widen again, the shape of the areola can distort or flatten, and scar problems can arise from the tension around the circumference. These headings may call for a corrective operation.

Adding volume with an implant

An implant is not a compulsory or default treatment. Rearranging the breast tissue may not be sufficient on its own; where there is marked tissue deficiency and asymmetry, adding volume is considered.¹ In the review of 897 patients, the most common technique was tissue rearrangement together with an implant (73 per cent), implants were used in 83 per cent of patients, and the mean implant volume per breast was 263 millilitres.³

Where an implant is used, the choice is made according to the width of the base of the breast, the soft tissue cover available, the capacity of the lower pole to expand, the shape of the chest wall, the level of the fold beneath the breast and the difference between the two sides. The volume, shape and surface of the implant follow from that assessment.

The layer in which the implant is placed is called the plane. In the tuberous breast the subglandular (beneath the breast tissue), dual plane (partly beneath the muscle) and submuscular (beneath the muscle) planes are all used. Those who favour the subglandular plane hold that the narrowed breast and skin expand more freely without the constraint of the muscle. Against this, higher rates of capsular contracture, a visible implant edge, rippling, late malposition and an unnatural result have been reported in that plane, and for this reason the dual plane and placement beneath the muscle have been said to warrant consideration.¹ There is, then, no single plane that suits every patient.

An implant may be used together with a flap raised from the breast tissue in order to thicken the cover and reduce how far the implant can be felt.¹

An implant is foreign material placed in the body. It may need to be replaced or removed over time. This heading is set out separately below.

Adding volume with fat transfer

A person's own fat can be used to soften the tissue deficiency in the lower pole, to conceal the edge of an implant, or to add volume on its own. In the review of 897 patients, fat transfer was performed in 13 per cent of patients and the mean volume transferred per breast was 185 millilitres.³

Fat transfer has a limit particular to the tuberous breast. While the narrowed ring remains in place the volume that can be delivered is restricted, and for this reason the ring has been said to need addressing first. Because the breast is narrowed and the volume that can be given in one session is limited, more than one session may be needed.¹ Fat transfer can also be used at a second stage to refine the result, fill the lower pole and soften a residual fold line.¹

How much of the transferred fat will remain is not certain. A meta-analysis of fat transfer to the person's own breast, pooling 4,425 participants from 47 studies, found that on average about 53 per cent of the transferred fat was retained per breast, and that fat necrosis was reported in 4.7 per cent per participant. A further session was needed in some people. That meta-analysis is not specific to the tuberous breast; it covers primary cosmetic augmentation and symmetrising the opposite breast after a breast reconstruction. Variation between studies was very high across all outcomes.⁷

This average does not predict any one person's result. How much of the transferred fat remains varies markedly from person to person and with the technique used. Fat necrosis, oil cysts, calcification and palpable firmness can occur. In the same meta-analysis, a subsequent biopsy was reported in some people.⁷ Calcifications that can form after fat transfer may also produce findings on mammography that require assessment, which is why the radiologist needs to know what was done.⁸

Where is the incision made?

The incision is chosen according to the work to be done. Where the areola bulges or is widened, working around the areola is one of the commonly used options, and the same incision also gives access to the narrowed ring.¹ The choice of incision depends on the findings to be corrected and the technique to be used.

Where the areola presents no problem and the priority is a small scar, the narrowing can also be released with a cannula or needle passed beneath the skin, without an open incision into the breast tissue.¹ An incision in the fold beneath the breast may also be used, leaving the scar within the fold.

The choice of incision therefore rests on no single criterion. The state of the areola, the degree of narrowing, any ptosis, the amount of skin, the volume plan, the difference between the two sides, the person's preference about scars and the surgeon's experience are all involved.

One stage or staged?

Completing the correction in a single operation is the aim.¹ In a series of 51 breasts entered around the areola with the implant placed in the dual plane, that is, partly beneath the muscle, correction was completed in one stage in 92 per cent, while a staged route with a tissue expander was followed in 8 per cent.⁶

The gain of a single stage is fewer operations and a shorter overall course. Its limit is this. Where skin and tissue are severely deficient, or where the difference between the two sides is marked, there is less control over the volume added in one go.

In the staged route a tissue expander is placed first, inflated gradually over weeks, and replaced with a permanent implant at a second operation.¹ This route allows controlled expansion of the tissue and finer shaping at the second stage. In return there is an additional operation, a longer course and a temporary expander to carry.

Where fat transfer is chosen, the course may consist of repeated fat transfer sessions.¹

Which route will be followed is planned before the operation, though the decision can change according to how the tissue behaves during surgery.

How do you prepare for the operation?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.⁹ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁰ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹¹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹² The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Weight: Weight is expected to have settled before the operation. Marked changes in weight afterwards can alter the shape of the breast and the result obtained. Where fat transfer is planned, there needs to be enough tissue at the donor site.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Imaging: Breast imaging may be requested before the operation depending on your age and history.

What is recovery like?

The recovery timetable varies with the extent of the implant, fat transfer and tissue rearrangement involved. The intervals below are a general framework. They can vary with the extent of the operation performed, the person's job, how quickly they heal and the surgeon's practice.

• The operation is performed under general anaesthetic and usually takes 1 to 2 hours
• The hospital stay is most often 1 night
• Stitches that need removing are taken out within 2 weeks; dissolving stitches do not need removing¹³
• Returning to work takes 1 to 2 weeks for most people
• At least 1 week is left before driving
• Heavy lifting and strenuous sport are deferred for 4 to 6 weeks
• Most everyday activities are resumed by 6 weeks
• Most of the swelling settles over the first months; the tissues softening and the final shape of the breast emerging can take 3 to 6 months

These intervals vary with the extent of the operation. A mild correction worked at the level of the areola alone and an operation combining an implant, tissue rearrangement and a lift do not follow the same timetable.

Where the staged route is chosen the timetable lengthens. The tissue expander is inflated gradually over weeks and the second operation follows at the end of that process.

Immediately after surgery the breasts can look higher, tighter or unfamiliar. As the swelling settles and the tissues relax, the breast moves out of this appearance and settles onto the fold beneath it.

What should you pay attention to after surgery?

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Bra: A supportive bra or a band is worn after surgery. How long it is worn varies with practice; wearing it around the clock and continuing for months may be asked of you.¹³ Your surgeon will say when to move to an underwired bra.

Sleeping: Lying on the back, or with the upper body slightly raised, is more comfortable for most people in the first weeks. When you can move to sleeping on your side or front depends on how healing is going and on your surgeon's advice.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Arm movement: The arms can be used for everyday tasks within the limits of pain. In the first weeks, sudden and forceful arm movements, heavy lifting and activities that stretch the chest are avoided. Where the implant sits beneath the muscle, returning to movements that work the chest muscle takes longer. Staying still for long periods is not right either. Short walks are encouraged early on and lower the risk of clots.

Pain: Pain and a feeling of pressure in the chest are expected in the first days and are controlled with the painkillers provided. Information on recovery after breast augmentation states that acute pain mostly eases within 1 to 5 days and that tenderness and swelling can last a few weeks.¹⁴

Returning to work and sport: Desk work is mostly resumed within 1 to 2 weeks. Work involving heavy lifting and strenuous sport are deferred for 4 to 6 weeks.¹³ The return to movements that work the chest muscle hard can come later, depending on which plane the implant was placed in and how healing is going. Returning to exercise starts with walking and low-impact movement, leaving running and chest work until last.

Driving: At least 1 week is allowed. You can drive once you can wear the seatbelt comfortably, perform steering movements and an emergency stop without pain, and are no longer taking painkillers that cause drowsiness.

Sexual activity: Sexual activity can resume once you feel comfortable and everyday movements no longer cause marked pain. In the first weeks, pressure on the breasts and forceful movement should be avoided.

Smoking and weight: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete. Gaining weight after surgery can change the shape of the breast.

What is normal: Swelling, bruising, a feeling of firmness and tightness in the breast, numbness at the nipple and in the breast skin, occasional stabbing pains and a temporary difference in swelling between the two breasts are all expected. Where fat transfer has been done, small firm areas can also be felt. The final shape of the breast takes months to settle.

How do the scars change?

Correcting a tuberous breast is an operation that leaves scars. Where the scar lies varies with the incision chosen, but there is no scarless correction.

The scar from an incision around the areola stays at the colour border of the areola. The scar from an incision in the fold beneath the breast stays within the fold. Where the work is done with a cannula or needle beneath the skin, the scars are pinpoint.

The scar looks red and raised in the first months, then fades and softens. This can take up to 1 year. Its final appearance depends on how the person heals, on skin colour and on the area; how well it will settle cannot be predicted with certainty beforehand.

The scar around the areola is a heading of its own. Because it forms a ring, it lies under tension around its circumference and can widen over time.

Some measures can be used to reduce the chance of a scar becoming raised, widened or prominent. Once the wound has closed completely and on your surgeon's advice, silicone-based gel or silicone sheeting and scar massage may be suggested. These measures do not guarantee the outcome. Starting too early can harm the wound, so your surgeon sets the timing.

Direct sun darkens a scar, so it needs protecting during the first year.

Risks and complications

The information below comes from particular groups of patients and does not represent one person's individual risk. The definitions of implant-related complications rest on the list published by the United States Food and Drug Administration (FDA).¹⁵

In the review pooling 897 patients the overall complication rate was 20 per cent.³ How that figure is to be read matters. The studies in the review used techniques that differed from one another, definitions of complications and follow-up periods varied, and most of the evidence comes from retrospective case series. Mean follow-up in the same review was 39 months.³

Single-centre series can report lower rates. In a series of 26 patients (51 breasts) entered around the areola with the implant placed in the dual plane, capsular contracture was reported in 2 breasts and implant malposition in 2 breasts, giving an overall complication rate of 7.8 per cent. Mean follow-up in that series was 22 months.⁶ These two figures do not measure the same thing and cannot be compared directly.

The headings below are grouped by the area they concern rather than by frequency.

Problems of shape and symmetry

Residual or recurrent asymmetry: A difference in shape, volume, level of the fold beneath the breast or areolar size can remain between the two breasts. Because the two sides in a tuberous breast are usually affected to different degrees, exact equality is not expected.

Insufficient expansion of the lower pole: If the narrowing is not released sufficiently, the lower pole does not fill and the shape of the breast can remain close to cylindrical.

A second fold line (double-bubble): If the old fold beneath the breast is not released sufficiently, a second line can appear in the lower pole.¹

The areola widening again: Even when the areola has been reduced, tension in the skin can widen it somewhat over time.

Recurrence of the bulging: Breast tissue bulging into the areola can recur.

Change in the shape of the areola: The areola can flatten or distort.

A conspicuous scar: A scar can remain raised or wide and may call for correction.

Not reaching the expected shape: The shape or volume obtained falling short of what was aimed for is an outcome that may call for a corrective operation.

Implant-related problems

Capsular contracture: The body forms a thin layer of scar tissue around the implant. If that layer thickens and tightens, the breast hardens, its shape distorts and there may be pain. The cause of capsular contracture is not fully known.¹⁵

Implant malposition: The implant can move from where it was placed. Because the base is narrow in a tuberous breast, the space available for the implant is limited and this risk is kept in view.¹⁵

Rippling and being able to feel the implant: Where the breast tissue covering the implant is thin, the edge of the implant can be felt or seen as rippling in the skin. Because the covering tissue in a tuberous breast is usually thin, this heading carries more weight.¹⁵

Fluid collection (seroma): Fluid collecting around the implant. Small collections may settle on their own; large collections need draining.

Exposure of the implant: If the blood supply to the skin and the tissue beneath it is impaired, tissue loss can develop; in advanced cases the implant can come through the skin.¹⁵

Rupture: An implant can rupture over time. With silicone gel implants this often goes unnoticed; monitoring is set out below.¹⁵

Later replacement or removal: An implant cannot be guaranteed to stay for life.¹⁵

Implant-associated lymphoma (BIA-ALCL): A rare condition, set out separately below.

General surgical problems

Blood collection (haematoma): It shows itself in the first hours or first days after surgery as rapidly increasing swelling, firmness and pain in one breast. A return to theatre may be needed to drain what has collected.

Infection: Presents with redness, warmth, increasing pain and discharge. It can appear in the first days after surgery but also much later. Where an infection does not respond to antibiotics, the implant may need to be removed.

Delayed wound healing and wound separation: Because the ring-shaped incision around the areola in particular lies under tension, this heading is kept in view.

Circulation problems of the nipple and areola: The areola is the darker area around the nipple. If the blood supply to this area is impaired, the colour darkens and partial or complete tissue loss can develop.

Change in sensation: Sensation at the nipple and in the breast skin may increase or decrease; the change may be temporary and it may also be permanent. The FDA states that changes in sensation in the breast and nipple may be temporary or permanent.¹⁵ This outcome is thought to vary with the incision used, the extent of the tissue rearrangement, the state of the vessels and nerves supplying the nipple, and the person's starting anatomy. No guarantee about sensation can be given before surgery.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

Anaesthesia and other risks: Problems related to general anaesthesia, allergic reactions and pain persisting after surgery can occur.¹⁶

Problems related to fat transfer

Fat necrosis and oil cysts: Part of the transferred fat may not survive; these areas can form firm nodules or fluid-filled cysts.⁷

Calcification: Calcium deposits can form over time and may require assessment on imaging.⁸

Contour irregularity: Uneven distribution of the fat can lead to irregularity of the surface.

Insufficient volume retention and the need for further sessions: Part of the transferred fat resorbing is expected, and further sessions may be needed to reach the volume aimed for.⁷

The need for further surgery

Many of the headings above are dealt with by a corrective operation. Correcting a tuberous breast is an operation in which the possibility of further surgery needs discussing from the outset. In a single-centre, retrospective study 129 patients were followed; during the primary correction process the mean number of operations was 1.2 in the implant group and 2.4 in the fat transfer group. Within the 5 years after that process was complete, the need for further surgery was reported as 46 per cent in the implant group and 21 per cent in the fat transfer group.¹⁷ Those rates relate to the patients who completed the primary process and could be followed over that period; they do not cover the whole group of 129.

These figures do not show one method to be superior to the other. The two groups were not randomly allocated. Indeed, a comparative study reported in the review by van Durme and colleagues found satisfaction to be higher with correction using an implant.¹ The available evidence therefore shows that the two routes carry different burdens, not that one replaces the other.

What does carrying an implant involve?

Where an implant has been used in the correction, the responsibilities that come with an implant begin as well. This heading is set out in detail in the breast augmentation article; a summary is given here.

An implant is foreign material placed in the body and cannot be guaranteed to stay for life. How long an implant stays in place varies from person to person and cannot be stated in advance.¹⁵ The FDA counts among the warnings that should appear in manufacturers' information that an implant is not expected to last a lifetime, that the chance of complications increases over time, and that some complications require further surgery.¹⁸

Knowing the manufacturer and model of the implant helps with follow-up. Keeping the implant card given after surgery is advised.¹⁸

When a silicone gel implant ruptures, it is usually impossible to notice. Assessing the integrity of the implant with imaging is therefore advised in people with silicone gel implants and no symptoms. The current approach is an initial ultrasound or magnetic resonance imaging without contrast 5 to 6 years after surgery, repeated every 2 to 3 years thereafter. This matches the FDA recommendation and appears in the current criteria of the American College of Radiology.¹⁹¹⁸

Where there are symptoms, assessment is made independently of that schedule. Where a problem with the integrity of the implant is suspected, such as rupture, magnetic resonance imaging without contrast is usually appropriate with silicone implants. Where an implant-associated cancer is suspected, ultrasound or magnetic resonance imaging with and without contrast is considered appropriate as the initial test.¹⁹ Monitoring the integrity of an implant does not take the place of breast cancer screening.

Implant-associated lymphoma (BIA-ALCL)

This is not breast cancer. It is a type of lymphoma arising from immune system cells, and it is usually found not in the breast tissue but in the scar tissue around the implant or in fluid collecting there.

Its frequency has been calculated in populations where implant numbers are known. A systematic review pooling 17,038,371 people from 38 studies found a prevalence of 30.54 per 100,000 among those with textured implants, that is, roughly 1 in 3,274. Counting everyone with an implant of any surface, the figure falls to 6.70 per 100,000, roughly 1 in 14,925.²⁰

These figures are averages calculated in defined groups of patients; they are not one person's lifetime risk.²⁰ The FDA states that BIA-ALCL occurs more commonly in people with textured implants than in those with smooth implants, and that deaths from it have been reported.¹⁸ Keeping a record of the manufacturer, model and surface of the implant used therefore matters.

Swelling that appears late and does not settle, a collection of fluid, a palpable lump or a marked change in shape all call for medical assessment.

Because correcting a tuberous breast is most often done at a young age, this responsibility for follow-up extends over many years. The decision needs discussing in that light as well.

Is breastfeeding possible?

The answer to this question rests on two separate headings. One is the situation before surgery, the other is the work done at the operation.

Independently of surgery, underdevelopment of the breast tissue can affect milk production. The evidence for that relationship is limited, however. A systematic review examining the relationship between breast hypoplasia and breastfeeding outcomes could find only 7 studies and 42 women in total; 40 of those 42 stopped exclusive breastfeeding within the first month after birth. The review's own conclusion is that the subject is underresearched.²¹ At the same time, some people with a tuberous breast may have normal breastfeeding capacity before surgery in any case.

Seen from the surgical side, what matters is preservation of the milk glands and ducts beneath the nipple and the state of the nerves running to the nipple. Procedures in which the breast tissue is rearranged have been noted as capable of disrupting the continuity of the milk ducts, while some authors report that their own technique preserves the ducts.¹

If you are thinking about breastfeeding you need to say so before the operation; both the site of the incision and the extent of the tissue rearrangement can change according to that information. Neither certain preservation nor certain loss of breastfeeding can be promised.

What can be expected from the result?

Reported satisfaction is high. In the review covering 897 patients across 38 studies, the satisfaction assessments gave 99 per cent satisfaction and the BREAST-Q measurements an average of 86.7 out of 100.³ These two results do not represent a single measurement made by the same method in all 897 patients.

These two figures are not a guarantee of success. Satisfaction was not measured in all the studies in the review, and those that measured it used different methods; most of the evidence comes from retrospective series.³ The figure therefore shows that in appropriately selected patients the result is generally found to be positive; it does not show what will happen in a particular person.

A few points help set expectations correctly. The result varies with the starting anatomy. Because the two sides are usually affected to different degrees, exact symmetry is not the aim; the aim is to make the difference no longer conspicuous. Mild asymmetry can remain. Correction may not always be finished in a single operation. Scars do not disappear completely. Where an implant has been used, the result is not one that stays unchanged; pregnancy, changes in weight and ageing alter the shape of the breast after surgery too.

The aim is not a flawless breast but a more balanced shape and proportion for that person's own anatomy.

When should you contact your doctor?

You need to contact the team that performed the operation in the following situations:

• Fever
• Increasing redness, warmth, discharge or a bad smell at the wound
• Rapidly increasing swelling, firmness or pain in one breast
• The wound opening noticeably
• Darkening, bruising or blackening in the colour of the nipple or areola
• Pain that keeps increasing despite painkillers

Where fat transfer has been done, this finding also calls for assessment:

• A firm area in the breast that is new, growing or painful

If you carry an implant, the following findings call for assessment later on:

• Swelling that does not settle, a palpable lump or pain in the breast
• The breast becoming firm, changing shape, or the implant moving

The following two findings call for urgent assessment:

• One-sided pain or swelling in the leg
• Sudden breathlessness or chest pain

About the figures in this article

The literature on the tuberous breast is narrower than that on other breast operations. Most studies are single-centre, retrospective case series; comparative and randomised studies are few. There is no consensus on the optimal technique.¹

The classifications vary from study to study as well. Because the same finding can be counted as moderate in one study and severe in another, the rates cannot be compared directly.

Some of the figures relating to fat transfer are not specific to the tuberous breast, and in this article the patient group covered by the source has been stated.

The figures here therefore do not predict one person's result. They give only a general framework.

References

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