Introduction

The treatment of tuberous breasts has always been a real reconstructive challenge for plastic surgeons. Tuberous breasts are a rare congenital deformity that can be uni or bilateral and result from abnormal breast development, becoming evident in puberty. The first authors to describe it were Rees and Aston, in 1976.¹ The main clinical features are reduced breast parenchyma (hypoplasia of one or all breast quadrants), abnormal inframammary fold elevation, decreased skin envelope in the horizontal and vertical dimensions, increased areolar diameter with herniation of the breast parenchyma through the nipple-areolar complex (NAC), and a constricted breast base.^2,3,4,5,6 Fibrous septa are the most significant factor in this condition, affecting normal breast development.

The classification of tuberous breasts was first introduced by Von Heimburg,⁴ in 1996, and modified in 1999 by Grolleau,⁵ who described only 3 groups based on breast base deformity. In 2013, Costagliola et al.⁶ proposed adding type 0 for the minor forms, characterized by the simple areolar protrusion, which may be permanent or intermittent on a regular breast base. In 2017, Innocenti et al.⁷ proposed a new classification including all presentation forms, considering the anatomical location of the defect, breast volume, and tissue quality.

For this article, we chose the classification proposed by Kolker et al.,⁸ in 2015, based on the Meara et al.⁹ classification from 2000 for tuberous breasts. It is a three-level classification system considering anatomical features and the severity of tuberous breast deformities (►Table 1).

Table 1 - Tuberous breast deformity classification

In addition to the multiple classifications, tuberous breast objective confirmation relies on the Northwood index as per a review from Pacifico et al.¹⁰ This index is the relationship between the areola diameter and the herniation measured in profile. An index greater than 0.4 defines a tuberous breast; regarding severity, the disease can be mild (0.4-0.5), moderate (0.51-0.6), or severe (0.61-0.7).

The treatment of tuberous breasts has always been controversial due to their anatomical complexity, and previous techniques in two or more stages were very complex, traumatic, and unsatisfactory.^{1,10,11,12,13,14,15,16,17,18,19,20,21} The One Selective Tissue Engineering Photostimulation (STEP) technique uses a new infrared laser diode with a wavelength of 1,210 nm acting directly on the denaturalization of the fibrous septa, which account for the rigidity of the histological support of the affected tissue, releasing the mammary fibrosis (collagen and reticulin fibers) and inframammary fold, allowing the creation of the subglandular pocket, increasing the lower pole and lowering the fold for breast implants. The previously collected fat preserved by the One STEP technique^22,23 contained stem cells stimulated by infrared light, and we immediately injected it into the areas requiring volume and skin elasticity. This technique provides satisfactory, natural, and less traumatic outcomes for patients regardless of disease classification with a one-stage correction.

The present paper presents the efficiency and simplicity of the One Step technique for adequate correction of this deformity in all its potential presentations (grades I—III) with an atraumatic postoperative period regardless of the classification in one-stage correction.

Materials and Methods

The current retrospective descriptive study included 15 patients (30 breasts) treated by the senior author, with a mean age of 28 years (range: 18-39), who underwent treatment with the One STEP technique from 2017 to 2020. Tuberous breast classification relied on the Meara et al./Kolker system (►Table 1).

Patient information included tuberous breast classification by three independent plastic surgeons, surgical outcomes, and complications. The minimum follow-up period was 10 months. We asked all patients to complete a Breast Cancer Quality of Life Questionnaire (BREAST-Q) to measure their satisfaction, using four scales from the Breast Q reduction/mastopexy module, namely, satisfaction with the outcome, satisfaction with breasts, psychosocial wellbeing, and sexual wellbeing. Patient scores ranged from 0 to 100.

The postoperative evaluation relied on photographs to analyze symmetry, breast shape, normalization of areola size, scar, and overall aesthetic outcome. We graded the postoperative outcomes as excellent, very good, good, or poor.

Surgical Technique

All patients underwent the same surgical procedure, regardless of their grade, starting with preoperative markings in the vertical position. Important landmarks included a vertical midline mark, the existing inframammary fold, and the proposed inframammary fold. All patients received sedation plus local anesthesia.

►Fig. 1

Fig. 1 - Surgical marking with the patient standing up. (0) Fat harvesting: One STEP technique. Adipocyte viability was 98%. (1) Denaturation of collagen fibers using laser. -Lower pole. -Inframammary fold. (2) Nipple-areolar complex (NAC) skin (subdermal) tension. (3) Subglandular implant pocket. (4) Fat grafting in the upper and lower poles.

Fig. 1 - Surgical marking with the patient standing up. (0) Fat harvesting: One STEP technique. Adipocyte viability was 98%. (1) Denaturation of collagen fibers using laser. -Lower pole. -Inframammary fold. (2) Nipple-areolar complex (NAC) skin (subdermal) tension. (3) Subglandular implant pocket. (4) Fat grafting in the upper and lower poles.

We will describe the procedure in three phases.

Fat Grafting

We performed minor liposuction in the abdominal region using the One STEP⁹ technique to harvest adipose tissue for fat grafting. We placed the fat graft in areas requiring volume and skin elasticity using PicoGraft, with no fat manipulation and preserving all stromal regenerative elements. We used a 2-mm curved cannula connected to a 10-mL syringe through two small incisions, one in the new lateral inframammary fold and the other in the medial inframammary fold. The injected volume ranged from 120 to 220 mL. Lastly, we sutured the medial and the lateral incisions.

This method treats breast deformity with a one-stage correction; it does not require another surgical time for reconstruction and is independent of the disease classification (►Fig. 2).

Fig. 2 - Treatment algorithm for tuberous breast deformity. Abbreviation: NAC, nipple-areolar complex. Note: Fat harvest occurs before breast correction surgery following the One STEP technique.

Fig. 2 - Treatment algorithm for tuberous breast deformity. Abbreviation: NAC, nipple-areolar complex. Note: Fat harvest occurs before breast correction surgery following the One STEP technique.

Results

From 2017 to 2020, a total of 15 female patients with tuberous breasts underwent treatment with the One STEP technique. The mean postoperative follow-up time was 10 months (range: 8-12 months). ►Tables 2 and 3 summarize the patient demographics. There were eight type-I deformities, four type-II deformities, and three type-Ill deformities. In all patients, we used a 2-mm inframammary fold incision approach. The mean BREAST-Q postoperative satisfaction score was 80 ± 12. The mean breast satisfaction score was 88 ±11, the mean psychosocial wellbeing score was 83 ± 12, and the sexual wellbeing score was 80 ± 16.

Table 2 - Tuberous breast deformity presentation

Table 3 - Demographic data from patients with tuberous breast deformity

In each patient, we released the breast fibrosis in the affected quadrants and lowered the inframammary fold, allowing the placement of a round subglandular breast implant, with reduction (skin tightness pre-configuration) of the areola-nipple herniation and NAC. We observed significant retraction of the NAC skin, increasing the distance between the NAC and the new inframammary fold.

All patients presented an increase in lower pole volume and elasticity using the PicoGraft fat grafting in conjunction with subglandular breast implant and natural atraumatic results, with less bleeding and edema.

In all cases, the final aesthetic outcome was acceptable to the satisfaction of the patient and the surgical team with a one-stage correction. The aesthetic outcomes based on symmetry, breast shape, areola size normalization, scar, and overall aesthetic result by blind scoring were excellent in 9 (60%) patients and very good in 6 (40%) patients. There were no poor aesthetic outcomes.

We observed no complications, such as infection, seroma, or hematoma, during the follow-up period. The technique has no functional impact on the breasts, nor does it interfere with future lactation. We placed drains in patients receiving breast implants (►Figs. 3,4,5).

Fig. 3 - Postoperative outcome of a patient with grade-Ill tuberous breast deformity using the One STEP technique.

Fig. 3 - Postoperative outcome of a patient with grade-Ill tuberous breast deformity using the One STEP technique.

Fig. 4 - Postoperative outcome of a patient with grade-l tuberous breast deformity using the One STEP technique.

Fig. 4 - Postoperative outcome of a patient with grade-l tuberous breast deformity using the One STEP technique.

Fig. 5 - Postoperative outcome of a patient with grade-ll tuberous breast deformity using the One STEP technique.

Fig. 5 - Postoperative outcome of a patient with grade-ll tuberous breast deformity using the One STEP technique.

Discussion

Although different techniques can treat tuberous breast deformity, they do not always provide the same outcome in distinct patients with the same disorder classification, and some subjects require a two-phase intervention. In addition, a more noticeable deformity requires careful surgical procedure planning to provide a satisfactory outcome.^{1,10,13,14,15,16,17,18,19,20,21}

Fasciotomies or flaps are often used to release or dissolve the fibrous septa of the lower pole of the tuberous breast and the short submammary fold. It is worth noting that the chemical connections between tissues are strong, and any attempt to use mechanical disruption for connective tissue dissolution is not feasible or complete.

The photochemical reaction from our technique can dissolve these fibrous septa by denaturalizing them without the thermal effect from other lasers.^22,23,24 This denaturalization frees the subcutaneous cellular tissue and the breast tissue from the rigidity in the lower pole. In fat harvesting for grafting, this technique also allows fat preservation with a 98% viability.^{11,12,22,23,24}

In our study, patients with tuberous breasts underwent the same treatment with the One STEP technique regardless of their disease classification in a one-stage correction. It is a much simpler way of treating the affected quadrant tissue, releasing breast fibrosis, retroareolar herniation/sagging, and NAC retraction; in addition, it allows repositioning of the inframammary fold for (previously harvested) fat grafting and preparing a wide retroglandular pocket for implant placement through a transareolapapilar (Pitanguy) incision.

No patient presented complications; however, as the literature has no clear data addressing the time to complications, such as the development of capsular contracture, our followup period may have been insufficient to detect cases of late capsular contracture, asymmetry, or deformity development.

Since complications may arise over a longer time, we cannot rule out the possibility of their late occurrence.^8,9

Our study has several limitations. Although our outcomes, technique, and patient satisfaction are promising, this is a retrospective review of 30 breasts in 15 patients. Therefore, our data do not necessarily reflect the general population. However, our results are promising, and our technique may treat patients with tuberous breast deformity. Further larger studies are required to confirm our results.

Conclusion

The present case series shows that the adjuvant use of this new technology is a safe procedure allowing the release of fibrous septa through the photochemical property of light, allowing expansion of the lower pole for treatment using prostheses, high-quality fat grafts, or both.