Breast shape malformations

Breast shape malformations are deformities of the breast contour involving the inferior breast pole. They range from minor forms such as a high submammary fold to major forms such as the tubular breast. The malformation implies an altered relationship between the mammary parenchyma and the superficial fascial system (SFS). The surgical correction consists of the releasing of the gland from all the connections with the surrounding tissues. In some cases, once the glandular tissue is freed from the constricting SFS, the parenchyma spreads revealing a sufficient volume to obtain a normal breast. If hypoplasia of the breast or inferior quadrant hypoplasia is present, the use of an implant is mandatory.

Mutations in human TBX3 alter limb, apocrine and genital development in ulnar-mammary syndrome

Ulnar-mammary syndrome is a rare pleiotropic disorder affecting limb, apocrine gland, tooth and genital development. We demonstrate that mutations in human TBX3, a member of the T-box gene family, cause ulnar-mammary syndrome in two families. Each mutation (a single nucleotide deletion and a splice-site mutation) is predicted to cause haploinsufficiency of TBX3, implying that critical levels of this transcription factor are required for morphogenesis of several organs. Limb abnormalities of ulnar-mammary syndrome involve posterior elements. Mutations in TBX5, a related and linked gene, cause anterior limb abnormalities in Holt-Oram syndrome. We suggest that during the evolution of TBX3 and TBX5 from a common ancestral gene, each has acquired specific yet complementary roles in patterning the mammalian upper limb.

An uncommon urologic presentation of a supernumerary breast

Polythelia and polymastia are common developmental abnormalities of the breast and nipple which usually present as small lesions along the mammary line, an embryologic line that extends bilaterally from the axillary regions to the inguinal ligaments. These lesions have been reported in various locations outside the mammary line. We report an unusual location of polymastia in the perineum of a newborn male. A brief discussion of the clinical relevance of such lesions is also included.

Ultrasonically assisted lipectomy in aesthetic breast surgery

A case report of a young patient with marked asymmetry treated successfully with ultrasonically assisted lipectomy with a good functional cosmetic result, undetectable scars, and mammographic control and showing no ill-effect on the breast parenchyma is presented. Further studies and follow-up are needed to confirm the value and advisability of using ultrasonic energy in the female breast.

Reconstruction of scleroderma of the breast

Although limited to a single case, our study suggests that patients with localized scleroderma of the breast can incur developmental impairment leading to severe breast deformity. The results of any of several methods of breast reconstruction were not available to us for review because of the rarity of this clinical problem. Tissue expansion allowed our patient to avoid the additional scarring and possible functional loss associated with the transfer of autologous tissues. Its successful completion in this one patient indicates that it can be considered for other patients encountered with similar unusual findings.

Reconstruction of breast asymmetry in Poland's chest-wall deformity using microvascular free flaps

Poland's syndrome comprises a spectrum of chest-wall deformities affecting, to various degrees, the rib cage, the chest-wall muscles, the neurovascular structures of the ipsilateral arm, and the overlying breast. This study details our experience with nine female Poland's syndrome patients who had chest-wall and breast asymmetry corrected by microvascular free-tissue transfer. Nine female patients with Poland's chest deformity underwent 12 microvascular free flaps between 1989 and 1994. Donor sites for free-tissue transfer included eight transverse rectus abdominis flaps, two superior gluteal flaps, one inferior gluteal flap, and one contralateral latissimus dorsi flap. Recipient vessels were branches of the subscapular vascular axis in all patients. Patients' ages ranged from 18 to 47 years at the time of reconstruction. Chest-wall and breast asymmetry varied from accompanying severe pectus and rib cage deformities to isolated breast involvement. Complications were limited to a superior gluteal flap loss due to anomalous subscapular venous drainage. This patient underwent a successful second superior gluteal flap reconstruction utilizing the cephalic venous outflow system. Chest-wall and breast symmetry was restored in all patients. This study demonstrates that microsurgical reconstruction of chest-wall and breast asymmetry in Poland's syndrome yields excellent results with a high degree of patient satisfaction. Careful intraoperative assessment of the recipient vessels prior to flap transfer is mandatory. Because Poland's chest-wall deformity may include anomalies of the vascular system, preoperative vascular assessment with duplex ultrasonography should be considered in all patients, and use of preoperative angiography or venography in selected patients also appears justified.

Multiple vertebral segmentation defects. Brief report of three patients and nosological considerations

Multiple vertebral segmentation defects i.e. multiple malformations of vertebrae and ribs are characterized by short neck, scoliosis, short trunk and deformity of the ribcage. There are three major subtypes; Jarcho-Levin syndrome, spondylothoracic dysostosis and spondylocostal dysostosis, with different inheritance patterns, survival rates and associated malformations. We describe three cases of multiple vertebral segmentation defects, two with familial spondylothoracic dysostosis and one with sporadic spondylothoracic dysostosis, and anomalies i.e. super-numerary breast, clubfeet deformity, myelomeningocele, intradural lipoma, and Arnold-Chiari malformation.

Vertical scar breast reduction with medial flap or glandular transposition of the nipple-areola

Vertical scar breast reduction is a well accepted technique which we believe improves the shape and projection of the breast and leaves no horizontal scars. Lassus and Lejour described superiorly based nipple flaps; we describe a medially based flap or glandular transposition of the nipple in small reductions. Fifty-seven consecutive patients are presented. Thirty-three patients had medial transposition of the nipple-areola with a mean resection of 608 g (range 220-1250 g). Twenty-four patients had a glandular transposition of the nipple-areola, with a mean resection of 380 g (range 220-600 g); transposition of the areola should be less than 5 cm in this group. After a short learning curve, the complications have been few and minor.

Clinical analysis of a large kindred with the Pallister ulnar-mammary syndrome

The ulnar-mammary syndrome (UMS) is an autosomal dominant disorder characterized by posterior limb deficiencies or duplications, apocrine/mammary gland hypoplasia and/or dysfunction, abnormal dentition, delayed puberty in males, and genital anomalies. We present the clinical descriptions of 33 members of a six generation kindred with UMS. The number of affected individuals in this family is more than the sum of all previously reported cases of UMS. The clinical expression of UMS is highly variable. While most patients have limb deficiencies, the range of abnormalities extends from hypoplasia of the terminal phalanx of the 5th digit to complete absence of the ulna and 3rd, 4th, and 5th digits. Moreover, affected individuals may have posterior digital duplications with or without contralateral limb deficiencies. Apocrine gland abnormalities range from diminished axillary perspiration with normal breast development and lactation, to complete absence of the breasts and no axillary perspiration. Dental abnormalities include misplaced or absent teeth. Affected males consistently undergo delayed puberty, and both sexes have diminished to absent axillary hair. Imperforate hymen were seen in some affected women. A gene for UMS was mapped to chromosome area 12q23-q24.1. A mutation in the gene causing UMS can interfere with limb patterning in the proximal/distal, anterior/posterior, and dorsal/ventral axes. This mutation disturbs development of the posterior elements of forearm, wrist, and hand while growth and development of the anterior elements remain normal.

Equatorial breast reduction: a new technique for the correction of moderate-to-large mammary hypertrophy

The author describes a personal technique for moderate-to-large breast hypertrophy, regardless of the degree of ptosis, based upon a personal experience of more than 200 breast reductions. It is a superior monopedicle nipple-areola flap procedure, which leaves an inverted-T scar. It was used in 35 cases over the last 3 years involving tissue reductions ranging from 500 to 1950 g per gland. All patients underwent follow-up evaluations 1, 3, 6, and 12 months after surgery. No complications were observed, and areolar sensation was preserved in all cases. Apart from its effectiveness in cases of massive hypertrophy and the absence of difficulties related to elevation of the nipple-areola complex, the equatorial technique offers the significant advantages of a simple preoperative marking phase and well-defined, reproducible parameters for reduction and reshaping. These characteristics reduce the need for subjective judgment and, therefore, the risk of error. The results obtained are highly satisfactory in terms of volume reduction, form, and symmetry.

"The reason for hating myself": a patient's request for breast reduction

A recent script from a patient highlights the problems often experienced by patients with an oversized bust and who wish for breast reduction. This may be of assistance in discussing contracts and the ever present threat of rationing.

Reduction mammaplasty with the inferior pedicle technique: early and late complications in 371 patients

A review of reduction mammaplasties with the inferior pedicle technique in 371 patients over 10 years is presented and the complications associated with this particular technique are discussed. The mean age was 33.1 years (range 15-67), the average preoperative sternal notch to nipple distance was 30.4 cm (range 21-43), the mean breast tissue resected was 870 g per breast (range 250-1960) and the mean operating time was 3.1 hours (range 2.5-4). The overall complication rate was 11.4%. The incidence of specific complications in our series was: haematoma 0.3%, nipple and/or pedicle necrosis 0.8%, wound dehiscence 4.6%, fat necrosis 0.8%, carcinoma 0.5%, loss of sensitivity of the nipple 1.3%, hypertrophic scars 3.3%, dermoid cysts 0.3% and marked lower fullness 0.3%. 72% of the patients that became pregnant were able to lactate.

A review of 120 Becker permanent tissue expanders in reconstruction of the breast

In reconstructive breast surgery, the permanent tissue expander has become popular because it avoids expander-implant exchange and gives the patient some control over the final breast size. It may, however, be associated with a number of complications. We therefore analysed the clinical notes of 111 consecutive recipients of Becker breast expanders with respect to complications and their possible predisposing factors. 120 prostheses were inserted in 111 consecutive patients with a mean age of 42.6 years. Median follow-up was 12 months (range 8 to 22). The commonest indication was postmastectomy breast reconstruction (81%) followed by congenital hypoplasia (14%) and acquired breast asymmetry following repeated biopsies (3%). Overexpansion before size adjustment was achieved after an average of 8 expander inflations. Complications included capsular contracture (9%), local tumour recurrence (8%), wound dehiscence (8%), filling port failure (6%), infected prostheses (4.5%) and ruptured implants (1.6%). The significant predisposing factors to wound dehiscence/infection were heavy smoking and radiotherapy (P < or = 0.05, chi 2 test). Expansion rate was not a factor. 89% of patients expressed satisfaction with the final aesthetic result. Despite the excellent results obtained with this technique, caution must be exercised in heavy smokers and the previously irradiated.

Breast and pectoralis muscle hypoplasia. A mild degree of Poland's syndrome

PURPOSE

Poland's syndrome is a congenital and unilateral aplasia of the pectoralis major muscle (PMM), with other anomalies of the ipsilateral upper extremity. We present 6 cases in which the only clinical expression was asymmetry of the breasts associated with partial absence of the PMM.

MATERIAL AND METHODS

We reviewed 95000 mammograms (obtained 1985-1995) to find patients with asymmetrical breast size. Where the asymmetry could not be ascribed to any other cause, the patients were recalled for an examination of the PMM which was conducted at rest and with active contraction of the muscle.

RESULTS

Unilateral volume reduction of the PMM was found in 5 women of whom 2 were studied with MR. A 6th case was a fortuitous finding in a male patient.

CONCLUSION

Mild forms of Poland's syndrome are more frequent than severe forms, and may go undiagnosed. Hypoplasia of one breast or a horizontal anterior axillary fold may be the sole clinical manifestation of this syndrome.

Personal approach to surgical correction of the extremely hypoplastic tuberous breast

A surgical method for treatment of the extremely hypoplastic tuberous breast is described. It is based on turning differently shaped glandular flaps to correct the deformity, followed by insertion of a prosthesis, and, where necessary, correction of areola size and position and adjustment of the skin of the inferior pole. The results so far have afforded total and recurrence-free aesthetic correction of the usual deformities. The underlying aim of the operation is to transform a hypoplastic tuberous breast into a simple hypoplasia without discarding gland tissue which can be used to thicken the most deficient mammary area.

The tuberous breast deformity: classification and treatment

To date there are many descriptive terms for the tuberous breast deformity but there is no widely accepted nomenclature. A retrospective study was undertaken of 68 tuberous breasts and the operative corrections performed. The deformities were classified into four types. Type I (hypoplasia of the lower medial quadrant), type II (hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region), type III (hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region) and type IV (severe breast constriction, minimal breast base). Areolar prolapse, usually regarded as a major symptom, was only found in 30 (44%) deformed breasts. Postoperative review of 51 breasts in 31 patients showed that type I cases treated by reduction mammaplasty of adequately sized breasts or augmentation of hypoplastic breasts had excellent results. These procedures with additional spreading of the breast tissue in type II deformities give good results. Severe cases (types III and IV) treated by augmentation and tissue spreading procedures have an unsatisfactory shape and have a 'second crease' deformity. For types III and IV, additional skin in the subareolar region by tissue expansion or flap procedures is necessary. There is no one method to correct 'the' tuberous breast but there are many procedures which should be used according to the type of deformity. The classification developed could end the confusion in nomenclature.

[Correction of the secondary deformity of reduction mammaplasty--the inframammary fold advancement]

The high position of the nipple-areola is one of the complications of reduction mammaplasty. The technique of lower thoracic advancement flap reestablishes a new inframammary fold. The edge of the advanced inferior flap is sutured to the chest wall and the rib cage. The advantages of the technique is that the scar is hidden in the depth of the inframammary fold and is usually fairly in-conspicuous. The technique gives an increasingly natural looking of the breast. The operation is appealingly easy and safe. Figures illustrate the effectiveness of this technique.

Correction of developmental breast abnormalities with a permanent expander/implant

Patients with developmental breast abnormalities often present to the plastic surgeon at a young age. We report our experience with 4 cases of unilateral breast abnormality (3 hypoplastic and 1 tuberous) treated with a Becker permanent expander/implant. Our approach is to insert the expander/implant, expand intermittently to keep pace with growth of the other breast and remove the filling valve under local anaesthesia on maturity. The techniques and advantages of this approach are illustrated and discussed.

Mammary hamartoma--an under-recognised breast lesion

The clinical, histological and immunohistochemical features of the first three cases of mammary hamartoma diagnosed at the University Hospital of the West Indies are reported. These tumours are innocuous and under-recognized although the mammographic features are characteristic. With increased utilization of this test in breast cancer detection in our region, it is likely that more of these lesions will be identified.

Accessory mammary tissue associated with congenital and hereditary nephrourinary malformations

BACKGROUND AND OBJECTIVES

The association between polythelia (supernumerary nipple) and kidney and urinary tract malformations (KUTM) is controversial. Some authors reported this association in newborns and infants. Case-control studies dealing with adult subjects are not found in the literature. The purpose of this study is to determine the frequency of the association between accessory mammary tissue (AMT) and congenital and hereditary nephrourinary defects in an adult population compared to a control group.

METHODS

The study was performed in 146 white patients (123 men, 23 women) with AMT out of 2645 subjects consecutively referred to us for physical examination. The following investigations were undertaken: ultrasonographic examination of the abdomen and the kidneys, ECG, echocardiogram, roentgenogram of the vertebral column, urinalysis, and other laboratory tests. A sex- and age-matched control group without any evidence of AMT or lateral displacement of the nipples underwent the same examinations.

RESULTS

Kidney and urinary tract malformations were detected in 11 patients with AMT (nine men, two women) and in one control. These data indicate a significantly higher frequency of KUTM in the AMT-affected patients compared to controls (7.53% vs. 0.68%, P < 0.001). A broad spectrum of KUTM was discovered in association with AMT: adult dominant polycystic kidney disease, unilateral renal agenesis, cystic renal dysplasia, familial renal cysts, and congenital stenosis of the pyeloureteral joint.

CONCLUSION

Accessory mammary tissue offers an important clue for congenital and hereditary anomalies of the kidneys and urinary collecting systems. Patients with AMT should, therefore, be extensively examined for the presence of occult nephrouropathies.

Expression of tropomyosin isoforms in benign and malignant human breast lesions

High molecular weight tropomyosins (tms) are commonly down-regulated in fibroblasts transformed by oncogenes. Previous studies have also demonstrated that specific tm isoforms are down-regulated in human breast carcinoma cell lines. We examined tropomyosin isoforms in cells prepared from non-cancerous breast lesions and primary human breast carcinomas. The average level of expression of all three high molecular weight tm isoforms (tm 1-3) in carcinomas was generally found to be less than 25% of that observed in non-cancerous breast lesions. Interestingly, the expression of tm 1 was found to be 1.7-fold higher in primary tumours with metastatic spread to axillary lymph nodes compared with primary tumours with no evidence of metastasis (p<0.05). Similarly, tm 1 expression was higher in two 12V-H-ras transformed fibroblast cell lines capable of experimental metastasis compared with three weakly metastatic cell lines. We conclude from these studies that expression of high molecular weight tm isoforms is low in primary breast carcinomas, and that metastatic tumours express relatively high levels of tm 1.