Pediatric Breast Deformity

Long-term results of the tuberous breast: What to expect after the primary correction process?

BACKGROUND AND AIMS

Tuberous breast is a rare anomaly affecting the development of mainly the female breast. It presents with varying degrees of hypoplasia in the breast base and skin. In some cases, herniation and widening of the areola is observed. The condition constitutes a great challenge for the reconstructive surgeon. In this study, the surgical cascades of implant and lipofilling corrections were compared with a focus on the need for re-interventions.

METHODS

In total, 129 patients whose treatment regimen started between January 2010 and October 2020 were included in this study. Patients were categorized into two groups based on the volume correction method used (lipofilling versus implant).

RESULTS

In 35 (27%) patients (41 breasts), breast volume increasement was executed with an implant, while 94 (73%) patients (169 breasts) underwent volume increasement with lipofilling. The mean number of operations during the primary correction process was 1.2 (range 1-5) for the implant group and 2.4 (range 1-5) for the lipofilling group. When assessing the need for re-operations within 5 years after completing the primary correction, 46% of patients in the implant group needed further surgeries, while the corresponding proportion for the lipofilling group was 21% (p = 0.04). There were six major complications, all of them in the implant group.

CONCLUSION

Implant-based reconstruction is associated with more revision surgeries and major complications compared to autologous lipofilling corrections. Lipofilling offers a more durable result with less re-operations over time despite initial sequential primary surgeries.

The Impact of Tuberous Breast on Adolescents: A Cross-sectional Study

Background

Tuberous breast deformity is a nondiagnostic, descriptive term for a congenital breast difference that becomes apparent at puberty. Although the negative physical and psychosocial effects of macromastia and breast asymmetry are established, no studies to date have explored the impact of tuberous breasts on health-related quality of life (HRQoL) outcomes using a robust sample size.

Methods

In this cross-sectional study, HRQoL surveys were administered to adolescent women with tuberous breasts and healthy female controls, aged 12-21 years. Surveys included the Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating Attitudes Test-26. Demographics were compared, and linear regressions were fit to determine the effect of tuberous breast deformity on survey scores, with body mass index (BMI) category as a covariate.

Results

Thirty-four patients with tuberous breasts and 264 controls participated. Patients with tuberous breasts had higher mean BMI than controls (P < 0.05). After adjusting for differences in BMI category, patients with tuberous breasts scored lower than controls on the Rosenberg Self-Esteem Scale and in Short-Form 36v2 domains related to physical and psychological health (P < 0.05, all). Compared with controls, patients with tuberous breasts had a higher mean score on the Eating Attitudes Test-26 (P < 0.05).

Conclusions

Tuberous breast deformity may negatively impact patients' physical and psychosocial HRQoL and increase their risk for disordered eating and higher BMIs. It is imperative that healthcare providers and third-party payors understand tuberous breast deformity is not just a cosmetic issue and tailor care and coverage policies accordingly.

Infantile Hemangioma of the Breast: Long-Term Assessment of Outcomes

Background

The literature is meager regarding the natural history and outcomes of infantile hemangiomas (IHs) in the breast. Treatment in childhood may be considered due to psychosocial and physical concerns with breast development. Early surgical intervention may cause iatrogenic breast asymmetry and possibly impair lactation later in life. This study characterizes the clinical presentation, management, and long-term outcomes of IHs arising in the breast.

Methods

Female patients aged 11 years or older at presentation were included in a retrospective review of the Vascular Anomalies Center database for patients with IHs of the breast seen at our institution between 1980 and 2020. Breast development was ascertained by a structured telephone interview, physical examination, or photographs.

Results

A total of 10 patients met criteria for inclusion in this study. The median age at enrollment was 14 years (11-36 years). Breast asymmetry was noted in 60% of patients (n = 6). Of the four patients who underwent subtotal excision of breast IH, three developed ipsilateral breast hypoplasia. Breast asymmetry was also noted in three of five patients who did not receive medical treatment: two with hypoplasia and one with hyperplasia. No asymmetry was noted in the single patient who received corticosteroid.

Conclusions

IHs involving the nipple-areola complex can be associated with breast asymmetry. Hypoplasia was noted in patients not treated with corticosteroid or resection in childhood. These findings suggest that systemic treatment should be considered. Longitudinal follow-up on patients treated with propranolol will elucidate its possible benefits in minimizing breast asymmetry.

The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Data Sets

BACKGROUND

Timing of surgical intervention is controversial among patients seeking correction of congenital breast deformities.

OBJECTIVES

This study aimed to assess the influence of age on 30-day complications and unplanned healthcare utilization after reconstruction of congenital breast deformities.

METHODS

Female patients undergoing breast reconstruction for congenital breast deformities and Poland syndrome were identified on the basis of International Classification of Diseases (ICD) codes in the 2012 to 2021 pediatric and adult National Surgical Quality Improvement Project (NSQIP) data sets. Complications based on age at correction were compared, and multivariate logistic regression was used to identify predictors of overall and wound healing complications.

RESULTS

Among 528 patients meeting inclusion criteria, mean (SD) age at surgical correction was 30.2 (13.3) years. Patients most commonly underwent implant placement (50.5%), mastopexy (26.3%), or tissue expander placement (11.6%). Across the cohort, overall incidence of postoperative complications was 4.4%, most commonly superficial surgical site infection (1.0%), reoperation (1.1%), or readmission (1.0%). After multivariate adjustment, increasing age at time of correction was associated with higher incidence of wound complications [odds ratio (OR) 1.001; 95% confidence interval (CI) 1.0003-1.002; P = .009], in addition to BMI (OR 1.002; 95% CI 1.0007-1.004; P = .006) and tobacco use (OR 1.06; 95% CI 1.02-1.11; P = .003).

CONCLUSIONS

Breast reconstruction for congenital breast deformities may be safely undertaken at a young age with a low associated risk of postoperative complications. Large, multi-institutional studies are needed to assess the influence of surgical timing on psychosocial outcomes in this population.

Prophylactic Desexualizing Mastectomy for an Intellectually Disabled Woman: Protective Measure or Disregard for Autonomy?

Historically, sterilization of the so-called feeble-minded has been advocated in the name of eugenics. Surrogate decision-making that impacts sexuality of the intellectually disabled presents significant ethical dilemmas. We describe a 19-year-old intellectually disabled woman who presented with her legal decision-maker for surgical correction of her asymmetric chest and hypoplastic breast. The decision-maker requested a mastectomy to make the patient's breasts as inconspicuous as possible, and to reduce the risk of sexual assault and pregnancy. This case covers the ethical considerations on whether or not to prophylactically desexualize an intellectually disabled woman.

Genetic Factors of Idiopathic Gigantomastia: Clinical Implications of Aromatase and Progesterone Receptor Polymorphisms

The role of estrogen, progesterone, their receptors and aromatase in the development of the breast is well documented. In this study we examined the association of genetic variants of progesterone receptor (PGR) and aromatase (CYP19A1) genes with gigantomastia risk. We conducted a case-control study among 124 women: 60 with gigantomastia and 64 controls. We examined the single nucleotide polymorphisms (SNPs) for CYP19A1 (rs749292 and rs7172156) and PGR (rs1042838). Our results showed that allele G in rs749292 (CYP19A1) increased the risk of gigantomastia, but not significantly (p = 0.09). There is a correlation between rs1042838 (PGR) and waist-to-hip ratio (WHR) in women with gigantomastia-AC genotype correlates with lower WHR and CC with higher WHR. There were no correlations between the onset of gigantomastia, the age of menarche and the length of the menstrual cycle, and rs1042838, rs749292 and rs7172156. We did not find differences in the SNP of PGR (rs1042838) between women with gigantomastia and controls. However, our findings showed more frequent G allele in CYP19A1 (rs749292) in women with gigantomastia.

Autologous Fat Grafting with Percutaneous Fasciotomy and Reduction of the Nipple-Areolar Complex for the Correction of Tuberous Breast Deformity in Teenagers

BACKGROUND

Tuberous breast deformity in the adolescent can be a source of anxiety and social isolation. Current techniques of implant placement and flap reconstruction are not always feasible in this population.

OBJECTIVES

The authors evaluated the use of autologous fat grafting with percutaneous fasciotomy and reduction in the nipple-areolar complex for correction of tuberous breast deformity in teenagers.

METHODS

A retrospective chart review was conducted for nine teenaged patients with tuberous breast deformity who received autologous fat grafting between January 2016 and December 2018. The recipient site was prepared with the use of percutaneous fasciotomies to release the constricted lower pole of the breast, lowering of the inframammary crease, and reduction in the nipple-areolar complex. Fat was harvested by conventional liposuction prior to injection through three designated sites located at the inframammary fold, anterior axillary line, and upper pole. Complications were recorded.

RESULTS

Patients had an average age of 14.9 years at the time of surgery. An average of 1.8 filling sessions were required with a mean of 220 cc of fat injected per breast. Patients were followed for an average of 21 months postoperatively. No serious complications were noted. All patients reported satisfaction with their final outcomes.

CONCLUSIONS

Autologous fat grafting in conjunction with percutaneous fasciotomy and reduction in the nipple-areolar complex is a safe and effective treatment of the tuberous breast deformity in teenage patients. It provides an esthetic result with minimal scarring and high satisfaction rates while eliminating the need for flaps or implants.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Body size measurements, digit ratio (2D:4D) and oestrogen and progesterone receptors' expressions in juvenile gigantomastia

Background Juvenile breast hypertrophy is characterised by massive enlargement of the breast in the peri-pubertal period. We aimed to analyse body size measurements (body mass index [BMI], waist-to-hip circumference ratio [WHR]), digit ratio (ratio of II and IV digits' length [2D:4D]) and oestrogen receptor (ER) alpha (ERα) and progesterone receptors (PRs) in the breast gland in women with juvenile gigantomastia. Methods The study involved 30 women (mean age 25.7 years) (mean age of onset - 14.8 years). ERα and PR expressions were detected immunohistochemically in breast gland samples. For comparison, 100 controls (50 women and 50 men) were included. Results BMI and WHR in women with gigantomastia were higher than in control women and the former had a higher WHR than expected for their BMI. 2D:4D in the examined women did not differ from that in control women. However, left 2D:4D was negatively related to the age of gigantomastia onset. There were no correlations between ER and PR expressions and the analysed body and digit ratios. Conclusions The lack of a relationship between 2D:4D and juvenile breast hypertrophy may suggest that foetal exposure to sex hormones may not be crucial in its aetiology. However, the link between high left 2D:4D and early development of gigantomastia suggests that prenatal sex hormones have a role in its development timing. High WHR, and particularly high WHR relative to BMI, may indicate that these women had at some stage of development higher circulating androgens, which may have been converted to oestrogens in breasts due to local aromatase activity. Verification of this hypothesis could allow consideration of the role of aromatase inhibitors in juvenile breast hypertrophy.

Correction of the tuberous breast deformity in a prepubescent male patient: A surgical approach to an unusual problem

Purpose

The management of the tuberous breast deformity in the female patient is well described. However, the presence of this variant in male patients is particularly rare, and few reports on the management of this condition are available.

Case presentation

A 12-year-old prepubescent male with bilateral gynecomastia and tuberous breast deformities was referred to our department for treatment. Our surgical management, including free nipple areolar complex harvest, mastectomy, removal of excess skin and subsequent nipple grafting, is presented in detail. We observed a cosmetically acceptable result with restoration of a masculine-appearing nipple-areolar complex and good patient satisfaction at 6-month follow-up.

Conclusions

Tuberous breast deformities in male patients are rare. Our treatment of a prepubertal male patient with this deformity using mastectomies and free nipple areolar complex grafting provided a cosmetically acceptable result. Here, we review the current literature on tuberous breast deformities in males and describe our approach to treatment.

Surgical Treatment of Adolescent Breast Disorders: Institutional Experience and National Trends

STUDY OBJECTIVE

Adolescent breast disorders are rare and typically benign in nature; however, surgical treatments might require multiple surgeries. Because of the limited existing data, we sought to evaluate national trends and describe our institutional experience to help guide patient conversations.

DESIGN

Retrospective review.

SETTING

National database and academic institution.

PARTICIPANTS

Patients 20 years old or younger who underwent a breast procedure in the Kids' Inpatient Database from January 2000 to December 2012 and at Mayo Clinic-Rochester from January 2000 to July 2016. Conditions were categorized into common and complex breast disorders.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

To assess any trend of adolescent breast procedures across the United States as a whole, weighted Kids' Inpatient Database data were assessed using a Rao-Scott χ² test. Within the institutional data, the average number of procedures needed to correct common vs complex breast disorders were compared using an unequal variance t test.

RESULTS

In recent years, the estimated number of hospitalizations for breast procedures decreased in the United States from 1661 in 2000 to 1078 in 2012 (P < .001). At our institution, 241 patients underwent a breast procedure (75.1% [181/241] female) over 16 years. Common breast disorders were corrected with fewer procedures than complex breast disorders (mean 1.09 vs 2.22 procedures; P = .0003).

CONCLUSION

Inpatient treatment of adolescent breast disorders has been decreasing in recent years, likely reflecting a trend to outpatient procedures. Common adolescent breast disorders might be surgically corrected with 1 procedure, whereas complex disorders often require multiple surgeries to correct. It is important to discuss this with patients and their families to adequately set up expectations.

Correction of tuberous breast deformity: A retrospective study comparing lipofilling versus breast implant augmentation

Breast implants and, more recently, autologous fat grafting are the two most common treatments used to correct tuberous breast deformity (TBD). The post-surgical quality of life between the two techniques is not well demonstrated. This study aimed to compare satisfaction and health-related quality of life in patients affected by TBD between these two techniques. All TBD patients operated between January 2008 and May 2015 were retrospectively identified, and only those treated with implants or lipofilling were included. Satisfaction was evaluated at least 6 months after surgery with the postoperative Breast-Q^® augmentation module. From January 2008 to May 2015, 62 patients were recruited in our study, and 37 patients were evaluated using a Breast-Q questionnaire after at least 6 months of follow-up. Breast implant-augmented patients were significantly more satisfied concerning the "satisfaction with breasts" module (p = 0.002) and the "satisfaction with outcome" module (p = 0.00008). A question-by-question analysis revealed several interesting and significant differences, showing higher scores in most of the questions in the breast implant group. Patients in the lipofilling group, interestingly, had a mean of 1.6 interventions compared to the mean 1.36 interventions in the implant group (p = 0.23). This reflects the need to perform more surgical sessions in the lipofilling group to achieve a satisfactory result. Our study demonstrated that tuberous breast correction with implants can achieve better satisfaction along with good outcomes than lipofilling usually does.

Pseudomamma of the inguinal region in a female patient: A case report

INTRODUCTION

Supernumerary breasts are relative common benign congenital anomalies. General population occurrence rates vary up to 6% according to ethnicity and gender. Higher incidence is recorded in Asian individuals, especially Japanese. Embryonic breast development of the mammary ridge (milk line) is explained and supernumerary breast tissue resulting from involution failure of any portion of the embryonic mammary folds is described.

PRESENTATION OF CASE

We report a case of supernumerary breast (pseudomamma) in a female occupying her right inguinal region that was treated in the breast unit of our hospital. Differential diagnosis, imaging methods, operative approach, surgical treatment and histological verification are specified.

DISCUSSION

Classification system for supernumerary breast tissue is presented, high risk population is identified and congenital malformations linked to it are outlined. Evaluation of diagnostic workup and limitations are stated. Cancerous degeneration and justification for surgical removal of the accessory gland is discussed.

CONCLUSION

Differential diagnosis of lesions along the milk line should always be inclusive of developmental abnormalities such as any type of supernumerary breast, often overlooked due to small size, although carrying a malignant potential equal to normally positioned breasts. Surgical correction is a sensible approach, often encouraged by the patients. Additional evaluation is recommended due to the frequent accompanying urinary tract and cardiac anomalies.

Nonsurgical management of fibroadenoma and virginal breast hypertrophy

The management and treatment of an adolescent presenting with a fibroadenoma or virginal breast hypertrophy can be challenging as there is a paucity of original research on these conditions. Although surgical therapies are often discussed as first-line therapy in adolescents presenting with a breast mass, it is prudent that nonsurgical interventions and medical therapies be considered as initial therapy with the goal of maintaining an acceptable cosmetic outcome.

Hypoplastic breast anomalies in the female adolescent breast

Hypoplastic breast anomalies remain a reconstructive challenge. In this article, the authors review the spectrum of nonsyndromic breast hypoplasia in the adolescent girl, namely idiopathic breast hypoplasia and tuberous breast deformity. Challenges specific to this population include (1) identifying the ideal timing for surgery, (2) choosing the optimal reconstructive method while taking into consideration ongoing changes in the female body (e.g., future pregnancy), and (3) considering the use of a two-stage reconstructive approach to gradually expand the skin envelope. A comprehensive review of surgical techniques that address these conditions is provided, taking into account the evolution and the most recent advances in surgical techniques.

Treatment of a supernumerary large breast with medial pedicle reduction mammaplasty

Accessory breast tissues including nipples, areolas, and glandular tissue may develop on the chest in addition to two normal breasts. An accessory breast with a complete ductal system, areola, and nipple is termed a "supernumerary breast." Supernumerary nipples are fairly common, but complete supernumerary breasts are rare. This report describes an 18-year-old woman who presented with a complete supernumerary breast including a nipple-areola complex located on the upper outer quadrant of her left breast and causing severe breast asymmetry. She was referred to the authors for aesthetic reasons. Unilateral reduction mammaplasty was performed to remove the supernumerary breast and correct the breast asymmetry. The medial pedicle Wise technique was used for en bloc resection of the ectopic breast, including the nipple-areola complex together with the upper outer breast quadrant. The woman's postoperative course was uneventful. At 8 months after surgery, she was very satisfied with the results. Ectopic breast tissue can be treated by a variety of methods such as liposuction or excision. However, breast deformation because of a complete supernumerary breast is very rare, and research on the treatment of such patients is lacking. No reports describing surgical treatment for this condition were identified in the literature. The authors suggest that unilateral breast reduction is the most appropriate treatment, allowing excision of the accessory tissues, with the best possible cosmetic outcome.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Congenital abnormalities of the breast

Congenital abnormalities of the breast and chest wall are seen frequently in breast, pediatric and plastic surgery clinics. Management involves a multidisciplinary team approach. The treatment for many of these conditions includes surgical correction. If the child is still growing, treatment timing is crucial and many of the surgical corrective procedures require more than one operation over a number of years. Although these deformities have less impact on functional capacity, the psychological consequences can be serious in adolescent patients. They can experience embarrassment, social isolation and complexities during sexual development, and this results in problems with relationships. The aim of this article is to spread awareness among the medical community of this range of conditions, so appropriate referrals are made and their impact is reduced by timely appropriate surgical intervention if appropriate.

Early, staged reconstruction in young women with severe breast asymmetry

STUDY OBJECTIVE

To retrospectively examine a cohort of young women with severe hypoplasia or asymmetric breast development who underwent breast reconstruction with tissue expansion and to determine complication rates as well as patient satisfaction.

DESIGN

Chart review.

SETTING

The University of Michigan Hospital, a tertiary care center.

PARTICIPANTS

Women less than 25 years of age who underwent staged breast reconstruction with a tissue expander between 1998 and 2006.

MAIN OUTCOME MEASURES

Complication rate and patient satisfaction.

RESULTS

The mean age of patients undergoing the procedure was 18.1 years (range 14-25 years). Of 10 patients with recorded tobacco use, 8 (80%) were noted to be nonsmokers. One of 14 patients (7.1%) was found to have a minor complication (cellulitis), and 2 of 14 (14.2%) were found to have major complications. Of the 13 patients who had at least 6 weeks of follow-up after completion of their reconstruction, 10 were subjectively documented as pleased with the result, 2 records made no mention of patient satisfaction, and 1 patient had concerns regarding her results.

CONCLUSION

Our study shows promising results for the use of tissue expanders in young women with significant breast asymmetry or unilateral/bilateral micromastia. The very important issues of short-term and long-term satisfaction and outcomes needs further study before advocating an early approach to teens with breast deformities.

Autologous rib transplantation and terylene patch for repair of chest wall defect in a girl with Poland syndrome: a case report

Poland syndrome is a constellation of anomalies including absent pectoralis muscle and rib defects, even with malformations of the upper extremity that more often affects boys than girls. This case describes a 5-year-old and 4-month-old girl diagnosed with Poland syndrome that required chest wall reconstruction. An autologous rib transplantation and terylene patch were used for repair of the chest wall defect. The girl had a satisfactory postoperative recovery. This technique was an effective method of treatment of this condition.

Disorders of sexual differentiation in the adolescent

Disorders of sexual differentiation (DSDs) presenting during adolescence are discussed, and molecular explanations are given for some. DSD conditions are often discovered during early adolescence, an age well known to predispose to high risk for adjustment problems. Presentation may be with lack of or minimal pubertal development, lack of menarche, vaginal, uterine, or breast agenesis and inappropriate sexual development such as virilization in females or feminization (gynecomastia) in males. Most such disorders require life-long therapy, with many of the medical, surgical and psychological aspects of management being accentuated during adolescence. Regardless of the age at presentation, all require skillful management to promote normal health and well-being. This care ideally involves specialists in endocrinology and medical therapy, psychology and, if required, surgery. A brief discussion of the needs of the adolescent with DSDs is presented.

Amazia with midface anomaly: case report

Amazia, the absence of the mammary gland, is a very rare congenital anomaly of the breasts. Bilateral absence of the breasts may occur as an isolated anomaly or may be associated with a syndrome or a cluster of other anomalies. Although the literature examining pediatric breast abnormalities is replete with case reports and series, bilateral amazia together with skeletal anomalies has not yet been described. An unusual case of amazia associated with face, limb, and vertebrae anomalies is presented.