The Incidence of Tuberous Breast Deformity in Asymmetric and Symmetric Mammaplasty Patients

This article, like others before it, documents that some form of breast asymmetry is the rule rather than the exception. Asymmetry is present in 81 percent of the patients in this study, and in 88 of 100 patients seeking augmentation mammaplasty by Rohrich et al.1 In 1976, Hueston2 said “asymmetry is normal” and prior and subsequent observers have agreed. There also is agreement that a wise surgeon recognizes and addresses asymmetry preoperatively and adjusts the surgical technique for each breast, as needed. The article then goes on to state that 88.8 percent of patients with asymmetry have tuberous breast deformity. The authors found tuberous deformity in 57 percent of all women coming in for reduction mammaplasty. They identified it in 83 percent of all those coming in for augmentation mammaplasty. This is very surprising because it would be an extraordinarily high prevalence of tuberous breast deformity and is not consistent with experience, or with what has been reported in the literature. Given this, the obvious thing to ask is, “What criteria were used to diagnose tuberous breast deformity? ” The authors used a classification described by Grolleau et al.3 and assigned “tuberous deformity” to any breast with a morphology falling into one of the three categories he set up. The problem with this approach is that Grolleau was grouping together anomalies of the breast base and those that preferentially involve the lower quadrants. He did not call all of these “tuberous breasts”; instead he referred to “lower pole hypoplasia,” “narrow-based breast,” and “minor deformities. ” His article states that “tuberous breasts are the most typical, but not the only, form of the deformity. ” (Italics mine.) It describes his hypothesis that breast base anomalies can be thought of on a continuum when devising treatment strategies and for this reason his classification focuses on restoring normal dimensions of the breast base, “whatever the type of deformity. ” Grolleau et al. did not focus on the nipple-areola complex when developing their classification. They remark in their article that areolae can be enlarged but that glandular hernia is not always present unless dealing with the severe types of breast base anomaly. With this understanding of the Grolleau classification, it becomes apparent that the present authors are probably applying the term “tuberous” to all breasts where the lower pole is narrow or tight and/or the inframammary crease is high. This would help to explain the 88.8 percent prevalence, but, even then, one wonders about their finding that 83 percent of all patients seeking augmentation have “tuberous deformity. ” Are they overreading deformity to include the many women, especially nulliparous ones, with small breasts who have a tight skin envelope and higher inframammary fold? This is an especially relevant question since the five evaluators who analyzed the patients’ photographs were medical students and residents with only one plastic surgeon involved. Experience counts in making the distinction between what is a normally tight skin envelope versus lower pole constriction. The single case shown in the article emphasizes this. It serves as more than an illustration of postoperative accentuation of the nipple-