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Breast/Problems

This section of our website contains a number of sections devoted to the explanation of a variety of breast problems that Dr. Creasman sees on a less frequent basis.  These include congenital breast problems as well as issues that arise as a consequence of breast implant surgery.

The topics presented here are:

1. Breast asymmetry
2. Tuberous breast deformity
3. Inverted nipples
4. Elongated nipples
5. Capsular contracture of breast implants
6. Visible rippling of breast implants
7. Malposition of breast implants (including “bottoming out”)

Please refer to the Photogallery where you will find a corresponding section showing images of patients Dr. Creasman has treated treatment of each of these problems.

BREAST ASYMMETRY

Breasts are almost never perfectly symmetrical.  All women have some degree of asymmetry, or difference in size or shape or location of the breast on the chest.  The point at which the breast asymmetry becomes a problem necessitating plastic surgery is when the degree of asymmetry is such that the woman has a day-to-day issue with camouflaging the asymmetry with padding or other such measures.  This is embarrassing and a nuisance.  It is not uncommon to see a patient who uses a D cup bra on one side, but could wear a B cup on the opposite side.

The exact nature of the asymmetry is not always readily apparent.  The patient usually realizes there is a different volume, or amount, of breast tissue.  But what is often not so obvious is that this is usually accompanied by more skin on the larger side, possibly a larger diameter areola, a difference in the relative position of the nipple and areola, a difference in the location of the crease beneath the breast, and sometimes even a different configuration of the underlying rib cage.  Not all of these facets of the asymmetry may be present and not all need be addressed to achieve an acceptable degree of symmetry.

The nature of the surgical approach to this problem varies from placing an implant on one side only to attempt to match the larger breast, to reducing the size of the larger breast to match the smaller breast, to placing implants of different sizes, to doing a breast lift with or without implants.  Rather than going into all the permutations of the treatment here, suffice it to say that Dr. Creasman will analyze to the best of his ability the patient’s asymmetry and will then tailor a treatment plan that will attempt to address as many of the aspects of the asymmetry as the patient is willing to have addressed.  By this, what is meant is that what may be required (e.g. a mastopexy or breast lift) may not be desired by the patient.  The patient may only wish to correct the volume issue but live with the difference in the positions of the nipple and areola.  So the treatment is individualized.  Long-term studies have shown that the stability of the asymmetry correction is greater if the larger breast is made smaller than is an implant is placed in the smaller side.  The stability of either a breast implant procedure or a breast reduction procedure can be adversely affected by pregnancy and nursing, such that revisionary surgery may be required after the completion of childbearing.

TUBEROUS BREAST DEFORMITY

The condition known as “tuberous breast deformity” is a developmental disorder of breast shape and growth wherein the breast assumes a constricted shape. The elements of this problem include a narrow base width of the breast much smaller than would be proportional to the chest, a tight inframammary crease with a very shortened distance from the nipple to the inframammary crease, and often a herniated, or bulging, nipple and areola that is larger in diameter than would proportional to the size of the breast. The condition may exist on one or both sides. 

Women who have developed in this way are usually very self-conscious about their condition and are very apprehensive about having their breasts seen by anyone. The treatment is somewhat complicated, but typically involves expanding the base width of the breast with an implanted prosthesis, lowering the inframammary crease, and reducing the bulging of the nipple and areola. The scars are similar to those used to place breast implants, but they go completely around the edge of the areola. Dr. Creasman will discuss in much greater detail certain aspects of the treatment of this condition, but more information can be found in the section on Breast Augmentation. 

INVERTED NIPPLES

In some women, the nipple (or papule in medical terms) may not protrude normally. When this is the case, the condition of inverted nipples exists. This is due to congenitally foreshortened milk ducts, the cause of which is unknown. With stimulation, the nipple may emerge from its cryptic location within the breast, but in some patients even stimulation may not bring the nipple out. In more advanced degrees of this problem, stimulation may actually lead to the nipple turning inward in a more pronounced way. This can even be uncomfortable. For the most part this is an aesthetic problem, but when the nipple is unable to protrude even with stimulation, then breast-feeding is impossible. 

Fortunately, there exists a procedure to surgically bring the nipple out. It involves incisions in or at the base of the nipple. This is a small procedure done under a local anesthetic with or without intravenous sedation. It can also be done at the same time as a breast enlargement. It may allow breast-feeding later in life, but the condition of inverted nipple is the result of foreshortened breast ducts that may not function normally under any circumstances. Nursing may not be possible whether or not such a procedure is done to correct the appearance of the nipple.

The recovery from this procedure is usually relatively painless and rapid. The sutures used are self-absorbing. The nipple scar is virtually invisible once healing is complete. Sensation to the nipple is usually not altered. Results are usually quite satisfactory.

ELONGATED NIPPLES

Elongated nipples are usually the result of prolonged breast-feeding, but may be an anatomical variant in some women. The elongated nipple (or papule, in medical terms) can be a source of embarrassment to some women. The nipples show through bras, even with padding. A simple procedure to reduce the length or projection of the nipple is available. This procedure involves removing a strip of outer nipple skin. The inner breast ducts are allowed to telescope in, and when the skin edges are then sewn together, the nipple protrudes far less. 

The procedure can be done under a local anesthetic with or without intravenous sedation, and is often done at the same time as a breast augmentation. The scar that results is located at the base of the nipple and is hardly noticeable. Sutures are self-absorbing, making post-operative care simple and relatively painless. Incisions heal in a week or so, but the nipples may be a bit sensitive for several weeks. Long term sensation of the nipple is rarely affected. Patients are usually very satisfied with the results of this simple procedure.

CAPSULAR CONTRACTURE

Capsular contracture is the term used to describe hardening of the breast that can occur as a consequence of implantation of a breast prosthesis. It actually represents shrinkage of the circumferential scar that universally occurs as a normal response to the presence of any foreign body, or in response to injury of tissue. Any wound to the body results in a biological response to that injury that ultimately leads to healing of tissues together by scar. Without scar, injured tissues would never rejoin. When a foreign object, including a medical device such as an artificial joint, a heart valve, or a breast implant is placed within the body, the normal biological response is for scar to be laid down where the prosthesis abuts the host’s tissues. 

When it comes to a breast implant, the surface area of this scar must exceed the surface area of the prosthesis for the prosthesis to freely move within the space that is occupies. If the layer of scar that surrounds the implant, which is itself like a bag or rough sphere of scar tissue, were to shrink (like “shrink wrap” on a package) then the implant would be unable to move around within that space. This results in a loss of fluidity of movement, which makes the implant feel hard to the touch. In severe cases, the breasts are distorted and tend to ride up on the chest. It can even become so hard that the breasts ache.

Plastic surgeons have studied this problem from many different perspectives and the exact cause of capsular contracture is unknown. What is known is that it doesn’t improve once is progresses to a particular degree. A classification scheme (known as the Baker Classification) has been proposed that describes different levels of severity of capsular contracture and it goes like this:

Grade I Normally soft and natural 
Grade II Firm to the touch, but not apparent without feeling the breast
Grade III Visible distortion of the breast
Grade IV Severe firmness, with distortion and pain

There are no tests that can predict whether a patient is likely to develop capsular contracture. There is currently no known non-surgical treatment, like a pill or physical therapy, which will improve capsular contracture. The treatment involves surgery in which the scar tissue surrounding the prosthesis is removed or scored to open up the space so that the implant can move around. This is sometimes more involved than the original breast implantation surgery, though the recovery is usually much less painful. Unfortunately, this treatment does not guarantee that the problem will not recur.

VISIBLE BREAST IMPLANT RIPPLING

Breast implants, particularly saline-filled implants, can in some patients be seen through the overlying skin and breast tissue. Especially with changes in position, such as leaning forward lying on one’s side, this may be more pronounced. This is more likely to occur under the following conditions:

1. Saline (vs. silicone gel) implants
2. Subglandular (vs. subpectoral) placement of the implant
3. Women with very small pre-operative cup sizes (A or AA)
4. When textured surface implants are used
5. When larger volume implants are used
6. In body builders who often have a low percentage of body fat

The best treatment for visible rippling is to reduce the probability of it occurring by avoiding election of any of the aforementioned options when deciding to undergo the procedure in the beginning. Dr. Creasman almost never uses textured saline implants, prefers to place the implants beneath the pectoralis muscle whenever possible, and discourages excessive breast implant size choice. 

Once it occurs, the treatment involves replacing the implant with a more favorable prosthesis for the patient, and often revising location as well if possible. The specific treatment for any given patient will be developed and discussed by Dr. Creasman in the consultation.

BREAST IMPLANT MALPOSITION

Following breast enlargement, breast implants may settle into an incorrect position. This is usually a technical or judgmental error by the surgeon, but may be due to the inherent asymmetry of the patient, unpredicted excessive tissue laxity, or positional variations after surgery (e.g. sleeping with one arm over the head). The most common form of undesirable implant location is commonly known as “bottoming out”, or a location lower than optimal aesthetically. Another is excessive spacing between the breasts.

In any event, the proper term used to describe this problem is implant malposition. The treatment is to relocate the implant by reconstructing the proper implant pocket. Sometimes the pectoralis muscle has been incompletely released, or over-released from the ribs or breastbone. Sometimes relocation of the implant to a different level of placement (subglandular or subpectoral) is necessary to correct the problem. It can be a difficult problem to correct precisely, but usually can be improved significantly with revisionary surgery. Dr. Creasman will analyze the particular problem in each patient and tailor the surgical approach to that specific situation.