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:
I. Breast asymmetry
II. Tuberous breast deformity
III. Inverted nipples
IV. Elongated nipples
V. Capsular contracture of breast implants
VI. Visible rippling of breast implants
VII. Malposition of breast implants (including “bottoming out”)
Please refer to the Photo gallery where you will find a corresponding section showing images of patients Dr. Creasman has treated with each of these problems.
I. BREAST ASYMMETRY
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 this requires plastic surgery is when the degree of asymmetry is so much that it requires camouflaging itby padding the bra every day. This is a nuisance and can be embarrassing. Asymmetry can be dramatic such as a D cup size breast on one side and an A cup on the opposite side. Improving this is sometimes not only cosmetic; it may also improve function.
The exact nature of the asymmetry is not always readily apparent, but Dr. Creasman will evaluate it in detail and describe it fully. He uses the Vectra 3D breast imaging system to help explain this. 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. Indeed, not all of these factors can be changed with surgery.
Treatment 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 variations in treatment here, Dr. Creasman will analyze your asymmetry and then tailor a treatment plan that will address as many aspects of the asymmetry as you wish to have done. What might be required – for example a mastopexy or breast lift – may not be acceptable to you because of the scars. You may only wish to correct the volume difference but live with an asymmetry in the positions of the nipple and areola. The treatment is individualized to your goals.
II. TUBEROUS BREAST DEFORMITY
The condition known as “tuberous breast deformity” is a developmental variation of breast shape and growth wherein the breast assumes a constricted or narrow shape. The breast has a tight inframammary crease at the bottom and a very short distance from the nipple to the crease, and often a bulging nipple and areola that is larger in diameter than fits the size of the breast. The condition may exist on one or both sides.
Women who have developed this way are usually very self-conscious about their condition and apprehensive about having their breasts seen by anyone. The treatment is involves expanding the base of the breast with a breast implant, 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 sometimes go completely around the edge of the areola and possibly under the breast in the new crease. 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.
III. 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 short milk ducts, the cause of which is unknown. With stimulation, the nipple may emerge from its inverted 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 even more inward. This can even be uncomfortable. For most women this is a cosmetic 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 minor procedure done under a local anesthetic with or without intravenous sedation. It can also be done at the same time as 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, so nursing may not be possible with or without the procedure. 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 excellent.
IV. ELONGATED NIPPLES
Elongated nipples are usually the result of prolonged breast-feeding, but may just be be an individual feature. The elongated nipple 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 pushed in, so 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.
V. CAPSULAR CONTRACTURE
Capsular contracture is the term used to describe shrinkage of scar tissue around a breast implant that can make the breast feel hard and/or distort its appearance. When severe enough, capsular contracture requires surgical removal of the scar and replacement of the implant. The frequency of this problem reported in the medical literature varies widely depending on what study is quoted, but seems to be reduced with use of cohesive gel implants, placement of the implants under the muscle, use of antibiotic solutions during the surgery, and placement of the implant with an insertion funnel to protect the implant from touching the skin.
Scar always forms around breast implants and is 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 body’s 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 not be less than the surface area of the prosthesis for the prosthesis 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, however limited evidence that an asthma drug called Singulair may help prevent recurrence of the problem after the scar is removed. The surgical treatment involves removal of the scar tissue surrounding the prosthesis 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.
There is also early evidence that placement of material known as ADM (acellular dermal matrix, brand names include Alloderm and Strattice) reduces the redevelopment of capsular contracture.
VI. VISIBLE BREAST IMPLANT RIPPLING
Breast implants, particularly saline-filled implants, may be seen through the overlying skin and breast tissue in some patients. Especially with changes in position, such as leaning forward, this may be more pronounced. This is more likely to occur under the following conditions:
Saline more often than silicone more often than cohesive gel (“gummy bear”) implants
Placement of the implant above the muscle more than placement under the muscle
Women with very small pre-operative cup sizes (A or AA)
When textured surface implants are used
When larger volume implants are used
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 the choice of any of the above options when deciding to undergo the procedure at the outset. Dr. Creasman almost never uses textured saline implants, prefers to place the implants beneath the pectoralis muscle whenever possible, and discourages use of very large breast implants because the more weight is placed on the skin, the more it stretches and thins out.
If it occurs, treatment involves replacing the implant with a more favorable prosthesis for the patient, and often revising location if possible. The specific treatment for any given patient will be developed and discussed by Dr. Creasman in the consultation.
VII. BREAST IMPLANT MALPOSITION
Following breast enlargement, breast implants may settle into an incorrect position. This is sometimes 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 “lower pole stretch deformity”, or a location lower than optimal aesthetically which can be the result of stretching of the skin between the nipple and the crease. Sometimes a “double bubble” occurs if the fold is excessively lowered during the original breast augmentation. Another location problem is excessive spacing between the breasts or detachment of the skin between the breasts known as symmastia.
Regardless of the type of 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. These can be difficult problems 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.