Hello! Tuberous breast deformity is tough! Yours is pretty severe in that the lower breast pole is very short and constricted. Luckily you have only mild asymmetry (as significant asymmetry in tuberous breast deformity is common) and not much droop (called ptosis). The underlying mechanism is a circular band of fibrous tissue that prevents the breast tissue from developing normally to expand the lower breast pole. Instead, the developing breast tissue takes the path of least resistance as it grows and it herniates through the nipple areola complex (because there is no thick tissue called fascia under this area). The developing breast tissue isn't able to expand the lower breast skin because of the fibrous band so the nipple areola complex accommodates it by allowing it to herniate through. This is why large, puffy/protruding nipple areola complexes are typically seen in association with tuberous breast deformity. So there’s several things that need to be corrected to allow the breast to take on a more aesthetic tear drop like shape. First the fibrous band needs to be released. Second, the lower breast pole needs to be expanded. The length from the nipple to the breast crease (inframammary fold or IMF) is very short so typically this point of natural attachment needs to be released to allow for an implant to fill out the lower breast pole. Releasing the IMF is tricky because it is the structure that helps hold up an implant and prevent it from sliding down towards the abdomen (what we commonly refer to as bottoming out). So once the high and tight IMF is released it must be reattached where in the new desired position. The native IMF is what gives the appearance of a double bubble deformity and so adequately releasing this and the fibrous band are what help allow the crease to stretch. Even still, the skin has some memory to it (think of it almost like scar tissue) because it was used to being in that position for your whole life. We’ll come back to that in a minute. Step three is placing the implant of your desired size and profile, which is partly based off of the base width of your breast footprint (you mentioned 12cm). Placing the implant above the muscle is possible, but has a slightly higher incidence of capsular contracture because it is close to the breast glandular tissue, which is open to the outside world via the breast ducts and so inherently contains some bacteria. Also, implants placed above the muscle are at risk for bottoming out over time because the only think holding them up is the skin, which tends to stretch under the weight of an implant and with decreased skin elasticity (both which occur over time/age). In a typical patient without tuberous breast deformity that wants implants placed above the muscle, I would recommend mesh placement to help prevent bottoming out. In a tuberous breast patient, I would lean towards no mesh placement because it counteracts the goal of stretching out the lower breast pole tissue. *If* the implant were to ever bottom out (which is less likely with smaller sized implants such as the one you mentioned, you could have a secondary surgery to reposition the capsule/implant (capsulorrhaphy) and possibly place mesh at that time. It is just a risk you have to be aware of. About the areola size – we commonly decrease the areola size with a donut areola reduction or donut mastopexy procedure and place a permanent suture to help prevent it from stretching back out. What we have seen over time is that the areola may still stretch out anyways now the patient has a scar around their areola and a permanent suture that may need to be removed one day (as sometimes they extrude, become visible or can be felt, or get infected). So patients without immensely large areolas (i.e. the size of your palm) that opt to not have their areolas reduced during their tuberous breast deformity surgery often do just fine and are happy if the areolas are left alone. Again, you can always go back do an areola reduction surgery in the future if you wanted to (no bridges burned). Rippling is common in slim patients such as yourself. The newer implants come in different fills (i.e. how much silicone is in them) and different cohesivities (how firm, soft, mobile the silicone is). You would do better with a more optimally filled silicone implant to decrease risk of rippling. It may still appear “shelfy” on the upper pole if it is placed above the muscle because the pectoralis muscle isn’t covering it and you are slim. So the last add on to consider in your procedure is fat grafting. We typically use this to fill out the upper breast pole (to decrease the “shelfy” appearance of the implant) and in the lower pole to help improve the tissue thickness, help with expansion a bit and fill out the crease from the native IMF (that causes the double bubble deformity). You are very thin, so it would likely be somewhat difficult to harvest a lot of fat, but generally we only transfer somewhere in the ballpark of 100-400cc in these types of cases anyways (since we are using the fat to soften the breast shape/curvature rather that to augment it in place of an implant). Even with all of these steps executed well, it is likely that you will need or want a secondary procedure in the future (and if you are happy with your result, then great, no need for it!...but I would recommend planning for it just in case). Tuberous breast deformity is a tough situation to correct, but there are certainly techniques that can markedly improve the breast shape. Hope that helps! Wish you all the best!
