Tuberous Breast Deformity: Features, Classification, and Surgery

This article explores tuberous breast correction, detailing aesthetic improvement strategies and symmetry via specific surgical techniques, guided by Von Heimburg's classification for precise and optimal outcomes.
Tuberous Breast Deformity: Features, Classification, and Surgery

Summary Card

Definition of Tuberous Breasts
A congenital deformity characterized by constricted, elevated, herniated, and hypoplastic features, while maintaining normal function.

Clinical Features of Tuberous Breasts
Features vary widely, commonly including asymmetry, hypoplasia, constricted base, IMF elevation, herniated nipple, ptosis, and skin envelope insufficiency.

Classification of Tuberous Breasts
Von Heimburg's 1996 system is crucial for assessing the condition, emphasizing the identification of specific affected areas to inform surgical strategies.

Surgery for Tuberous Breasts
Aims to release constrictions, restore volume, reposition the inframammary fold, and achieve symmetry, involving techniques like periareolar incisions, radial scoring, dual-plane pocket creation, and may require single or two-stage procedures depending on severity.

Primary Author:
Dr Kurt Lee Chircop, Plastic Surgery Trainee, Malta

Definition of Tuberous Breasts

Key Point

Tuberous breast is a congenital deformity characterized by a constricted, elevated, herniated, and hypoplastic appearance, with normal function retained.

A "tuberous breast" is a congenital breast deformity that results in a constricted, elevated, herniated and hypoplastic breast (Rees, 1976). The breast maintains normal function and physiology.

Tuberous Breasts, Breast Deformity
Definition of Tuberous Breasts

True incidence is unknown in view of significant under-reporting, especially with the minor forms of the spectrum of deformity. Typically found in patients presenting for breast augmentation or mastopexy with incidence of 30-50% (Klinger, 2016)

Fun Fact: It's aetiology is most likely of embryologic origin. It occurs due to peri­-areolar ring constriction and thin or hypoplastic areolar fascial support (Pacifico, 2007)

Clinical Features of Tuberous Breasts

Key Point

Tuberous breast deformity features asymmetry, hypoplasia, constriction, and ptosis, making accurate diagnosis crucial for effective aesthetic correction beyond just volume increase.

Tuberous breast deformities present on a clinical spectrum. The condition can be unilateral or bilateral and is very commonly asymmetric in nature.

The key clinical findings include the following:

  • Volume: parenchymal hypoplasia and asymmetry.
  • Base constricted: deficient width (horizontal) and height (vertical)
  • IMF: medial and or lateral elevation; complete absence.
  • Nipple: herniated and widened
  • Ptosis: mild to severe, often defies stan­dard classification.
  • Skin envelope: insufficiency, typically inferior pole.

Below image identifies the clinical features of Tuberous Breast Deformity.

Clinical Features of a Tuberous Breast, Breast Deformity, Surgical Procedures
Clinical Features of a Tuberous Breast

Tip: The diverse and asymmetrical nature of tuberous breasts complicates aesthetic corrections. Proper diagnosis is key, as solely increasing volume may not yield satisfactory outcomes. (Rees, 1976).

Classification of Tuberous Breasts

Key Point

Von Heimburg's 1996 classification is key for accurately assessing and predicting outcomes of tuberous breast deformity by detailing specific affected areas.

Precise nomenclature and classification are crucial for preoperative assessment of tuberous breast deformity, enabling the identification of specific characteristics and their severity to ensure more predictable outcomes.

Among the various classification systems Von Heimburg's 1996 framework has been popularised. It categorises the deformity based on the affected areas (von Heimburg, 1996)

von Heimburg Classification of Tuberous Breasts, Breast Deformity Treatment
Classification of Tuberous Breasts

Fun Fact: The Northwood index, calculated by dividing the nipple's forward projection from the areola edge by the areola's diameter (both in centimeters), objectively identifies tuberous breasts in a clinical setting; a ratio over 0.4 suggests areolar herniation indicative of the condition

Surgery for Tuberous Breasts

Key Point

Tuberous breast correction surgery involves periareolar incision for precise adjustments, radial scoring to release constrictions, and dual-plane pocket creation for optimal shape, with procedures varying from single to two-stage based on individual needs for achieving desired breast volume and symmetry.

Goals of Surgery

For patients dissatisfied with their breast shape or size due to tuberous deformity, surgical correction aims to:

  1. Release constrictions.
  2. Restore breast volume.
  3. Reposition the inframammary fold.
  4. Achieve symmetry.

Typically, a single-stage procedure suffices, leveraging the distensibility of soft tissues. However, for severe cases or when larger volumes are desired and tissues lack pliability, two-stage procedures with expanders may be necessary.

Check out these below video for more insights on the surgical procedure for Tuberous Breasts.

1 hour Video on Surgical Technique

Overview of Surgical Technique

This guide outlines common steps in tuberous breast correction surgery, noting that techniques may vary among surgeons.

  • Periareolar Skin Incision: Allows areolar reduction, access to the subglandular plane, and radial release of constriction rings.
  • Dissection: Proceeds down to the subglandular prefascial plane, extending inferiorly to the new inframammary fold (IMF) position.
  • Radial Scoring: Involves radial incisions into the glandular tissue perpendicular to the subglandular layer, particularly at the lower pole to release constrictions and facilitate expansion.
  • IMF Positioning: Through transglandular dissection to the prepectoral fascial plane, defining the new lower limit of the breast.
  • Pocket Creation: Establishes a dual-plane pocket via a horizontal incision in the lower part of the pectoralis major muscle, combined with retropectoral dissection, resulting in a Dual-Plane Type 3 pocket.
  • Volume Replacement: Selection between implants or expanders, round versus anatomical shapes. Utilizes a sizer with tailor tacking before final insertion.
  • NAC (Nipple-Areola Complex) Herniation/Ptosis Correction: Employs circumareolar and/or vertical mastopexy techniques, either immediate or delayed. This includes concentric de-epithelialization for areolar size reduction and circumareolar mastopexy using round-block suturing.

Specific Aspects to Surgery

Skin Incision

A periareolar incision is crucial for precise breast reshaping, combining flexibility and predictability. Advantages include:

  • Allowing precise inframammary fold adjustment.
  • Providing direct access to correct glandular constrictions.
  • Effective in treating herniation, enlarged NAC, and ptosis.

Radial Scoring

Radial scoring involves transglandular dissection towards the prepectoral fascia, extending to the new lower breast boundary. This method targets the constricting fascial bands, employing perpendicular (vertical/radial) cuts from the subglandular layer, aiming to:

  • Expand the breast's lower pole.
  • Visually eliminate the memory of any preexisting inframammary fold.

In cases of severe constriction, subdermal scoring may be employed for enhanced results.

Pocket Creation

The dual-plane technique, combining the benefits of both submuscular and subglandular placements, is favored for tuberous breast corrections. It facilitates lower pole expansion and shaping while maintaining minimal fill in the upper pole, allowing the muscle to move up, away from the adjusted inframammary fold (IMF). This approach enhances the natural contour, improves soft-tissue coverage, stabilizes breast position, and reduces the risk of capsular contracture.

Conversely, subglandular placement directly shapes and expands the breast but can lead to:

  • Higher capsular contracture rates.
  • Visible implant edges and rippling.
  • Risk of implant malposition.
  • Unnatural appearance, particularly due to the scoring and thinning required in tuberous breast correction.

Single-stage vs Two-stage

In tuberous breast correction, choosing between single-stage and two-stage procedures depends on individual patient factors and desired outcomes:

Single-stage correction is suitable for patients with distensible lower pole skin and soft tissues who have conservative size expectations. This approach allows for immediate correction and repositioning of the breast tissue and inframammary fold in a single procedure.

Two-stage correction, involving initial tissue expander placement followed by implant insertion, is recommended for:

  • Patients desiring a fuller outcome with moderate to severe breast hypoplasia.
  • Situations where overcoming the memory of the preexisting inframammary fold is challenging.
  • Cases with severe constriction and superior malposition of the inframammary fold, allowing for a secondary "fine-tuning" procedure to enhance breast symmetry and achieve optimal aesthetic results.


Upon completing this article, you will have accomplished the following:

1. Nature of Tuberous Breast Deformity: Acquired knowledge of tuberous breasts, a congenital condition characterized by a variety of physical manifestations including asymmetry, constricted base, and herniated nipple, while maintaining normal breast function.

2. Clinical Features and Diagnosis: Enhanced the ability to recognize the clinical features of tuberous breasts, crucial for accurate diagnosis and effective aesthetic correction, acknowledging the condition's spectrum from asymmetry and hypoplasia to ptosis and skin envelope insufficiency.

3. Classification of Tuberous Breast Deformity: Learned about Von Heimburg's 1996 classification system, an essential tool for assessing tuberous breast deformity, facilitating the identification of specific areas affected to inform tailored surgical strategies.

4. Surgical Interventions: Gained insights into the surgical goals and techniques for correcting tuberous breasts, including the importance of releasing constrictions, restoring volume, repositioning the inframammary fold, and achieving symmetry, with the choice between single or two-stage procedures tailored to the severity of the condition and patient desires.

Further Reading

  1. Klinger M, Caviggioli F, Giannasi S, Bandi V, Banzatti B, Veronesi A, Barbera F, Maione L, Catania B, Vinci V, Lisa A, Cornegliani G, Giaccone M, Siliprandi M, Klinger F. The Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients. Aesthetic Plast Surg. 2016 Aug;40(4):492-6. doi: 10.1007/s00266-016-0650-9. Epub 2016 Jun 6. PMID: 27271839.
  2. Pacifico MD, Kang NV. The tuberous breast revisited. J Plast Reconstr Aesthet Surg. 2007;60(5):455-64. doi: 10.1016/j.bjps.2007.01.002. Epub 2007 Feb 21. PMID: 17399653.
  3. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg. 1976 Apr;3(2):339-47. PMID: 1261187.
  4. von Heimburg D, Exner K, Kruft S, Lemperle G. The tuberous breast deformity: classification and treatment. Br J Plast Surg. 1996 Sep;49(6):339-45. doi: 10.1016/s0007-1226(96)90000-4. PMID: 8881778.
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