The Different Surgical Strategies for Treating Tuberous Breast Deformity: A Scoping Review

Summary

Tuberous breast deformity is a congenital breast anomaly that emerges during puberty and is characterized by breast base constriction, breast hypoplasia, superior malposition of the inframammary fold, enlarged areola, herniation of breast tissue into the areola and breast asymmetry. Patients may exhibit one, several or all of these characteristics in their unilateral or bilateral deformity presentation. Numerous surgical treatments have been described, yet no consensus has been reached regarding the optimal treatment. A scoping review was conducted according to the PRISMA guidelines using the following databases: PubMed, EMBASE, Cochrane, Web of Science, Scopus, clinicaltrial.gov and ICTRP databases. Inclusion criteria were English- or French-language articles published after January 1, 2000 that included at least 20 patients in their study on the surgical treatment of tuberous breast deformity in women. The initial electronic database search identified 2,210 records, 27 of which met the inclusion criteria. We summarized the 27 articles, focusing on the classification system, number of patients, treatments for hypoplasia, constricted ring, areolar herniation, enlargement and incision used. This review explored the different surgical approaches suited to the varying characteristics of tuberous breast deformity. It is important to consider the various surgical approaches to achieve the most suitable treatment as each patient presents with unique characteristics and preferences.

Introduction

Tuberous breast

Tuberous breast deformity is part of the congenital breast anomalies characterized by impaired development that becomes evident at puberty. Rees and Aston were the first to describe this deformity in the late 1970s.1, 2, 3 The prevalence of tuberous breasts is uncertain, with reported rates ranging from 6-73%.⁴ Multiple names have been given to this deformity including tuberous breasts, tubular breasts, Snoopy deformity, domed nipple, constricted breast, lower pole hypoplasia and herniated nipple areolar complex (NAC). Despite the varying nomenclature and widely varying degree of presentation, the characteristics are recurrent and include breast base constriction, parenchymal hypoplasia, superior malposition of the inframammary fold (IMF), enlarged areola, herniation of breast tissue into the areola and breast asymmetry. Patients may exhibit one, several, or all of these characteristics in their unilateral or bilateral deformity presentation.^2,4, 5, 6, 7, 8, 9, 10 The surgical management for achieving a conical breast shape requires a customized technique while addressing all the key points, which explains the variety of approaches. Precise diagnosis and effective treatment are essential for achieving satisfactory outcomes, physically and mentally.^1,10

Pathophysiology

The breast tissue is contained within a fascial envelope. The superficial fascia extends from the abdominal Camper's fascia, whereas the deep fascia, resting on the pectoralis muscle, extends from the abdominal Scarpa's fascia.⁴ The superficial fascia consists of 2 layers. The superficial layer envelops the breast parenchyma anteriorly and is absent at the NAC. The deep, glandulopectoral layer forms the posterior boundary of the breast parenchyma and lies on the deep fascia⁶ (Figure 1). In tuberous breasts, a thickened superficial fascia forms a denser constricted fibrous ring, especially at the lower part of the breast. Histology confirms the existence of dense fibrous tissue in and around this “constricting ring” with increased collagen and elastic fibers.^6,10 During puberty, the breast tissue will have little opportunity to expand radially and will therefore grow in the direction of the least resistance, resulting in herniation into the NAC. Thus, a cylindrical, rather than conical breast shape will be obtained.^1,3, 4, 5, 6, 7, 8, 9^,11

Figure 1.

Anatomy of the breast.

Classification

Various classification systems exist for categorizing tuberous breast deformity. In 1996, Von Heimburg introduced a 4-tier classification. Grolleau later modified this system to create a 3-tier classification. Type I involves the lower medial quadrant, Type II affects both lower quadrants and Type III impacts all 4 quadrants (Figure 2).^4,7 Although most widely accepted, this system did not address the minor form of the breast deformity featuring isolated nipple-areola protrusion with a normal breast base.^1,7,11 Therefore, Costagnolia added Type 0, identifying a simple areolar protrusion with a normal mammary base.¹² Pacifico and Kang proposed the Northwood index (NI), calculated as the ratio of areolar forward projection to areolar diameter. Any breast with NI >0.4 was considered as a tuberous breast.^4,13

Figure 2.

Grolleau classification of tuberous breast deformity (A) Normal breast. (B) Type I: deficiency of the lower medial quadrant. (C) Type II: deficiency in both lower quadrants. (D) Type III: deficiency in all 4 quadrants, severe breast constriction and global hypoplasia.

Materials and methods

The PRISMA guidelines were employed to ensure the clarity and comprehensiveness of this scoping review. Seven different databases (PubMed, EMBASE, Cochrane, Web of Science, Scopus, clinicaltrial.gov and ICTRP) were consulted in April 2023. The same search strategy was applied on each database using the concept “tuberous breast” and its synonyms with a filter for the English language. The search strategy can be found in detail in Appendix I. After removal of duplicates, 2 review authors (JVD and AC) determined the eligibility of all retrieved studies independently by screening the titles and abstracts. Any disagreements regarding study inclusion and exclusion were resolved by an independent third party (JP). Full-text versions of the articles were obtained for the second screening, with each article being reviewed and confirmed as appropriate by the authors (JVD and AC). Disagreements were resolved by the same independent third party (JP). Inclusion criteria were English- or French-language articles published after January 1, 2000 that included at least 20 patients in their study on the surgical treatment of tuberous breast deformity in women. A full list of the inclusion and exclusion criteria is outlined in Table 1.

Table 1.

Inclusion and exclusion criteria.

Criterion	Inclusion	Exclusion	Exception
Study focus	Articles where the overwhelming theme relates to the surgical treatment of tuberous breasts	- Articles that made a passing or token reference to the surgical treatment of tuberous breasts - Articles that describe multiple pathologies besides tuberous breasts - Articles proposing nonsurgical treatment for tuberous breasts
Time period	Articles published after January 1, 2000	Articles published before January 1, 2000	Articles from Grolleau (1999) and Von Heimburg (1996) *
Patient population	- A study cohort comprising at least 20 patients - Women	- Inclusion of a study cohort comprising <20 patients - Men
Language	English or French	Other languages
Type of article	Original research	- Articles lacking original searches, such as commentaries and discussion pieces. - Reviews and books

* Exception made for the articles of Grolleau and Von Heimburg as they are crucial for the recognition, classification and treatment of tuberous breasts.

Results

The initial electronic database search identified 2,210 records (Appendix II). Following the removal of duplicates and screening of all titles and abstracts, 331 trials underwent further scrutiny for eligibility. Among these, 27 articles met the eligibility criteria and were subsequently included in our scoping review. Most records were excluded because the articles did not discuss the surgical treatment of tuberous breasts. Table 2 provides a summary of the 27 included studies, focusing on the classification system, number of patients, treatments for hypoplasia, constricted ring, areolar herniation, enlargement and the incision used. Sample size included in this scoping review ranged from 21 to 246 with a total of 1674 participants. Various classification systems were used across the studies: 14 studies used the Grolleau classification, 4 studies used the Von Heimburg classification, 3 studies referred to the Costagnolia classification, whereas another 3 studies devised their own classification system. Additionally, 3 studies did not adhere to any classification system.

Table 2.

Overview of included studies.

Author	Classification	N	Hypoplasia	Constricted ring	Areolar herniation and enlargement	Incision	Extra
Abboud 202226	Grolleau	47	- Subcutaneous tunnelization followed by the footprint loop - Fat grafting if a larger volume is needed	Infiltration, tunnelization and power-assisted liposuction.	- Mild liposuction behind the NAC - Periareolar loop	Minimal incision	IMF-loop to define the new IMF position
Mandrekas 20106	/	21	- Vertical dissection of the gland - Implant placed in a subglandular or dual-plane pocket, if needed	Disruption of the constricted ring during glanduloplasty	Donut-shaped circumareolar de-epithelialization	Periareolar inferior incision
Rigotti 201927	/	22	Expansive morphogenesis	Expansive morphogenesis	Reductive morphogenesis	Minimal incision
Zholtikov 20218	Grolleau	26	- Glanduloplasty - Resection of glandular tissue and skin in the lateral vertical direction - Implant placed in a dual-plane pocket - Liposuction correction, if needed		Donut-shaped circumareolar de-epithelialization	Circumlateral vertical (with/without horizontal component)
Brault 201718	Grolleau	62	Fat grafting	Several rigotomies		Minimal incision	Better satisfaction and good outcomes in the implant group than that in the fat grafting group
			- Glanduloplasty using the Puckett technique - Implant placed in a retropectoral pocket	- Radial incisions on the GP-fascia - Disruption of the constricted ring during glanduloplasty	Donut-shaped circumareolar de-epithelialization with round block sutures	Periareolar (inverted-T or vertical scar) incision
Oroz-Torres 201417	Grolleau	26	Glanduloplasty using the Puckett technique - Type II and III: + implant placed in a subglandular or dual-plane pocket	- Radial incisions on the GP-fascia - Disruption of the constricted ring during glanduloplasty	Donut-shaped circumareolar de-epithelialization	Periareolar inferior incision
Serra-Renom 201221	Grolleau	68	Implant, if needed	Vertical and horizontal incisions using an endoscalpel on the GP-fascia	Donut-shaped circumareolar de-epithelialization, if needed	- Axillary incision for endoscopic approach - Periareolar incision, if enlarged areola and/or placement of an implant is required	For Type I and II (otherwise open surgery suggested) Fat grafting to correct the double-bubble sign
Grolleau 199914	Grolleau	37	- Type I: triangular flap with lower lateral pedicle - Type II with adequate volume: glanduloplasty using Ribeiro technique - Type II with volume depletion: glanduloplasty using Puckett technique and implant placed in a retropectoral pocket - Type III: 2-staged procedure	Radial incisions on the GP-fascia in type III	Donut-shaped circumareolar de-epithelialization	- Periareolar - Vertical or inverted-T-scar, if needed
Chan 201115	Von Heimburg	36	Implants placed in a subglandular pocket	Radial incisions on the glandulopectoral fascia	Donut-shaped circumareolar de-epithelialization	Periareolar
Ionescu 201932	Costagnolia	22	Implant placed in a dual-plane pocket		The ‘Compass Rose’ suture technique	Inframammary fold incision	Only for type 0 Costagliola
Andjelkov 20217	Costagnolia	87	- Fat grafting in the breast parenchyma and pectoralis muscle, if needed - Implant placed in a dual-plane pocket, if needed	Fasciotomy using a cannula followed by fat grafting	- Resection of the herniated gland - Percutaneous electrocoagulation of muscle in NAC - Donut-shaped circumareolar de-epithelialization	Periareolar
de Mortillet 202231	Costagnolia	145	- Horizontal dissection of the gland - Implant placed in a dual-plane pocket		Donut-shaped circumareolar de-epithelialization	Periareolar inferior incision
Tenna 20173	Grolleau	46	- Glandular mobilization - Permanent expandable implants placed mostly in a dual-plane pocket	Radial incisions on the posterior surface of the gland followed by perpendicular incisions	Donut-shaped circumareolar de-epithelialization	Periareolar with/without inverted-T scar	High patient satisfaction in autologous and implant-based groups.
			- Glanduloplasty - Fat grafting	Rigotomies
Pancha-pakesan 20099	Von Heimburg	>50	- Implant placed in a subglandular pocket (dual-plane pocket in some cases) - Tissue expander in severe cases type IV	Radial incisions if the pocket dissection alone did not release the constricted bands enough	Donut-shaped circumareolar de-epithelialization	- Inframammary fold - Periareolar incision, if areola enlargement is needed
Moltó-García 201922	Grolleau	56	- Vertical dissection of the inferior part of the gland creating a medial and lateral glandular pillar - Implant placed in a dual-plane pocket	Disruption of the constricted ring when performing glanduloplasty	Donut-shaped circumareolar de-epithelialization with round block sutures	Periareolar incision
Innocenti 20155	Grolleau	71	- Retro-areola distally based flap - Implant placed in a dual-plan pocket	- Disruption of the constricted ring during glanduloplasty - Radial incisions	- Retro-areola distally based flap - Donut-shaped circumareolar de-epithelialization with round block sutures	Periareolar inferior incision
Klinger 201729	Own 8-tier classification	246	- Implant placed in a dual-plane pocket - Glanduloplasty - Fat grafting	- 360° glandular detachment - Fat grafting	Resection of the herniated gland	Periareolar with/without inverted T
von Heimburg 199623	Von Heimburg	40	Several different operative procedures - Glanduloplasty - Implant placed in a subglandular pocket - Mammaplasty - Tissue expander - …
Serra-Renom 201120	Grolleau	28	- Glanduloplasty using the Puckett technique - Implant	- Disruption of the constricted ring during glanduloplasty - Fat grafting 6 months post-operative, if the constricted ring is still present	Donut-shaped circumareolar de-epithelialization	Periareolar incision
Delay 201324	Grolleau	31	Fat grafting in the breast parenchyma and in the pectoralis muscle	Percutaneous fasciotomy using a cannula or trocar followed by fat grafting		Minimal incision
Ferraro 201730	Grolleau	25	Implant placed in a subglandular pocket	Five-pointed star full thickness incision on the posterior surface of the gland	Donut-shaped circumareolar de-epithelialization	Periareolar inferior incision
Zholtikov 201910	Von Heimburg	208	- Glanduloplasty - Implant placed in a dual-plane pocket	- Incisions on the posterior surface of the gland - Glandular detachment - Fat grafting, if needed	Donut-shaped circumareolar de-epithelialization	Periareolar inferior incision
Faure 202119	Grolleau	82	- Glanduloplasty using the Puckett technique - Implant placed in a dual-plane pocket	- Disruption of the constricted ring during glanduloplasty - Radial incisions on the GP-fascia	- Donut-shaped circumareolar de-epithelialization with round block sutures - Additional triangular resection if needed	Periareolar with/without vertical or inverted-T incision	Patient satisfaction was similar in the autologous and implant-based groups
Kolker 20152	Own classification	26	- Implant placed in a dual-plane pocket - Type II and III: tissue expander followed by implant placed in a dual-plane pocket - Mastopexy, if ptosis exists	Radial incisions on the GP-fascia Subdermal radial incisions, if severe soft-tissue or native IMF constriction	Donut-shaped circumareolar de-epithelialization	Periareolar incision
Gentile 202225	Grolleau	64	- Glanduloplasty using the Ribeiro technique - Implant placed in a subglandular or retropectoral pocket	Vertical and radial incisions on the posterior surface of the inferior part of the gland		- Inframammary fold incision - Periareolar incision, if nipple asymmetry	Patient satisfaction was similar in the implant-based group and fat grafting groups.
			Fat grafting			Minimal incision
Innocenti 201811	Own 5-tier classification	78	- Glanduloplasty - Implant placed in a dual-plane pocket, if needed - Retro-areolar distally based flap is possible in severe cases	- Disruption of the constricted ring during glanduloplasty - Radial incisions at the base of the tuberosity	Donut-shaped circumareolar de-epithelialization (round block sutures, if needed)	Periareolar inferior incision
Campiglio 202228	/	24	Implant placed in a dual-plane pocket	Percutaneous fasciotomy using an 18-gauge needle		- Periareolar incision - Inframammary incision

N = number of patients, NAC = nipple-areolar complex, IMF = inframammary fold, GP-fascia = glandulopectoral fascia.

Discussion

Despite the various approaches proposed by different authors, the majority focussed on addressing the primary characteristics of the condition including treating the hypoplasia, expanding the constricted base, lowering the IMF and correcting areola herniation or enlargement; thus, restoring normal breast shape.⁹ Table 3 provides a summary of the different surgical approaches for the different characteristics.

Table 3.

Summary of the different surgical treatments for the different characteristics.

Hypoplasia

Glanduloplasty

Through the modification of breast parenchyma, the constricted base can be released and redistributed to the glandular tissue to address areas of hypoplasia, particularly in the lower quadrants. Type 1 tuberous breasts can be effectively addressed by releasing the constriction in the medial base and augmenting the medial lower pole through glandular modification.^14,15 Ribeiro et al. introduced a modification involving the horizontal cleavage of the gland from the front to the back to form a posterior-pedicled flap. This flap was folded over itself to augment the lower pole and enhance breast projection¹⁶ (Figure 3). Several other studies adopted this technique or modified versions of it. The Ribeiro technique is frequently used for addressing Type 2 Grolleau tuberous breasts when an adequate breast volume is present.¹⁴ The technique of Puckett et al. involves horizontal cleavage of the gland from the back to the front while preserving a superior areolar pedicle (Figure 3). This glandular flap is mainly used when volume augmentation with implants is required, mostly in Type 2 Grolleau patients.^14,16, 17, 18, 19 At times, the glandular flap may not extend sufficiently to cover the implant and reach the inferior poles of the breast, necessitating additional incisions.^17,20 Glanduloplasty is associated with the interruption of the lactiferous ducts. Nonetheless, Mandrekas et al. assert that their technique preserves the lactiferous ducts, thereby maintaining the initial normal breast function.⁶

Figure 3.

Glandyloplasty (A) Implantation of a prosthesis alone without glanduloplasty results in a double inframammary fold (double bubble). (B) Puckett technique. (C) Ribeiro technique.

Implants

In cases of severe tuberous breasts and associated asymmetry, exclusive glandular tissue modification may not be sufficient, thereby, making the use of implants necessary. Certain studies consistently incorporate implant placement, whereas other studies use implants only if breast volume augmentation is necessary or desired. The implant placement can be subglandular, dual-plane or retropectoral. Supporters of subglandular implant placement argue that it allows for expansion of the constricted breast and skin, without the constraint of the pectoralis major muscle. However, the associated adverse outcomes, such as increased contracture rates, visible implant edges, rippling, delayed malposition and unnatural appearance, warrant the consideration of the dual-plane/retropectoral approach.^2,9 Attention must be paid in treating tuberous breasts with implants, as neglecting the constricted ring during insertion can result in the persistent double-bubble deformity.^5,11,14,20, 21, 22 Implants can be combined with a glandular flap to enhance support and provide additional padding, especially to address concerns about palpability. Oroz-Torres et al., Innocenti et al. and Serra–Renom et al. used a glandular flap to prevent the appearance of the double-bubble sign.^5,17,20

Brault et al. found in their comparative study that correcting tuberous breasts with breast implant augmentation generally results in higher patient satisfaction and more favourable outcomes compared to the conventional method of fat grafting.¹⁸

Tissue expanders

Although every effort is made to correct tuberous breasts in a single stage, severe cases of tuberous breasts with significant glandular tissue and skin deficiency may occasionally require tissue expanders, followed by a secondary procedure to replace them with permanent implants. Von Heimburg et al. recommended overexpanding the pocket, as they observed superior outcomes with this approach.^2,9,11,23

Fat grafting

Fat grafting typically uses donor sites such as the abdomen and trochanteric area, depending on the distribution of adipose tissue.¹⁸ Although healthy breast tissue is an optimal recipient site for fat grafting, the presence of a constricted ring in tuberous breasts limits the possibility of achieving a larger volume. Consequently, it is imperative to address and treat the constricted ring before embarking on the fat grafting process.³ Rigotomies in studies that exclusively use lipofilling with minimal incision access, are commonly conducted percutaneously using a needle, cannula or trocar.^7,18,24 Fat grafting involves injecting fat into multiple layers of subcutaneous and breast tissue, starting from the deep plane and progressing towards the superficial plane. Notably, fat grafting can be extended to the pectoralis muscle, which has proven to be a favourable recipient site.^7,18,24,25 Multiple sessions are required owing to the constricted aspect of the breast, coupled with the limited fat injection volume per session.²⁶ Fat grafting is also frequently used to refine the ultimate outcome, addressing issues such as the pseudo double-bubble sign and enhancing volume in the lower quadrants or cleavage area.^3,21

Rigotti et al. introduced the innovative “biological morphogenetic surgery (BMS)” technique. This minimally invasive procedure was designed to use biological mechanisms to induce expansive and reductive morphogenesis in the treatment of tuberous breasts. During the expansive morphogenesis procedure, fat is extracted during liposuction and then injected percutaneously into the breast. For the injection of the fat, a needle with a cutting tip is used so that small openings are created in the fibrotic tissue, thereby no radial incisions are needed. This process helps loosen and weaken the fibrotic tissue. The injected fat contains substances that trigger mesenchymalization in the local subcutaneous fat tissue. Using this method, augmentation of breast volume is achieved through the mechanical addition of fat and induction of adipogenesis, leading to additional volume enhancement.²⁷

Constricted ring

Incision

Incisions in the constricted ring will disrupt the fibrotic tissue, leading to relaxation of the breast tissue. The incisions can be superficial on the superficial or deep fascia or extend through the glandular tissue. Glandular scoring is commonly performed through a periareolar approach or percutaneously using a cannula or needle to release the constricted ring.^24,27,28 Campiglio et al. indicated that the percutaneous glandular scoring expands the gland and stretches the skin envelope.²⁸ Serra–Renom et al. even uses an endoscopic approach in Type 1 or 2 Grolleau classification, as this technique results in minimal scarring and preservation of nipple sensitivity.²¹ Incisions extending through the glandular tissue are typically performed in the inferior region of the breast, where the constricted ring is most prominent. This approach results in the creation of distinct glandular flaps as described earlier. In some studies, a combined approach is undertaken, involving superficial incisions and the creation of glandular flaps.¹⁷

In more severe cases, certain studies propose an initial strategy of loosening the constricted ring by expanding the glandular tissue using a tissue expander.^9,22 Nonetheless, not all studies uniformly address the constricted ring. Klinger et al. asserted that in less severe cases, a glandular detachment procedure, which involves releasing the glandular tissue from the subcutaneous tissue and pectoralis muscle, is adequate to release the constriction.²⁹

Fat grafting

Fat grafting can alleviate constriction in fibrotic tissue, but limited space may lead to increased interstitial pressure, necessitating a fasciotomy to release the constricted ring. This combined approach of fasciotomy and fat grafting has been used in several studies to release the constriction.^7,24,26 Serra–Renom et al. and Ferraro et al. used fat grafting as a secondary procedure if the initial fasciotomies did not adequately release the constricted ring.^20,30

As stated, Rigotti et al. described expansive morphogenesis. Percutaneous injection of fat administered while creating small openings in the fibrotic tissue will lead to spontaneous filling of the openings with the injected fat. These dual mechanisms contribute to the relaxation of the fibrotic tissue.²⁷

Lowering the IMF

The elevated IMF results from the constrained base of the breast. The IMF can be lowered by dissecting towards the new IMF position, and releasing the constricted ring, particularly at the native IMF as the inferior pole experiences the most constriction. The dissection can be performed subcutaneously, as suggested by Grolleau et al., or as recommended by Kolker et al., it can be performed prepectorally by starting the first incision periareolarly.^2,6,14 Serra–Renom et al. stated that an old IMF will consistently result in a pseudo double-bubble effect, which they addressed through fat grafting for correction.²¹ Kolker et al. used a two-stage approach with a tissue expander if the preexisting IMF memory could be overcome.² After completing their footprint loop, Abboud et al. employed the IMF loop that spans the superficial subcutaneous tissue along the location where the new IMF will be.²⁶ However, according to de Mortillet et al., increasing the projection while expanding the lateral part of the breast will naturally decrease the IMF.³¹ The position of the new IMF in unilateral cases is based on the contralateral breast and in bilateral cases, the sixth rib serves as a landmark.^6,17,20

Areolar herniation and enlargement

The predominant approach used for herniation and areola enlargement correction involves a circumareolar de-epithelialization in the form of a donut-shaped incision.^{3,5,6,8,9,11,}13, 14, 15^,18, 19, 20, 21, 22^,30,31 Following this de-epithelialization, the resultant zone is frequently closed using the round block technique to lift the areola more upwards. Herniation can also be managed via glanduloplasty and, if necessary, via glandular tissue resection.^5,7,11,21 In contrast, less severe cases usually do not encounter the issue of herniation through the NAC and primarily demand breast augmentation with a preference for minimal scarring.

Andjelkov et al. created controlled burns with percutaneous electrocoagulation when they identified a relaxed erectile muscle in the NAC during clinical examination. The procedure induced scar tissue formation and retraction of the muscle fibres. Consequently, this led to the prevention of gland herniation through the NAC.⁷

Abboud et al. used a combination of liposuction and a periareolar loop to address herniation and enlargement of the areola. Moreover, by using their footprint loop, they achieved an expansion of the lower pole and a corresponding reduction in herniation.²⁶

Ionescu et al. introduced the ‘scarless compass rose suture technique’, which involves the use of 3 layers of sutures to mitigate the expansion of the areola. This method is particularly applicable in cases of mild tuberous breasts characterized by isolated areolar enlargement.³²

The BMS theory of Rigotti et al. includes reductive morphogenesis as an addition to expansive morphogenesis. By surgically scraping the NAC zone percutaneously at the junction of the dermal and subcutaneous tissues, a granulation tissue-fibrotic response can be generated, resulting in reduced epidermal surface of the areola through fibrotic contraction.²⁷

Conclusion

Given the uncertain prevalence of tuberous breasts, it is crucial to focus on making the right diagnosis, particularly for milder, less evident forms. The Grolleau classification and the extension by Costagnolia with Type 0 is used the most widely used classification system. Although several surgical treatments have been described, no guidelines have been established. Nearly every author in our study states that their approach yields favourable aesthetic outcomes, high levels of patient satisfaction and minimal scarring. Considering that each patient presents with unique characteristics and preferences, various surgical approaches must be considered to achieve the most optimal treatment.

Conflict of interest

None.