ORIGINAL ARTICLE Treatment of Grade 3 Tuberous Breasts with Puckett’s Technique (Modified) and Fat Grafting to Correct the Constricting Ring Jose Maria Serra-Renom • Juan Mun ˜ oz-Olmo • Jose Maria Serra-Mestre Received: 8 January 2011 / Accepted: 11 February 2011 / Published online: 17 March 2011 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011 Abstract Background Augmentation of tuberous breasts classified as grade 3 is a challenge to surgeons. The authors describe their technique for correcting grade 3 tuberous breasts with a book-shaped opening of the breast, insertion of an ana- tomic prosthesis, and fat grafting. Methods The authors’ technique for correcting grade 3 tuberous breasts consists of reducing the areolar diameter and performing a book-shaped opening of the breast, applying a modified version of Puckett’s technique. The modification consists of opening each breast, remodeling the glandular flap on each side to make them symmetric, inserting the same size subglandular anatomic prosthesis, and covering the prosthesis with the glandular flaps held in place by transcutaneous fixation stitches. After 6 months, fat grafting of the remaining constricting ring and the cleavage is performed. Results The study enrolled 28 patients with asymmetric bilateral tuberous breasts ages 18 to 39 years. At 12 months, using a questionnaire to rate their results, 68% of the patients were ‘‘very satisfied,’’ 25% were ‘‘satisfied,’’ and 7% were ‘‘not satisfied.’’ The medical team’s ratings at 12 months were ‘‘excellent’’ for 82% of the cases and ‘‘good’’ for 18% of the cases. Conclusion For patients with grade 3 tuberous breasts, the authors perform aesthetic breast enlargement by reducing the size of the areola, making a book-shaped opening in the breast, and carrying out fat grafting to correct the cleavage and the remaining constricting ring. The patients and the medical team both expressed high levels of satisfaction with the results. Keywords Breast asymmetry Á Breast implants Á Breast surgery Á Congenital breast Á Fat grafting Á Tuberous breast Tuberous breasts are a malformation that may appear in breast formation during puberty [3, 8, 14]. The deformity may be unilateral or bilateral, symmetric or asymmetric and can cause profound psychological distress. Several theories regarding the etiology of the syndrome have been advanced, but none of them is entirely con- vincing [7, 13, 31, 32]. The term ‘‘tuberous breast’’ was first used by Rees and Aston [17] in 1976. It refers to a malformation in which the superficial layer of Camper’s fascia in the area below the areola is absent, and the superficial fascia is thickened, especially in the lower pole of the breast. Tuberous breasts have a constricting ring around the nipple–areola complex (NAC), which alters its normal development. The result is that the breast cannot develop toward the lower pole. The absence of this fascial layer creates a weak point at the level of the areola, allowing the developing breast to herniate toward the NAC [2]. We present a new procedure for correcting tuberous breasts categorized as grade 3 in Grolleau’s classification [7]. In these cases, all the quadrants are affected and deficient. The base of the breast is constricted, producing a narrow, elongated, tubular shape; an excessively large areola; and a higher than average inframammary fold. J. M. Serra-Renom (&) Á J. Mun ˜oz-Olmo Á J. M. Serra-Mestre Hospital Quiro ´n Barcelona, Institute of Aesthetic and Plastic Surgery, Plaza Alfonso Comin, 5-7, 08023 Barcelona, Spain e-mail: serrarenom@gmail.com 123 Aesth Plast Surg (2011) 35:773–781 DOI 10.1007/s00266-011-9686-z