|Year : 2019 | Volume
| Issue : 4 | Page : 1303-1307
Different modalities for correction of breast asymmetry
Mohamed A Megahed, Yasser M Elsheikh, Ahmed A Talab, Mohammed S AboShaban
Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt
|Date of Submission||11-Nov-2018|
|Date of Decision||16-Dec-2018|
|Date of Acceptance||22-Dec-2018|
|Date of Web Publication||31-Dec-2019|
Mohammed S AboShaban
Shebin El-Kom, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the different types of breast asymmetry and choice of the suitable approaches for each type of deformity.
Naturally, there is asymmetry in female normal breast. When the difference in the site, size, shape, or volume of the breast, nipple–areola complex, and inframammary crease position is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon.
Patients and methods
The study included 29 female patients presented by breast asymmetry aged 14–43 years in the period from September 2016 till September 2018 at the Department of Plastic and Reconstructive Surgery of Menoufia University Hospitals. All patients were evaluated by history, physical examination, investigations, and photography. Surgical methods used for correction of breast asymmetries include: reduction mammoplasty, mastopexy, breast lipofilling, silicone gel implant and reconstruction of the missing breast, nipple–areola complex, and inframammary fold using different methods including pedicled latissimus dorsi, free transverse rectus abdominis myocutaneous, deep inferior epigastric artery perforator as well as a combination of the mentioned techniques.
Most of the breast asymmetries were corrected by a combination of surgical procedures. Having combined different surgical procedures achieve satisfactory results.
The key to successful treatment is to define the nature of the breast asymmetry, respecting the patient's esthetic goals. It is critical to grasp the concept that the more similar the procedures performed on each breast, the more likely there will be symmetry over time.
Keywords: asymmetry, breast, correction, different, modalities
|How to cite this article:|
Megahed MA, Elsheikh YM, Talab AA, AboShaban MS. Different modalities for correction of breast asymmetry. Menoufia Med J 2019;32:1303-7
|How to cite this URL:|
Megahed MA, Elsheikh YM, Talab AA, AboShaban MS. Different modalities for correction of breast asymmetry. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1303-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1303/274262
| Introduction|| |
The breast is a symbol of femininity. The attractive breast is characterized by proper symmetry in contour, projection, softness and sensitivity to touch, especially in the nipple–areola complex . Asymmetric breast is defined as an asymmetric morphology of site, size, shape or volume of the breast, nipple–areola complex and inframammary crease position. It represents the greatest challenges for a plastic surgeon in technique selection .
There is no practical way to estimate the incidence of breast asymmetry. Variable degrees of asymmetry present in more than half of the female population . The incidence of significant asymmetries in patients requesting breast surgeries was estimated as 4 or 10% .
The definite cause of breast asymmetry is unknown, but possible contributors include hormonal changes, traumatic injuries, spine curvature abnormalities, and deformities in the chest wall .
Several classifications were put for breast asymmetries, application of appropriate principles for esthetic breast surgery is necessary to achieve the best esthetic outcome .
Correction surgery for breast asymmetry falls into the sphere of cosmetic surgery. Once examination and diagnosis have been completed, the patient is informed about the principles, advantages, and disadvantages of surgical procedures. Upon reaching an agreement, the patient and the doctor decide on the surgical technique that will achieve optimal results . The number of surgical procedures for correction of breast asymmetry using either patient's own tissue or artificial material is large and may need to combine one or more surgical techniques .
Asymmetries required multiple reconstructive and esthetic surgical modalities in the form of skin graft, pedicled and free flaps, breast reduction, augmentation, or mastopexy .
The aim of this work was to study and evaluate different types of breast asymmetry and choice of the suitable approaches for each type of deformity as regards the cosmetic outcome; breast contour, shape, nipple–areola complex, scars and inframammary line position.
| Patients and Methods|| |
The study was approved by the Research Ethics Committee of Faculty of Medicine, Menoufia University, Egypt. This prospective study was done at the Plastic Surgery Department Menoufia University Hospital from April 2016 till August 2018; 29 patients visited the plastic surgery outpatient clinic, with symptomatic asymmetry with stable medical conditions with no exclusion criteria with age range from 14 to 43 years. An informed written consent was obtained from each patient after complete declaration of the study. All patients were evaluated by history, physical examination, investigations, and photography. Preoperative assessment of the nipple–areola complex, inframammary crease position, base width, glandular asymmetry and chest-wall deformities was done. Informed consent was taken for every patient.
On the basis of the type of asymmetry and surgical requirements, the patients were divided into three main groups. Group I included seven (24.2%) patients with congenital breast asymmetry. Group II included nine (31.4%) patients with developmental asymmetry; ultrasound examination of both breasts and hormone status were determined in all the patients. Group III included 13 (44.4%) patients with acquired asymmetries mostly a consequence of surgical treatment for benign or malignant breast tumor, postburn deformities, and revision surgery. The availability of a large number of surgical techniques for the correction of breast asymmetry provides selecting one or more surgical procedures that would allow for achieving optimal functional and esthetic results for each patient [Table 1].
|Table 1: Distribution of patients in dependence on breast asymmetry and surgical technique applied|
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The position of the patient is in the semisitting position or standing. The suprasternal notch, the midline, and the inframammary fold were marked first. The breast axis is drawn from the suprasternal notch downwards. It passes through the center of the breast's apex. It does not necessarily pass through the nipples as their position may vary and are frequently asymmetric. The axis is a very important landmark as we plan on it for the ideal site of the future nipple, the symmetric resection of the excessive tissues, as well as the site of the flap and its pedicle.
All patients were operated upon under general anesthesia and received prophylactic broad-spectrum antibiotics at the beginning of the procedure. Close observation of the nipple–areola complex viability and drains collection were done and on discharge they were instructed to keep wearing the pressure garment for 4 weeks and received the postoperative medications (e.g. painkillers) and follow-up appointments.
| Results|| |
Surgical methods used for the correction of breast asymmetries included reduction mammoplasty, breast augmentation and mastopexy, reconstruction of the missing breast using different types of flaps, tissue expansion, fat injection, and silicone gel implants as well as a combination of different techniques [Table 1].
Group I with congenital asymmetries include three (10.35%) cases who were treated for Poland's syndrome by autologous fat grafting enriched with platelet-rich plasma followed by placement of high cohesive silicone gel implant in the affected side with reduction mammoplasty in the contralateral side 3 months later [Figure 1]. Those with tuberous breasts (two cases, 6.9%) were treated using implants. Accessory breasts (two cases, 6.9%) were excised without the need for additional correction of the existing breasts.
|Figure 1: Poland syndrome (implant with fat injection on the right side; reduction suspension mammoplasty on the left side).|
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Group II patients were with developmental asymmetries. Hypoplastic asymmetries (five cases, 17.2%) were mostly corrected by silicone gel implant on the affected side with mastopexy in the contralateral side [Figure 2], where hypertrophic asymmetries (four cases, 13.8%) were managed by reduction or suspension mammaplasty on both sides.
|Figure 2: Asymmetric hypoplasia (implant on the left side; mastopexy on the right side).|
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Acquired breast asymmetries in patients from group III were mostly a consequence of post-tumor excision deformity (two cases, 6.9%) corrected by mastopexy on the affected side with reduction mammoplasty on the contralateral side [Figure 3], delayed breast reconstruction after modified radical mastectomy (two cases, 6.9%) corrected by Free transverse rectus abdominis myocutaneous flap with NAC reconstruction, oncoplastic breast surgery (three cases, 10.3%) managed by pedicled lastissimus dorsi flap reconstruction, burn deformities (four cases, 13.8%) managed by flaps and nipple–areola complex reconstruction and revision surgery (two cases, 6.9%) by liposuction from lateral bulges. In patients with such condition arising out of unilateral mastectomy, color Doppler of the blood vessels in the scapular and axillary region was performed before the surgical procedure to exclude the injury of a thoracodorsalisthat could happen during the primary surgery.
|Figure 3: Postexcisional tumor deformities (reduction mammoplasty on the left side; mastopexy on the right side).|
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The postoperative recovery lasted 14–21 days in 97% of the cases. No major complications (total or partial nipple–areola necrosis, hematomas formation or flap necrosis) were found. Minor complications included: three (10.2%) cases were unhappy with the scar but not considered to be a problem and did not ask for scar revision, two (6.8%) cases developed superficial wound dehiscence and two (6.8%) cases with persisted diminished nipple touch sensation. The touch sensation of the nipple was impaired in the early postoperative period (3 months), then improved to a comparable degree to the preoperative sensation over 6 months postoperatively.
Satisfaction of the patients was scored regarding shape, size, scar, and symmetry to evaluate the overall achieved results. The final esthetic outcome was accepted by the patients because of the severity of the presenting deformities.
| Discussion|| |
The results of this study show giving importance to a preoperative evaluation of asymmetry and the different options of esthetic surgical methods can ensure complete symmetry with female patients' satisfaction.
Breast asymmetry presents a problem in surgical management for the discrepancy in size, volume, shape and contour and even the sites of differences or excess in these breasts. In addition to some associated discrepancies of breast bases on which the breasts are seated such as the thoracic cage abnormalities and unevenness. Hence, the difficult differentiation of the breast problems which root to even the origin of their etiologies has to be understood in order to deal with the associated pathologies that cause these abnormalities . Different classifications were proposed about the different configurations of breast asymmetries and many ways of management reflect the difficulty with which this problem is tackled .
The patients were informed about the advantages and disadvantages of sub-mammary, periareolar and axillary pattern for breast augmentation, as well as the shape and size of the scar arising out of the breast reduction or mastopexy. A special consideration was given to the choice of technique for patients who had not breastfed. The submammary approach was always used to insert the implant in those patients, and it was placed subglandularly to avoid additional trauma to the breast tissue. In patients with lactation period definitely completed, the choice of the surgical procedure was much more facilitated. However, high cohesive silicone gel implants were used in all the cases because they provided the best optimal results of a decreased percentage of infections and rejection of the implant as a foreign body .
A correction of breast asymmetry accompanied by congenital chest-wall deformities was corrected by a perforator or microvascular free flaps, Gautam et al.  favor perforator flaps. In our study, the most less invasive options were used; we do serial stages of fat injection with plasma-enriched platelet to increase the taken and survival followed by placement of implant without any donor site morbidity, functional deficit, and avoid a scar that occurs as a consequence of the secondary defect of flap harvesting.
Persichetti et al.  studied tuberous breast deformity and proposed modifications of already described techniques. Their observations were of great significance to us in selecting the surgical techniques. In our study, placement of different size implants through circumareolar incision with release of breast base constriction and areolar reduction on the affected side.
Our choice of treatment with accessory breasts was excision with direct closure even though liposuction allows equally successful esthetic results .
In classifying breast asymmetries and in the hypertrophic group, it is much better to use the same technique on both breasts. Moreover it is much better to be operated on both sides by the same operator. What is important in these reductions is not what to remove but what to leave behind so that the remaining breasts would be symmetrical. Taking into consideration that the measurements taken on the heavier side would be adapted to the effect of gravitational stretch with more recoil back when the excess tissue weight is taken off, that is to say that the nipple levels should be measured at a slightly lower level than on the lesser sized breast and also the length of the infra-areolar segment a little larger than on the smaller sized breast to allow for this recoil.
The number of glandular resections should be tailored differently in order to allow for a comfortable closure of the breasts without tension which would jeopardize the results. In our study, we make superior pedicle technique had the advantages over other pedicle techniques with their inherent disadvantages like bottoming out and high riding areola and poor esthetic fill-up of the upper segments of the breast and resulting in square flattened breasts with long scars, in addition, the lack of adaptability to the pattern of asymmetry by their presentable designs which do not tailor well the asymmetry and amounts of resection and the unevenness of the remaining breasts. If the patient needs a mastopexy and reduction, the mastopexy is performed first to have a model to match with the reduction.
The other categories of breast anomalies as aplasia, hypoplasia, atrophy, achieving symmetry may be possible with unilateral surgery, but frequently bilateral surgery is required. It is important to grasp the concept that the more similar the procedures performed on each breast, the more likely there will be symmetry over time.
In choosing reconstruction method, we followed reconstruction ladder to achieve desired result with a simpler method. Reconstruction by some of perforator flaps, deep inferior epigastric artery perforator (epigastric flaps), transverse rectus abdominis myocutaneous flaps, or distant gracillis flap.
Over the last years, a great significance has been given to the preventive and early detection of breast tumors, so the relationship between tumor excision and breast asymmetry was often found . All breast asymmetry correction surgeries performed were preoperatively planned in detail with its multiple options for best esthetic outcome.
We think that breast reconstruction surgery with the latissimus dorsi myocutaneous island flap on the vascular pedicle with the primary reconstruction is the method of choice . According to our experience, latissimus dorsi myocutaneous flap has many advantages such as the length of vascular pedicle, the possibility of taking a large dermal island, as well as esthetically acceptable secondary defect-associated scar that may be hidden by a bathing suit.
In addition, general endotracheal anesthesia provided the best possible comfort for both the surgeon and the patient . In our study, all patients were operated under general anesthesia.
There are other classifications available, but we followed a classification of asymmetric breasts by Bruschi et al.,  as very precise, clear, and most comprehensive.
| Conclusion|| |
Breast asymmetry represents the greatest challenges in the surgical management for the discrepancy in size, volume, shape, and contour and even the sites of differences or excess in these breasts. The availability of a large number of surgical techniques for the correction of breast asymmetry provides selecting one or more surgical procedures that would allow for achieving optimal functional and esthetic results for each patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]