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J. M. Avelar et al.
Classication ofBreast Asymmetry
Mammary asymmetry has been reported since 1950, when Maliniac (1950) divided
breast asymmetries into four categories: asymmetry with bilateral hypertrophy,
hypertrophy on one side and amastia or hypomastia on the other, hypertrophy on
one side and a normal size on the other, amastia or hypomastia on one side and
normal breast size on the other. Pitanguy etal. (1973, 1977) referred to asymmetrical breasts and the physical repercussions to body contouring and to the respiratory
system. Other authors have referred to this, such as Broadbent and Woolf (1978)
and Sepúlveda (1981). Later, Juri (1989) presented a simplied classication of
asymmetrical breasts, dividing them into only three grades. More recently, Jales
(2004) and Karim etal. (2009) wrote reports on the asymmetry of the breasts and
proposed specic classications. Given that breast asymmetry is very common and
is important in plastic surgery, it is divided (Avelar 1989, 2018a) into two major
categories in accordance with what is helpful to know for surgical correction: congenital and acquired.
Congenital
(a) Without a chest deformity
1. Bilateral hypertrophy (Figs.17.1, 17.2, 17.4 and 17.5).
2. Hypertrophy in one breast and normal size for the other.
3. Hypertrophy in one breast and hypomastia in the other (Fig.17.3).
4. Hypertrophy in one breast and ptosis in the other.
5. Bilateral hypomastia.
6. Hypomastia in one breast and normal size for the other.
7. Asymmetrical breasts with bilateral ptosis (Fig.17.8).
(b) With a chest deformity
1. Bilateral hypertrophy.
2. Hypertrophy and normal size.
3. Hypertrophy and hypomastia.
4. Bilateral hypomastia.
5. Hypomastia and normal size.
(c) Without nipple deformity
1. Atelia and normal size.
2. Amastia and normal size.
3. Amastia and hypomastia.
4. Polythelia.
5. Polymastia.
ab
cd
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Fig. 17.8 Asymmetry of the breasts presenting severe ptoses with unilateral hypertrophy in a
19-year-old patient. Photos a and c—preoperative; photos b and d after reduction mastoplasty on
the left side and mastopexy on right one
(d) With nipple deformity
1. Atelia and normal size.
2. Amastia and normal size.
3. Amastia and hypomastia.
4. Polythelia.
5. Polymastia.
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J. M. Avelar et al.
Acquired
(a) Traumatic
1. Burns.
2. Human and animal bite.
(b) Iatrogenic
1. After mastectomy for resection of breast cancer.
2. Secondary to augmentation mastoplasty.
3. Secondary to reduction mastoplasty.
Method
Mastoplasty for the correction of asymmetrical breasts is always a challenge because
during the operation, the surgeon must perform a one approach on one side and
another on the other. It has been much more complex than a standard aesthetic
cd
Fig. 17.9 Asymmetry of the breasts presenting asymmetric ptoses in a 21-year-old patient. Photos
a and c—preoperative; photos b and d after bilateral mastopexy with inverted T and periareolar
incision for reparation of asymmetric nipple-areolar complex
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surgery because surgeons need to achieve an appropriate balance among both
breasts and keep them in harmony with the chest to improve body contouring
(Fig.17.9).
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Surgical Planning
Surgical planning is an essential step before any operation in plastic surgery, but for
the correction of asymmetry in the breasts, it is even more important because of the
different approaches necessary for this surgery. When a patient mentions an evident
asymmetry between their two breasts, surgical planning will usually require two
operations. A good example is when a patient presents with hypertrophy on one side
and hypomastia on the other, in which case the surgical plan must include reduction
mastoplasty on one breast and augmentation mastoplasty using an implant on the
other (Fig.17.3). However, when a patient presents with bilateral hypertrophy with
noticeable asymmetry, surgical planning must be directed to reduce both sides for
the reparation of the different sizes of the breasts (Figs.17.1, 17.2, 17.4 and 17.5).
Surgical planning for this surgery is much more complex because bilateral hypertrophic breasts featuring severe asymmetry may require specic procedures to achieve
aesthetic bilateral balance (Figs.17.1 and 17.4).
Surgical Demarcations
The surgeon should carry out premarking at their ofce or at the hospital before
medication because at this time, the patient is awake and may follow the preliminary demarcation (Avelar 1989, 2018c). Also at this time, some references points
are drawn on both breasts, as recommended by Erfon etal. (2018). In the case of
mammary hypertrophy on one side, add a landmark for the reference points for
reduction mastoplasty (Avelar 2018b). Depending on the abnormality in the opposite breast, appropriate premarkings are made. Nevertheless, when the patient is in
operating room, the nal surgical markings are made according to the surgeon’s
technique.
The Operation
In all cases of aesthetic breast surgery, the correction of deformities requires a previous clinical evaluation, meticulous surgical planning, and preliminary demarcations, as mentioned in the preceding subsection. In most cases of asymmetric breast
ptosis, surgeons should create a medial dermogladular ap with a superior pedicle
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J. M. Avelar et al.
because it is versatile in remodeling the breasts (Figs. 17.10, 17.11 and 17.12)
(Avelar 1980; Sinder 2018).
Asymmetry with breast hypertrophy on both sides requires bilateral reduction
mastoplasty (Figs.17.1, 17.2, 17.4 and 17.5). Although the purpose of this chapter
is not to describe the operation, my preference is to perform breast reduction for the
correction of asymmetry by using Pitanguy’s technique because it is easy to adapt
for each case of deformity (Figs. 17.13, 17.14 and 17.15) (Pitanguy 1959,
1961, 1967).
Also, the correction of asymmetry in a hypertrophic breast has been well
described by Paulino Costa et al. (2018), Caldeira et al. (2018), and Martire Jr
(2018); Matire used his versatile “L” mastoplasty technique.
When a patient presents with hypertrophy in only one breast, unilateral reduction
mastoplasty must be performed. However, the most complex asymmetries feature
hypomastia in one breast and hypertrophy in the other (Fig. 17.3). The surgical
d
Fig. 17.10 Sequential diagrams to demonstrate mastopexy by creation of a medial glandular ap
with superior pedicle (Avelar 1980). Drawing (a)—after resection of skin on inferior pole of the
breast two parallel incisions are done; (b, c) the inferior pole of the glandular ap is pulled forward; (d) after backwards rotation, similar to a pendulum, it is sutured to the muscle on chest wall
Fig. 17.11 Preoperative photos to demonstrate creation, rotation, and suture of the medial glandular ap with superior pedicle. Photo (a)—the mammary dermal ap is raised and pulled forward;
(b) the ap is already rotated backward supported by borders; (c) after suture of the end of the
dermal glandular ap to the muscle on the chest
ab
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c d
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Fig. 17.12 Sequential photos during mastopexy with the creation of a medial dermal glandular
ap with superior pedicle on the right breast. Photo (a) the mammary dermal ap is being incised;
(b) the ap is pulled forward; (c) the ap is already rotated backward being saturated on the muscles of the chest wall; (d) the nal suture of the cutaneous covering of the right breast
planning must be carried out with reduction mastoplasty on one side and augmentation mastoplasty on the opposite breast. Some patients have mentioned that since
the age of 10 years, they have had a hyperdeveloped breast on one side and an
underdeveloped breast on the other. The main purpose of surgery in this case is to
correct the severe imbalance of the body contour, which can come with severe physical and psychological repercussions. There is very wide variation among breasts,
nipples, and chest deformities according to the classication described above
(Avelar 1989). Because of this immense variety of congenital anomalies, surgical
planning is key to achieving balance between the breasts and with the chest (Avelar
2018c). The most frequent asymmetry of the breasts is ptosis associated with
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Fig. 17.13 Modications on Pitanguy’s technique to reduce the length of the horizontal scars on
submammary fold during reduction mastoplasty. Scheme (a) and preoperative photo (b), demonstrate Avelar’s contribution: points A,B, C, D, and E are demarcate according to original technique.
Points A1, B1, C1, D1, and E1 are the references to reduce the scar
J. M. Avelar et al.
a
d
Fig. 17.14 Scheme and preoperative photos to demonstrate Pitanguy’s technique for glandular
resection during mastoplasty for correction of asymmetric breasts. Drawing (a) a medial segment
is demarcated; (b) photos shows the amount of mammary tissue to be resected; (c) it is being
resected with knife; (d) the segment already resected to demonstrate the shape of the glandular
resected
ab
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c
Fig. 17.15 Schemes and preoperative photo showing the creation of the “third” Pitanguy’s pedicle
during reduction mastoplasty with purpose to correct asymmetric breasts. Scheme (a) and photo
(b) one can see the “third” pedicle from bottom; (c) scheme on prole view
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accidity, which requires bilateral mastopexy with the removal of some of the mammary tissue to achieve a good balance between the two breasts (Figs.17.6, 17.8 and
17.9). There are other congenital deformities, polymastia or polythelia, that become
evident only during puberty, when the breasts start to develop. Patients bring up
these abnormalities in consultation, but they are usually not aware of them unless
they experience monthly alterations related to menstruation.
Acquired asymmetry of the breasts is a special eld in which patients’ normal
organs incur damage, bringing imbalance to the body contour with physical and
psychological repercussions. Deformities of the breast caused by burns to the chest
are very common after accidents in infancy or adolescence (Avelar 2018a). As the
mammary glands originate and develop from the dermis (Pitanguy etal. 1973), they
may be damaged when the trauma impacts the chest wall. Surgeons must be very
careful when a child presents with burns on their chest near the nipple–areolar complex (NAC).
During puberty, when physical development makes signicant alterations to the
body, the growing breast may show some asymmetry, which requires repair or
reconstruction (Avelar 2018a). Just as some patients’ ear deformities are caused by
burns, some patients’ breast abnormalities are caused by burns. Other traumas may
also damage the breast, partially or totally. Human/animal bites are quite unusual
causes, but when they occur, they may have severe consequences.
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Nowadays, breast cancer is a substantial social and medical problem and is
becoming more and more frequent. When unilateral or bilateral mastectomy is performed, severe wide deformities often occur. Neither the pathological conditions
nor the treatment is within the scope of this chapter, except to demonstrate the
imbalance of the body contours caused by mastectomy (Avelar 2018a). Therefore,
in this chapter, the problem is limited to including one example of the causes of
asymmetrical breasts.
J. M. Avelar et al.
Unsatisfactory Surgical Results
As the operation to repair asymmetrical breasts is performed, the most feared result
is not achieving perfect bilateral harmony between the two sides because the anatomical mammary structures of each breast don’t have a uniform constitution
(Avelar 2000b, 2018d). Such a situation may be the main reason for litigation
between patients and plastic surgeons. When the operation performed on one side is
a reduction mastoplasty and on the other requires the implantation of a silicone
prosthesis, achieving a high level of bilateral symmetry is quite difcult but possible
(Figs.17.3 and 17.8). Even when mastopexy is performed on both sides and when
patients then have asymmetry, maintaining perfect symmetry is a constant challenge. Because there many patients with several kinds of asymmetries, each patient
must be informed of the limits of the operation and those limited must be specied
in the documents on informed consent (Avelar 2000a, b, c).
Discussion
The theme of breast asymmetry is important in the study of the pathological conditions of aesthetic breast surgery. Although it is recommended to delay surgical treatment until after puberty, quite often the problem originated at birth or during
childhood (Figs.17.3 and 17.8). Besides the asymmetric breasts presented in the
classication in this chapter, tuberous breasts quite often exhibit deformities associated with asymmetry, as described by Ribeiro etal. (Ribeiro etal. 2018).
The asymmetry concerns not only the volume of breast tissue but also the mammary gland’s structure, the thickness of the skin, the nipple–areola complex, and the
thoracic wall (Figs.17.6, 17.8 and 17.9) (Avelar 1989, 2000a, b, c). A broad classication of breast deformities has been presented, addressing the diverse pathological conditions and the appropriate age for surgery. Each patient must be treated
according to the deformity in their breast(s). For this reason, clinical evaluation and
surgical planning are crucial steps to carry out before the operation (Avelar 2018c).
Breast asymmetry is common and represents a problem for many patients (Avelar
2018a). Although most of them are looking for a mastoplasty procedure without any
reference to some sort of asymmetry in their breasts, it may be solved during
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surgery. Even if they don’t mention it before mastoplasty, any asymmetry after the
operation may cause dissatisfaction (Avelar 2000a, b, 2018d). For this reason, adequate evaluation is crucial during consultation as surgery is planned and during
surgical demarcation. However, the surgical technique isn’t described in this chapter, because each deformity requires a specic approach to solve the asymmetry, but
we did add a few words to state our preference for solving this problem. Since the
beginning of our practice, we have sought to reduce the nal scar on the submammary folds without causing any damage to the shape of the breasts. One should not
insist on prioritizing small scars over the shape, harmony, and symmetry of the
breasts. We employ Pitanguy’s (1959) technique with our own contribution in order
to obtain a short horizontal scar while adapting to the different sizes of asymmetric
breasts.
Conclusions
From birth until puberty, the breasts remain in a latency stage. When a young patient
presents with asymmetric nipples or breasts, the surgeon must inform their parent or
guardian about the indication for surgical correction. Each deformity may be treated
according to its specic problem. The most frequent abnormality is bilateral hypertrophy with asymmetry (Figs.17.1, 17.2, 17.4 and 17.5). Therefore, surgical planning and surgical marking are essential to achieving good results with a good
balance between the two breasts.
References
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