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Chapter 11
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Treatment of Symmastia after
Breast Reconstruction: Integration
o
f Techniques
Márcia Balbina LorenzoHoyos
Abstract
Introduction: Acquired Symmastia (or synmastia) after breast implants is an
uncommon complication after breast reconstruction. There are several techniques
for correcting this complication, but there is no consensus. Methods: The surgical
treatment of three cases of acquired retromuscular symmastia after breast reconstruction are described with the integration of techniques: points of adhesion in the
intermammary groove, elevation of the anterior capsule flap with the creation of
a neopectoral pocket (precapsular space) and exchange of implants. In two cases,
the procedure was associated with fat grafting. Results: The patients evolved well,
with correction of the symptoms and were satisfied with the esthetic result. There
was no recurrence of the problem, with a follow-up from 9months to 3years.
Conclusions: It is suggested an integration of techniques for the correction of symmastia (adhesion points and confection of a neopectoral pocket store with anterior
capsule flap) after breast reconstruction, which can also be performed in cases of
such complication after breast augmentation. This procedure can be associated with
fat grafting for esthetic refinement and there may be an improvement in eventual
contracture.
Keywords: mastectomy, segmental, surgery, plastic, prostheses and implants,
prosthesis implantation, mammaplasty
. Introduction
Symmastia after breast implants is a rare and highly recurrent complication
[1]. The incidence is unknown [2]. In 1983, Symmastia (from Greek syn - together,
masto - breast) was defined for the first time as a confluence of the mammary
borders through the midline and loss of the intermammary fold [3]. Symmastia can
be congenital or acquired, when it is due to the poor positioning of the implants that
cross the midline. The first reference for correction of acquired symmastia was in
1988 [4]. The acquired symmastia can be monocapsular (Figure (a)) (when the
implant pocket communicate becoming only one), or bicapsular (Figure (b)) (when
there are two capsules, one or both implants can be medialized and there is a loss of
insertion of the midline adhesions) [5]. It is considered severe when both sides of the
capsule need to be corrected. When the implants are medialized, but with the medial
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Figure 1.
(a) Representation of retromuscular monocapsular symmastia. (b) Representation of retromuscular bicapsular
symmastia. (c) Representation of simasty correction with central membership points and making new retro
pectoral pocket.
sternal fascia intact, the term “medial malposition” is preferred [5]. Khan [6] suggests
an etiological classification for the types of symmastia (Tabl e ). In this work, we
describe three cases of patients with symmastia after breast reconstruction who were
treated surgically with an integration of techniques.
Tipo 1 Developmental synmastia. No aberrant communication between the two breasts anterior to the sternum.
Tipo 1a Idiopathic webbing of cleavage in a small or average-sized breast.
Tipo 1b Traction synmastia. Webbing seen with mammary hyperplasia.
Tipo 2 Acquired synmastia. Aggressive medial dissection resulting in gradual detachment of presternal skin
Tipo 2a Synmastia following subglandular augmentation.
Tipo 2b Synmastia following submuscular augmentation.
Tipo 3 Synmastia associated with capsular contracture. Medial boundary of the breast is displaced toward
Tipo 3a Complete or bilateral, where both medial boundaries are displaced medially and are joined in the middle.
Tipo 3b Incomplete or unilateral, where medial displacement of the breast has taken place unilaterally.
with underlying communication between the two mammary pockets.
the midline without any communication between the two implant pockets.
Table 1.
Khan’s etiological classification of symmastia.
Treatment of Symmastia after Breast Reconstruction: Integration of Techniques
ITexLi.112917
. Objective
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To report an integration of techniques for the surgical treatment of symmastia
after breast implant reconstruction, also indicated for the treatment of symmastia
after breast augmentation.
. Methods
For the discussion of this report, a bibliographic survey was carried out in the
Medline and Cochrane Database, using the descriptors “symmastia”, “breast reconstruction” and “surgical treatment”. All articles were reviewed, with inclusion only of
those that referred to acquired symmastia.
. Procedure
The patients underwent a surgical procedure under general anesthesia, and all were
discharged the next day. Initially, the desired breast furrow was marked with methylene blue, as well as the midline and the inner edge of the breasts to be reconfected.
The prostheses and/or expanders were removed through a scar in the breast crease
(previous or not) or by the scar from the mastectomy.
The midline region was scarified with a small curette or electrocautery, followed by
adhesion points with non-absorbable threads: at least three points on the midline with
2–0 mononylon, following previous demarcation and a sequence of at least three points
for delimitation of the new medial margin of the breasts (on each side of the store).
Then, the anterior capsule flap was made. Decreasing the power of the electro
cautery, the anterior capsule of the pectoralis major muscle was detached, which was
folded, in order to make a neo pectoral pocket. In two cases, partial capsulectomy was
performed and material was sent for anatomopathological examination. The anterior
capsule was fixed to the posterior by some points of mononylon 2–0 to close the previous pocket and inferiorly it was fixed with several points on the lower edge of the
previous space. This prevented the accumulation of liquids (seroma/hematoma) in
the old pocket, as well as sliding movements of the new prosthesis over the previous
space. Thus, the previous area was completely closed and the manufactured pocket
can be expanded laterally, inferiorly or superiorly, according to the need of each case.
Finally, new breast implants were placed, suction drains were inserted and the
usual synthesis of the tissue planes was carried out (Figure (c)). The drains were
removed on an outpatient basis, after 2 to 5days.
There were no major complications. Patients 1 and 3 required drainage for a longer
time due to high blood flow rate, and patient 2 used antibiotics for 2weeks in the
postoperative period, due to a slightly hyperemic irradiated breast.
-
. Results
Case 1: Patient operated on 03/15/2017 presenting mono capsular symmastia
(previously submitted to bilateral mastectomy in another service, with resection of
the areola on the right and resection of inverted T skin on the left; placement of an
anatomical expander on the right 450cc and prosthesis anatomical left of 490cc textured and evolving at the time with partial necrosis of flaps on the left). Right breast
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previously irradiated. Symmastia correction was performed (there was complete communication of 6cm vertically in the pre-sternal region) as described and placement of
455cc microtextured super high profile prostheses and correction of left breast scars.
Figures –. There was no recurrence of symmastia, but she evolved with distant and
locoregional tumor recurrence on 03/03/2019, and death on 07/2020 Tab le .
Case 2: Surgery performed on 23/05/2018. Patient underwent bilateral mastectomy
in another service with resection of the nipple areola complex on the right and
implant placement - expander prosthesis on the right 460 (Becker 35) and390
anatomic prosthesis on the left. She presented bicapsular symmastia, separated only
by a capsule beam, with complete loss of sternal adhesion. The implants were changed
to ultra-high profile round prostheses 590cc on the right and high profile 450cc on
the left. On that occasion, fat grafting was also performed on theright breast (70cc).
Figures –
. Subsequently, 120cc lipografting was performed on the right on
7/7/2019 and the reconstruction of the areomamilar complex (CAM) on 7/2020 was
reconstructed. Right breast previously irradiated Table .
Figure 2.
Case 1: Preoperative.
Treatment of Symmastia after Breast Reconstruction: Integration of Techniques
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Figure 3.
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Case 1: Immediate postoperative period.
Figure 4.
Case 1: Postoperative 5months.
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Figure 5.
Case 1: Postoperative 3years.
Case Type of retro
muscular
symmastia
1 Monocapsular Mentor
Implants
withdrawn
from
patients
with
symmastia
Texturized
anatomic
prosthesis
490cc (left).
Mentor
texturized
anatomic
expander
450cc
(right)
Implants placed
for the correction
of symmastia
Mentor texturized
super high profile
round prostheses
455cc
Associated
fat
grafting
with the
exchange
of
implants
Not done Right capsule:
Anatomopatological
capsule
Fragments exhibiting
involvement
inflammatory process
Focal and discreet
fibroplasia. Absence
of malignancy
Treatment of Symmastia after Breast Reconstruction: Integration of Techniques
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Case Type of retro
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muscular
symmastia
2 Bicapsular Mentor
3 Bicapsular Mentor
Implants
withdrawn
from
patients
with
symmastia
Texturized
anatomic
prothesis
390cc (left).
Mentor
texturized
anatomic
expanding
prosthesiis
Becker
35,460cc
(right)
texturized
anatomical
prostheses
440cc
Implants placed
for the correction
of symmastia
Mentor texturized
high profile round
450cc (left)
Mentor texturized
super high profile
round 590cc
(right)
Mentor texturized
super high profile
round prostheses
450cc
Associated
fat
grafting
with the
exchange
of
implants
70cc fat on
the right.
Not done
on the left
60cc fat
on the left.
110cc on
the right
Anatomopatological
capsule
Not done
Capsules with
no lymphocytic
proliferation.
Absence of
malignancy
Table 2.
Summary of cases regarding the type of simastia, implants before and after correction of the problem, association
of fat graft during implant replacement and anatomopathological examination of the implant capsule.
Figure 6.
Case 2: Preoperative.
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Figure 7.
Case 2: Immediate postoperative period.
Figure 8.
Case 2: Postoperative 3weeks.
Case 3: Surgery performed on 06/2020. Patient previously submitted to bilateral
mastectomy in another service with resection of the nipple-areola complex on the
right and placement of 440 textured anatomical implants. Bicapsular symmastia,
separated only by the capsules, and disinsertion of the skin of the pre-sternal region.
Correction of symmastia and placement of 455cc super high profile microtextured round prostheses and fat grafting 110cc on the right and 60cc on the left.
Subsequently, a new fat graft was performed (40cc on the right and 30cc on the
left) with reconstruction of the CAM on the right and correction of scars on the left
Figures – and Table .
Treatment of Symmastia after Breast Reconstruction: Integration of Techniques
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Figure 9.
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Case 2: Postoperative 1year.
Figure 10.
Case 2: Postoperative period 1year and 8months.
Figure 11.
Case 2: Postoperative 2years and 6months.
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Figure 12.
Case 3: Preoperative.
Figure 13.
Case 3: Intraoperative detail: Marking with methylene blue for adhesion points.
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