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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
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21 Asymmetric Breasts
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Fig. 21.6 (a, b) 32-year-old lady suffering from a 10cm by 8cm broadenoma of the right breast. (c, d) 38-year-old lady having a right sided
breast enlargement caused by broadenosis which had to be excised and the breast was reconstructed
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Fig. 21.7 42-year-old patient had undergone saline breast implants in 2004. She had deation of the implant in 2012. Photograph taken when she
presented with the deated breast
M. Thomas and J. D’silva
21.2 Clinical Assessment
A good rapport with the patient who might already be
depressed and angry due to these unevenly sized breasts is a
priority. It is better to have your mature female nurse or staff
along with you when consulting with the patient who should
ideally be accompanied with a relative who she trusts. The
rst part of the discussion should be to reassure the female
that such things are not uncommon and can be treated.
A successful treatment requires a complete assessment of
the asymmetry, creates a treatment plan depending on the
requirement of the patient, and achieves a semblance of
symmetry.
History taking should include the following leading
questions:
1. When did you notice the asymmetry of the breasts? Does
it run in the family?
2. Have the breasts grown in the last few years? Has there
ever been an infection, surgery, or injury to the breast?
3. Has the patient breast fed? Has there been any preference
in breast feeding?
Examination of the Patient
It is important that before examining the patient, you should
have successfully established a rapport with her so that any
psychosocial issues she might be experiencing are
understood.
Steps of clinical examination: Systematic examination of
all the relevant anatomical areas is of paramount
importance.
1. First step is the examination of the skeletal framework
which should include the spine (for kyphosis and/or scoliosis), rib cage for pectus excavatum/carinatum, aring
of the ribs as well as any asymmetry of the rib cage.
2. Examine the musculature specially the pectoralis major
muscle on the hypoplastic side.
3. Inspect the breasts on both sides so as to assess the type
of deformity, whether one or both sides need to be treated
and at the same time enquire which breast the patient
prefers.
4. Conrm the ndings by taking sternal notch to NAC dis-
tance, NAC to inframammary crease distance, position of
the inframammary crease on both sides as well as the
overall breast base width on each side.
5. Make a rough estimate on the difference in volume
between the two breasts which can be assessed based on
the cup size of the two breasts.
21.3 Investigations Required
Routine blood and other tests.
Specic tests include an MRI scan of the breast along
with an ultrasound. Skeletal abnormalities can be ruled out
using X-rays.
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21.4 Treatment Plan Based onExtent
ofAsymmetry (Reilley 2006)
Following are some guiding principles:
• Ask the patient which breast she prefers.
• Operate when the patient experiences the problem as a
problem.
• Reduce the larger breast rst.
• Work on the more difcult side rst.
• The more similar the procedures (on each breast) the
more long-lasting the result.
• Accept that there will be some deterioration of the result
over time.
21.5 Timing ofTreatment
There are no hard and fast rules regarding the timing of this
elective surgery. Usually it is better to wait till the breast
growth is fully completed, i.e. until she is in her late teens.
However, there are many patients in whom such a delay
would be cruel specially those who have prominent issues
with self-esteem. Earlier surgery is offered to such patients
with the clear understanding that touch up procedures may
be required at a later date to improve the nal outcome.
Pregnancy can cause changes in the size and shape as the
normally larger breast will enlarge even more. Moreover
many females would not like to get the normal breast operated on as they would like to breast feed. However, to delay
correction until child-bearing is completed is not the right
approach.
Type I Asymmetry which can be easily hidden by wearing
custom clothes and can be permanently corrected by similar
procedures on both sides or a single procedure on one side. If
augmentation of the breasts is considered with one breast
signicantly smaller than the other (Fig.21.8), then use of
two different sizes and/or shape of implants can improve the
symmetry to a great extent. It is easier to achieve a symmetry
in the volume but difcult to achieve symmetry in the location of NAC as well as the shape of the breast.
Choosing the implant with the right base, projection, and
volume has to be chosen. We can choose from high prole,
moderate prole to low prole depending on the breast projection. If the breast is tubular, then radial incision of the
breast parenchyma is required to atten the breast and reduce
its conical shape (Fig.21.9).
When undertaking procedures with use of asymmetric
implants, always operate the affected side rst (right side in
Fig.21.8a) as that is the side with reduced skin cover. Once
the affected side has been augmented to the desired breast
size, a smaller implant or fat graft can be used on the normal
side to match it with the new affected side (Fig.21.8c, d).
Place a sizer in the normal side to check for symmetry before
placing the implant.
Breast reduction surgery if planned will require asymmetric removal of breast tissue (Fig.21.10). The smaller breast
may or may not require any tissue removal. It is recommended that the smaller breast should be operated rst so
that the larger can be reduced adequately.
Finally any minor asymmetries regarding size and shape
can be corrected using autologous fat graft 3months after the
primary surgery.
Type II
Signicant asymmetry which needs a reduction on
one side and an augmentation on the other breast (Figs.21.11,
21.12, and 21.13).
Signicant asymmetry of the breasts needs different surgical procedures to be carried on either breast, namely one
breast will require an augmentation, while the other will
require a breast reduction. The breast augmentation is done
rst so that the breast to be reduced is shaped according to
the shape of the augmented breast. The nal outcome of the
surgery should include the following:
1. Both NACs at a similar level.
2. The volume of the two breasts should be very close to
each other.
3. The diameter of the areola should be similar.
4. The nal result should be such that both cups of the bra
are lled equally.
5. The patient should be informed that gravity will cause
more ptosis of the enlarged normal breast which may
need secondary correction.
Type III Patients requiring complete reconstruction of one
breast such as seen in Poland’s syndrome/after mastectomy.
These are the most difcult cases to reconstruct specially
those having Poland’s syndrome as these people have other
deciencies such as those of the pectoral muscle, rib cage as
well as upper limbs and hands. In young females this causes
psychological distress and loss of self-esteem (Furnham
et al. 1990). The rst step in treatment of patients with
Poland’s syndrome is a complete clinical analysis. The
spectrum of thoracic defects in Poland syndrome includes a
wide range of anomalies from subtle hypoplasia to aplasia
of the breasts and ribs, chest wall depression, sternal anomalies, absence of axillary hair, and limited subcutaneous fat
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M. Thomas and J. D’silva
Fig. 21.8 (a, b) Preoperative photographs of a married lady who had
asymmetry of breasts because of which she was not condent during
intimacy. Breast augmentation was undertaken using a 350 gm high
prole silicone implant on the decient side and a 225 gm moderate
prole on the normal side. (c, d) Post-operative photographs taken
6months after surgery
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Fig. 21.9 (a, b) Preoperative photographs of a young lady who had
come for breast augmentation and was diagnosed with tubular breasts
with mild asymmetry of the breasts. Radial scoring of the glandular
tissue was carried out to release the constriction along with placement
of 325 and 350gm high prole implants are placed in the subglandular
pockets. (c, d) Post-operative photographs taken after 3 months of
surgery
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M. Thomas and J. D’silva
Fig. 21.10 (a, b) A young girl with grade III ptosis of her breasts with
one side larger than the other. She was happy about the volume of her
smaller breast which also needed to be lifted. The treatment plan
included a breast lift on the left side along with a breast reduction and
lift on the right side to match the left side. (c, d) Post-operative photographs 3months after the surgery
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Fig. 21.11 (a, b) Patient presented with asymmetry of the breasts with
a very low self-esteem due to the signicant difference between the two
breasts. The left breast (smaller) was augmented using a 345gm high
prole silicone implant, while the right breast was reduced and lifted
using a short scar supero-medial pedicle technique to match the augmented breast (c, d). Photographs (e, f) are seen 4weeks after surgery
with one breast enlarged and the other reduced
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M. Thomas and J. D’silva
Fig. 21.12 Correction of breast asymmetry in a young lady who had an A cup on the right side and a C cup on the left side (a, b). She underwent
a 250gm silicone high prole implant into the right breast and a left sided breast lift (short scar) to achieve a very symmetric breast (c, d)
(Cingel etal. 2013). Theories have been proposed to explain
the etiology of the congenital malformations. The most
accepted theory refers to a hypoplasia of the subclavian
artery and its branches. The site and degree of ow velocity
impairment determines the extent and severity of the developmental changes (Bavinck and Weaver 1986). The diagnostic criteria include isolated absence of the pectoralis
major muscle and breast hypoplasia. In almost every case,
there is absence of the sternocostal head of the pectoralis
major muscle and in most cases, absence of the pectoralis
minor muscle is also found. Other muscle units that also can
be involved at a lower frequency are the latissimus dorsi, the
external oblique, and the serratus anterior muscles (Haller Jr
et al. 1984). The breast involvement varies greatly.
Hypomastia and even amastia are the presentations most
frequently found (in more than 30% of female patients). The
nipple-areolar complex usually is involved, and it can be
superiorly sited, hypoplastic, or even absent. Correction of
this nipple-areolar complex dystopia is one of the most difcult reconstructive stages. To achieve symmetry, we have
made a bilateral periareolar incision, with skin resection on
the top of the normal nipple-areolar complex and on the bottom of the affected complex. After a round- block suture,
both complex positions are compensated to an intermediate
site, giving a more symmetric appearance. Moreover, for
some patients with a severe hypoplastic nipple- areolar complex, we have used the whole complex to reconstruct the
nipple, with a peripheral tattoo performed to achieve areola
symmetry (Figs.21.14, 21.15, 21.16, 21.17, and 21.18) (da
Silva Freitas etal. 2007).
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Fig. 21.13 Correction of breast asymmetry in a 32-year-old lady who
had bilateral inferior pole tubular breasts with grade III ptosis and
hyperplasia of the right breast and grade I ptosis and hypoplasia of left
Pearls
1. Always establish a rapport with the patient and her family
before examining the patient or discussing about the
treatment plan.
2. Advice what you think is right but undertake what the
patient wants.
breast (a, b). She underwent a 350gm silicone high prole implant into
the left breast and a right sided breast reduction and lift (short scar) to
achieve similar breasts (c, d)
3. There is no opportune time for the surgery, operate when
it concerns the patient.
4. Operate on the complex side rst so that the simpler procedure can be used to match the other breast.
5. Always inform patient about the need for a touch up
procedure.
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M. Thomas and J. D’silva
Fig. 21.14 An 18-year-old lady with amastia, hypoplastic pectoralis
major and latissimus dorsi muscle and short upper limb due to Poland’s
syndrome. There is a deformity of the rib cage too which is depressed.
This patient and their relatives were categorically against doing any
procedure on the normal breast as they wanted to keep it unaltered for
breast feeding
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