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Chapter 11

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Treatment of Symmastia after Breast Reconstruction: Integration o

f Techniques

Márcia Balbina LorenzoHoyos

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 9months to 3years. 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 5days.

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 2weeks 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 450cc and prosthesis anatomical left of 490cc 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 6cm vertically in the pre-sternal region) as described and placement of 455cc 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) and390 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 590cc on the right and high profile 450cc on the left. On that occasion, fat grafting was also performed on theright breast (70cc). Figures –

. Subsequently, 120cc 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 ITexLi.112917

Figure 3.

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Case 1: Immediate postoperative period.

Figure 4. Case 1: Postoperative 5months.



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Figure 5. Case 1: Postoperative 3years.

Case Type of retro

muscular symmastia

1 Monocapsular Mentor



Implants withdrawn from patients with symmastia

Texturized anatomic prosthesis 490cc (left). Mentor texturized anatomic expander 450cc (right)

Implants placed for the correction of symmastia

Mentor texturized super high profile round prostheses 455cc

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 ITexLi.112917

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 390cc (left). Mentor texturized anatomic expanding prosthesiis Becker 35,460cc (right)

texturized anatomical prostheses 440cc

Implants placed for the correction of symmastia

Mentor texturized high profile round 450cc (left) Mentor texturized super high profile round 590cc (right)

Mentor texturized super high profile round prostheses 450cc

Associated fat grafting with the exchange of implants

70cc fat on the right. Not done on the left

60cc fat on the left. 110cc 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 3weeks.

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 455cc super high profile microtextured round prostheses and fat grafting 110cc on the right and 60cc on the left. Subsequently, a new fat graft was performed (40cc on the right and 30cc on the left) with reconstruction of the CAM on the right and correction of scars on the left

Figures – and Table .

