Aesth Plast Surg DOI 10.1007/s00266-014-0282-x
CASE REPORT
BREAST
An Easy Way for Congenital Symmastia Correction Mehtap Karamese • Mustafa Hancı • Malik Abacı • Ahmet Akatekin • Zekeriya Tosun
Received: 19 June 2013 / Accepted: 19 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Congenital symmastia is described as a connection between the breasts without macromastia. In this condition, there is accumulation of fat and glandular tissue between the breasts, which produces a unified appearance of the breast tissue across the chest. We report a case of congenital symmastia in a 21-year-old woman with normal-sized and -shaped breasts. We achieved satisfying aesthetic results using suction-assisted lipectomy and the patient’s complaint was resolved without scar or major surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Congenital symmastia Suction-assisted lipectomy Symmastia Presternal tissue
Introduction Symmastia is defined as unification of the breasts by soft tissue on the sternum causing a lack of separation between the breasts [6]. There are several recent reports of symmastia after augmentation mammoplasty and the surgical options for repair include allogeneic dermal grafting, fibrin-based tissue glue, and delayed filling of an adjustable implant [1, 2]. Congenital symmastia is not associated with
M. Karamese (&) M. Hancı M. Abacı A. Akatekin Z. Tosun Department of Plastic Surgery, Faculty of Medicine, Selcuk University, Konya, Turkey e-mail: [email protected]
macromastia and its surgical management does not require reduction mammoplasty. Congenital symmastia requires reduction mammoplasty only for large breasts and liposuction or minimal incision for small ones. We present a case of congenital symmastia corrected with suction-assisted lipectomy resulting in good aesthetic results with a minimally visible scar.
Case Report A 21-year-old woman was referred to our clinic with a complaint of excess tissue between her breasts. She had not undergone any previous breast operations and she was satisfied with the actual size and shape of her breasts. She wished to have a defined separation and cleavage between her breasts. There was no family history of this deformity. Examination revealed a large amount of tissue on the sternum with the tissue creating a bridge connecting the breasts. The nipple–areola complex of each breast was located laterally because of the aberrant tissue (Fig. 1). The inframammary fold and midline were marked perioperatively (Fig. 2). With the patient under general anesthesia with oral intubation, an incision in the inframammary fold was made on the right breast. Dissection was then performed toward the midline. Our first plan was to excise the presternal tissue and to apply subdermal sutures. However, during dissection, we found that the tissue between the breasts was lipomatous so we decided to perform conventional liposuction instead. Hartmann’s solution (1,000 ml), 1 mg adrenaline, and 20 ml of 0.5 marcaine were applied to the presternal area for the tumescent technique. Remodeling of the superomedial and inferomedial segments of the breast was also completed using liposuction and 285 cc of lipoaspirate was obtained.
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Aesth Plast Surg
8 weeks to stimulate adherence of the presternal skin to the sternum. At the 8- and 25-month visits, we found a successful and satisfactory appearance of the cleavage, with unchanged breast size (Figs. 4, 5).
Discussion
Fig. 1 Preoperative frontal view of a 21-year-old patient with congenital symmastia
Liposuction of the medial and inferior segments of the left breast was performed through a small incision in the inframammary fold and 270 cc of lipoaspirate was obtained. Lipoaspiration was performed via a 26-cm-long Sattler-tipped cannula with a diameter of 3 mm (Byron, USA). Two closed suction drains were placed in each breast and removed after 48 h. We encountered no complications during the postoperative follow-up. Tightening of the skin in the midsternal line occurred quickly (Fig. 3). A sternal shaper brassiere (VOE, Spain) was used for
Fig. 2 Preoperative markings
Fig. 3 Early postoperative result (2 weeks)
123
Iatrogenic symmastia, a complication of over dissecting a pocket during breast augmentation or using implants with a diameter too large for the chest wall, is a very common problem [1, 2, 5]. However, congenital symmastia is extremely rare. Also, there are very few reports of congenital symmastia without macromastia and our knowledge of the pathophysiology and ideal treatment of this condition remains insufficient. Massive hypertrophy of the breasts can have a symmastia-like appearance. Obvious macromastia can be treated with presternal skin and gland resection and transdermal sutures [6], and reduction mammoplasty techniques are also helpful [3, 6]. However, in congenital symmastia, the breasts have a normal shape and volume so treating the condition with a minimal scar or, if possible, with a scarfree technique is preferable. Spence [7] was the first to describe ‘‘symmastia’’ and used Y–V plasty methods to
Aesth Plast Surg
Fig. 4 Postoperative views of the patient 8 months after suction lipectomy
Fig. 5 Postoperative view at 25 months
correct it. Current methods focus on retaining medial skin and soft tissue flaps and surgeons have searched for a method to hide the visible scar in the intermammary space. The presternal tissue connects to the sternum and then to the breasts medially and consists of glandular tissue, subcutaneous fat, and minimal fibrous septa [4]. According to Sillesen et al. [6], in congenital symmastia, the medial adherence to the sternal periosteum is lost. Piza-Katzer et al. [3] histologically examined the tissue bridge between the breasts and found no abnormalities but ultrastructural investigation of the breast tissue (including Cooper’s ligaments) showed an abnormal arrangement of the collagen fibers. The underlying intermammary tissue is primarily fat, with a deficiency of fibrous septa; therefore, suctionassisted lipectomy, as in our case, was preferable for removing the excess fat and produced good aesthetic outcomes and a minimally visible scar. We suggest that liposuction should be the first option for all congenital symmastia without macromastia. In some cases, for the reconstruction of the septa and medial adherence to the sternum, subdermal sutures can be placed between the skin and the sternum. However, this technique can cause ‘‘dimpling’’ [3, 4], although there are reports that the dimpling improves with time. Transdermal suturing to the sternum is another method, but hypertrophic scarring in the cleavage can occur [1, 3]. A third method, ultrasoundassisted liposuction, can stimulate adherence to the
sternum. We obtained successful results in our case with conventional liposuction. Our initial plan for correcting this deformity was to transpose the subcutaneous tissue of the sternum as a flap to the medial bases of the breasts. However, after the initial incision, we realized that the excess tissue could be removed with suction lipectomy. The postoperative use of surgical drains for negative pressure and the use of a special brassiere assisted in remodeling the cleavage. There was no disturbing visible scar or complications at the operation site following this procedure. We recommend an inframammary incision to avoid unsightly scars usually obtained with a central skin incision or periareolar incisions. Salgado and Mardini [4] recommended periareolar incisions to avoid scar formation, but this approach can produce hypopigmentation. An inframammary incision is more concealable than a periareolar incision. See and Hazari [5] used inframammary incisions located at the medial end of both inframammary creases; however, there is a risk of these incisions being visible. We recommend incisions at the center of the inframammary line and liposuction as a first-line treatment for correction of congenital symmastia. Midline vertical skin incisions over the sternum with lateral extensions into the inframammary folds and various local flaps for repair should be avoided. Aggressive subdermal or transdermal sutures are not recommended.
123
Aesth Plast Surg
To our knowledge, ours is the first report of the effectiveness of liposuction alone in treating symmastia. Liposuction can be a safe, useful, and simple alternative method for the satisfactory treatment of congenital symmastia. Conflict of interest disclose.
The authors have no conflicts of interest to
References 1. Foustanos A, Zavrides H (2008) Surgical reconstruction of iatrogenic symmastia. Plast Reconstr Surg 121:143e
123
2. Maxwell GP, Birchenough SA, Gabriel A (2009) Efficacy of neopectoral pocket in revisionary breast surgery. Aesthet Surg J 29:379–385 3. Piza-Katzer H, Engelhardt TO, Steiner HJ, Zelger B (2009) Familial congenital symmastia: ultrastructurally abnormal breast tissue. Scand J Plast Reconstr Surg Hand Surg 43:339–342 4. Salgado CJ, Mardini S (2004) Periareolar approach for the correction of congenital symmastia. Plast Reconstr Surg 113:992–994 5. See MS, Hazari A (2010) The inframammary approach for the correction of iatrogenic synmastia. J Plast Reconstr Aesthet Surg 63:e96–e97 6. Sillesen NH, Ho¨lmich LR, Siersen HE, Bonde C (2012) Congenital symmastia revisited. J Plast Reconstr Aesthet Surg 65:1607–1613 7. Spence RJ, Feldman JJ, Ryan JJ (1984) Symmastia: the problem of medial confluence of the breasts. Plast Reconstr Surg 73:261–269
CASE REPORT
BREAST
An Easy Way for Congenital Symmastia Correction Mehtap Karamese • Mustafa Hancı • Malik Abacı • Ahmet Akatekin • Zekeriya Tosun
Received: 19 June 2013 / Accepted: 19 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Congenital symmastia is described as a connection between the breasts without macromastia. In this condition, there is accumulation of fat and glandular tissue between the breasts, which produces a unified appearance of the breast tissue across the chest. We report a case of congenital symmastia in a 21-year-old woman with normal-sized and -shaped breasts. We achieved satisfying aesthetic results using suction-assisted lipectomy and the patient’s complaint was resolved without scar or major surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Congenital symmastia Suction-assisted lipectomy Symmastia Presternal tissue
Introduction Symmastia is defined as unification of the breasts by soft tissue on the sternum causing a lack of separation between the breasts [6]. There are several recent reports of symmastia after augmentation mammoplasty and the surgical options for repair include allogeneic dermal grafting, fibrin-based tissue glue, and delayed filling of an adjustable implant [1, 2]. Congenital symmastia is not associated with
M. Karamese (&) M. Hancı M. Abacı A. Akatekin Z. Tosun Department of Plastic Surgery, Faculty of Medicine, Selcuk University, Konya, Turkey e-mail: [email protected]
macromastia and its surgical management does not require reduction mammoplasty. Congenital symmastia requires reduction mammoplasty only for large breasts and liposuction or minimal incision for small ones. We present a case of congenital symmastia corrected with suction-assisted lipectomy resulting in good aesthetic results with a minimally visible scar.
Case Report A 21-year-old woman was referred to our clinic with a complaint of excess tissue between her breasts. She had not undergone any previous breast operations and she was satisfied with the actual size and shape of her breasts. She wished to have a defined separation and cleavage between her breasts. There was no family history of this deformity. Examination revealed a large amount of tissue on the sternum with the tissue creating a bridge connecting the breasts. The nipple–areola complex of each breast was located laterally because of the aberrant tissue (Fig. 1). The inframammary fold and midline were marked perioperatively (Fig. 2). With the patient under general anesthesia with oral intubation, an incision in the inframammary fold was made on the right breast. Dissection was then performed toward the midline. Our first plan was to excise the presternal tissue and to apply subdermal sutures. However, during dissection, we found that the tissue between the breasts was lipomatous so we decided to perform conventional liposuction instead. Hartmann’s solution (1,000 ml), 1 mg adrenaline, and 20 ml of 0.5 marcaine were applied to the presternal area for the tumescent technique. Remodeling of the superomedial and inferomedial segments of the breast was also completed using liposuction and 285 cc of lipoaspirate was obtained.
123
Aesth Plast Surg
8 weeks to stimulate adherence of the presternal skin to the sternum. At the 8- and 25-month visits, we found a successful and satisfactory appearance of the cleavage, with unchanged breast size (Figs. 4, 5).
Discussion
Fig. 1 Preoperative frontal view of a 21-year-old patient with congenital symmastia
Liposuction of the medial and inferior segments of the left breast was performed through a small incision in the inframammary fold and 270 cc of lipoaspirate was obtained. Lipoaspiration was performed via a 26-cm-long Sattler-tipped cannula with a diameter of 3 mm (Byron, USA). Two closed suction drains were placed in each breast and removed after 48 h. We encountered no complications during the postoperative follow-up. Tightening of the skin in the midsternal line occurred quickly (Fig. 3). A sternal shaper brassiere (VOE, Spain) was used for
Fig. 2 Preoperative markings
Fig. 3 Early postoperative result (2 weeks)
123
Iatrogenic symmastia, a complication of over dissecting a pocket during breast augmentation or using implants with a diameter too large for the chest wall, is a very common problem [1, 2, 5]. However, congenital symmastia is extremely rare. Also, there are very few reports of congenital symmastia without macromastia and our knowledge of the pathophysiology and ideal treatment of this condition remains insufficient. Massive hypertrophy of the breasts can have a symmastia-like appearance. Obvious macromastia can be treated with presternal skin and gland resection and transdermal sutures [6], and reduction mammoplasty techniques are also helpful [3, 6]. However, in congenital symmastia, the breasts have a normal shape and volume so treating the condition with a minimal scar or, if possible, with a scarfree technique is preferable. Spence [7] was the first to describe ‘‘symmastia’’ and used Y–V plasty methods to
Aesth Plast Surg
Fig. 4 Postoperative views of the patient 8 months after suction lipectomy
Fig. 5 Postoperative view at 25 months
correct it. Current methods focus on retaining medial skin and soft tissue flaps and surgeons have searched for a method to hide the visible scar in the intermammary space. The presternal tissue connects to the sternum and then to the breasts medially and consists of glandular tissue, subcutaneous fat, and minimal fibrous septa [4]. According to Sillesen et al. [6], in congenital symmastia, the medial adherence to the sternal periosteum is lost. Piza-Katzer et al. [3] histologically examined the tissue bridge between the breasts and found no abnormalities but ultrastructural investigation of the breast tissue (including Cooper’s ligaments) showed an abnormal arrangement of the collagen fibers. The underlying intermammary tissue is primarily fat, with a deficiency of fibrous septa; therefore, suctionassisted lipectomy, as in our case, was preferable for removing the excess fat and produced good aesthetic outcomes and a minimally visible scar. We suggest that liposuction should be the first option for all congenital symmastia without macromastia. In some cases, for the reconstruction of the septa and medial adherence to the sternum, subdermal sutures can be placed between the skin and the sternum. However, this technique can cause ‘‘dimpling’’ [3, 4], although there are reports that the dimpling improves with time. Transdermal suturing to the sternum is another method, but hypertrophic scarring in the cleavage can occur [1, 3]. A third method, ultrasoundassisted liposuction, can stimulate adherence to the
sternum. We obtained successful results in our case with conventional liposuction. Our initial plan for correcting this deformity was to transpose the subcutaneous tissue of the sternum as a flap to the medial bases of the breasts. However, after the initial incision, we realized that the excess tissue could be removed with suction lipectomy. The postoperative use of surgical drains for negative pressure and the use of a special brassiere assisted in remodeling the cleavage. There was no disturbing visible scar or complications at the operation site following this procedure. We recommend an inframammary incision to avoid unsightly scars usually obtained with a central skin incision or periareolar incisions. Salgado and Mardini [4] recommended periareolar incisions to avoid scar formation, but this approach can produce hypopigmentation. An inframammary incision is more concealable than a periareolar incision. See and Hazari [5] used inframammary incisions located at the medial end of both inframammary creases; however, there is a risk of these incisions being visible. We recommend incisions at the center of the inframammary line and liposuction as a first-line treatment for correction of congenital symmastia. Midline vertical skin incisions over the sternum with lateral extensions into the inframammary folds and various local flaps for repair should be avoided. Aggressive subdermal or transdermal sutures are not recommended.
123
Aesth Plast Surg
To our knowledge, ours is the first report of the effectiveness of liposuction alone in treating symmastia. Liposuction can be a safe, useful, and simple alternative method for the satisfactory treatment of congenital symmastia. Conflict of interest disclose.
The authors have no conflicts of interest to
References 1. Foustanos A, Zavrides H (2008) Surgical reconstruction of iatrogenic symmastia. Plast Reconstr Surg 121:143e
123
2. Maxwell GP, Birchenough SA, Gabriel A (2009) Efficacy of neopectoral pocket in revisionary breast surgery. Aesthet Surg J 29:379–385 3. Piza-Katzer H, Engelhardt TO, Steiner HJ, Zelger B (2009) Familial congenital symmastia: ultrastructurally abnormal breast tissue. Scand J Plast Reconstr Surg Hand Surg 43:339–342 4. Salgado CJ, Mardini S (2004) Periareolar approach for the correction of congenital symmastia. Plast Reconstr Surg 113:992–994 5. See MS, Hazari A (2010) The inframammary approach for the correction of iatrogenic synmastia. J Plast Reconstr Aesthet Surg 63:e96–e97 6. Sillesen NH, Ho¨lmich LR, Siersen HE, Bonde C (2012) Congenital symmastia revisited. J Plast Reconstr Aesthet Surg 65:1607–1613 7. Spence RJ, Feldman JJ, Ryan JJ (1984) Symmastia: the problem of medial confluence of the breasts. Plast Reconstr Surg 73:261–269
