Breast Asymmetry: Presentations and Choice of Suitable Method of Correction

Breast Asymmetry: Presentations And Choice Of Suitable Method Of Correction

Thesis

Submitted by

Dr. Rasha Mohamed Abdel Kader

In the partial fulfillment of the Master degree in General surgery

Under supervision of

Prof Dr. Alaa Gheita Professor of plastic and general surgery Faculty of Medicine, Cairo University

Prof Dr. Aly Moftah Aziz Moftah Professor of plastic and general surgery Factuly of Medicine, Cairo University

Ass. Prof Dr. Wael Mohamed El Shaer Assistant Professor of plastic and general surgery Faculty of Medicine, Banisweif University

Cairo University 2008 Contents

List of Figures iii List of Tables v List of Abbreviations vi Acknowledgments vii Abstract and Keywords viii I Introduction Chapter 1 – Introduction Introduction 1 Aim of work 1 II Review of Literature Chapter 2 – Embryology and Anatomy of the Breast Embryology 3 Anatomy 5 Breast Histology 11 Chapter 3 – Breast physiology and development Breast Development 13 Breast Physiology 15 Chapter 4 – Aesthetics of the Breast Principles of Breast Aesthetics 17 Chapter 5 – Breast asymmetry Definition of developmental breast asymmetry 22 Incidence 22 Classifications 22 Breast asymmetry aetiology 24 Developmental anomalies 24 Pathopysiology 32 Psychological impact 34 Chapter 6 – Breast Asymmetry Management Timing 35 Case evaluation 35 Non surgical treatment 39 Surgical management 40 Symmetrising procedures 54

i Postoperative course 59 Postoperative evaluation 60 Revision surgery 60 III Methodology Chapter 7 – Patients and Methods Patients 62 Methods 62 Chapter 8 – Results Patients 71 Preoperative evaluation 71 Operative plan 71 Postoperative care, complications and follow-up 84 Patient photos 85 IV Discussion and Conclusion Chapter 9 – Discussion and Conclusion Discussion 103 Conclusion 106 Bibliography 108 V Summary Chapter 10 – Summary English Summary 118 Arabic Summary 120

ii List of Figures

Chapter 2 2.1 Arterial supply of the breast. (Sadove and Van Aalst, 2005) 9 2.2 Histology of the breast. (Muntan et al., 2000) 11 Chapter 3 3.1 Tanner Staging (Beller et al., 1991) 14 Chapter 4 4.1 Aesthetics of the female breast 17 4.2 Triangle of Penn 20 Chapter 5 5.1 Polymastia of the Left side of the patient (Aslan et al., 2004) 25 5.2 Depiction of normal and tuberous development. (Latham et al., 2006) 27 5.3 A patient having pectus excavatum as obvious through photography and 29 CT study. (Park et al., 2008) 5.4 Poland’s syndrome: A diagram showing associated skeletal deformities. (Abhinav et al., 2007) 30 5.5 A patient photo showing breast deformity in Klippel-Trenauney syndrome. (Baldwin et al., 2006) 32 5.6 Congenital amniotic fold in the thoracoabdominal area (Tepavicharova- Romanska, 2002) 33 Chapter 6 6.1 A photo taken to a patient with breast and onto which breast measurements are applied (Left and right respectively). (Maxwell, 2001). 36 6.2 Representative images of illustration and measurement capabilities. (Left Laterally rotated image and coordinate axes. (Right Image of breast using the mesh mode and surface of the breast. Breast projection and volume enclosed 38 between the base and the surface are estimated quantitatively. (Denoel et al., 2002) 6.3 MRI with axial reconstruction for 3D application in volume rendering. (Pozzobon et al., 2008) 38 6.4 Chest wall implant. (Longaker et al., 1997; Rocha et al., 2008) 43 Chapter 7 7.1 A diagram showing measurements for breast asymmetry (Maxwell, 2001) 65 7.2 Diagram of the preoperative markings.The various important items illustrated for proper planning of the procedure mainly: S.S.N. Supra sternal notch, I.M.F. Infra mammary fold, Breast axis. of the inverted (T) at one inch 67 from the infra-mammary fold 7.3 Intraoperative photo of tuberous breast treatment 69 7.4 Telescoping of the areola 70

Chapter 8

iii 8.1 Asymmetrical Hypertrophy, Case 1 86 8.2 Asymmetrical Hypertrophy, Case 3 87 8.3 Asymmetrical Hypertrophy, Case 5 88 8.4 Asymmetrical Hypertrophy, Case 6 89 8.5 Asymmetrical Hypertrophy, Case 7 90 8.6 Asymmetrical Hypoplasia (Ptosis), Case 8 91 8.7 Asymmetrical Hypoplasia (Ptosis), Case 9 92 8.8 Asymmetrical Hypoplasia (Ptosis), Case 10 93 8.9 Asymmetrical Hypoplasia (Hypoplastic Breasts), Case 11 94 8.10 Asymmetrical Hypoplasia (Hypoplastic Breasts), Case 12 95 8.11 Asymmetrical Hypoplasia (Tuberous Breasts), Case 14 96 8.12 Asymmetrical Hypoplasia (Tuberous Breasts), Case 15 97 8.13 Asymmetrical Hypoplasia (Tuberous Breasts), Case 16 98 8.14 Hypertrophy/Hypoplasia, Case 17 99 8.15 Combined, Case 19 100 8.16 Combined, Case 20 101

iv List of Tables

Chapter 3 3.1 Tanner staging of breast development. (Beller et al., 1991) 14 Chapter 5 5.1 Tuberous breast incidence 28 Chapter 6 6.1 Evaluation of patients with breast asymmetry. (Rohrich et al., 2003) 39 6.2 Approach of augmentation in breast asymmetry. (Chang et al., 2001) 46 Chapter 8 8.1 Classification of breast asymmetries & patient numbers 71 8.2 Preoperative evaluation of Breast asymmetry cases 72 8.3 Summary of Age, weigh and height findings in patients with breast asymmetry 73 8.4 Summary of findings of breast sizes in patients with breast asymmetry 74 8.5 Summary of skin envelope findings in patients with breast asymmetry 75 8.6 Summary of measurements of SNN and CN in patients with asymmetric breasts 76 8.7 Summary of measurements of BBW and NIMF in patients with asymmetric breasts 77 8.8 Summary of measurements of Areolar diameter and intermammary distance in patients with asymmetric breasts 78 8.9 Operative plan of Breast asymmetry cases (First 10 patients) 79 8.10 Operative plan of Breast asymmetry cases (Second 10 patients) 80 8.11 Details for patients undergoing Correction of hypertrophic asymmetry 81 8.12 Details for patients undergoing correction of asymmetric ptosis & asymmetric Hypoplasia 81 8.13 Details for patients undergoing correction of tuberous breast deformity 82 8.14 Details for patients undergoing correction of Hypertrophy-hypoplasia 83 8.15 Details for patients undergoing correction of Combined cases 83 8.16 Complications of Breast asymmetry operations 84 8.17 Secondary surgeries and number of patients undergoing them 84 8.18 Long term results in patients with breast asymmetries surgery 84 8.19 Postoperative aesthetic results for patients with breast asymmetry 85 8.20 Table showing the degree of patients satisfaction following Breast asymmetry Surgeries 85 Chapter 9 9.1 Comparing different types of pedicles 104

v Abbreviations

MPC Myogenic Progenitor Cells SFS Superﬁcial Fascial System cm centimeter TGF Transforming Growth Factor FSH Follicle Stimulating Hormone LH Luteinizing Hormone BDD Body Dysmorphic Disorder NAC Nipple Areola Complex IMF Infra Mammary Fold CN Midclavicular Point to Nipple SNN Suprasternal Notch to Nipple BBW Breast Base Width NIMF Nipple to Infra Mammary Fold PRP Platelet Rich Plasma TTM Thermal Texture Mapping

vi Acknowledgements

I would like to express my deep appreciation to the most Senior Advisors, of Department 29A at Kasr El Aini University Hospital Professor Dr. Mostafa El Sharkawy and Professor Dr. Alaa Gheita, to whom I owe everything I learnt and know, and their fatherly help and assistance. A special gratitude and appreciation, to Professor Dr. Alaa Gheita who suggested the topic of this thesis, his guidance, help, and most of all his constructive criticism throughout the completion of this work. To Professor Dr. Aly Moftah Head of Department 29 and my direct Supervisor for his unrelented support and patience during my tenure in the Department and, for his continuous support and encouragement during difﬁcult times. My sincerest gratitude to Prof. Dr. Aly Moftah for his contribution and professional advice that made the completion of this study possible. To Assistant Professor Dr. Wael El Shaer, a special word of appreciation for not sparing any time or effort in assisting me in every way possible to complete this work. To the entire staff of Department 29 for their support during the past three years. Last but not least, I would like to thank Professor Dr. Hani Rateb my ﬁrst Supervisor where I was initially appointed in Department 11B.

vii

Abstract and Keywords

Abstract

Background

The problem of breast asymmetry is an important issue that is worth studying. The breast represents one of the most important entities for the female. Females worry about their cosmetic look a lot and breast asymmetry. Breast asymmetry presents a problem in surgical management as regards the discrepancy in size, volumes, shapes and contour and even the sites of differences or excess in these breasts. In addition to some associated discrepancies of breast bases on which the breasts are seated as thoracic cage abnormalities and unevenness, hence, the difﬁcult differentiation of the breast problem which root to the origin of their etiologies that has to be understood in order to deal with the associated pathologies that cause this abnormalities. Breast asymmetry’s only hope for treatment is the surgical treatment. This study was done between April 2005 and March 2009 with the intention of choosing a speciﬁc method of correction for each subtype of breast asymmetry.

Methodology

The study was held in Kasr Al Ainy hospital and other private hospitals on 20 female patients having different types of breast asymmetry. The patients were examined and evaluated preoperatively and according to the type of breast asymmetry, a speciﬁc surgical plan was devised. The patients were then followed up in the early postoperative period for possible complications and for at least one year after surgery to check for patient satisfaction and second look surgeries. The methods used were mastopexy, reduction and augmentation whether alone or in combination in order to correct breast results.

Conclusion

Categorizing the patients and conducting a tailored plan for each patient was the key to successful outcome. The study concluded that no technique is superior over the other and that there are guidelines to be followed to achieve patient satisfaction.

Keywords Breast Asymmetry, Reduction mammaplasty, Augmentation mammaplasty, Mastopexy, Poland’s syndrome, Tuberous breast.

viii

Part I

Introduction

ix Introduction:

Breast asymmetry is a highly important entity of breast deformities. Surgery is the only treatment. It is a relatively common condition; however mild breast asymmetries occur but could be taken in the range of normality. (Tepavicharova, 2002) Gross breast asymmetry could be due to asymmetry of size, shape or of the nipple areola complex (NAC) position and/or size. The etiology of breast asymmetry may be due to several factors such as congenital, unilateral agenesis, trauma, burns, iatrogenic (post-surgical), inﬂammatory e.g. abscess in childhood (Munhoz et al., 2007) or neoplastic. (Scutt et al., 2006) However, our concern in this study is dealing with developmental gross breast asymmetry. Correction of asymmetric breasts could represent a great challenge in breast surgery. The thorough knowledge of the anatomical abnormalities present and their analysis is mandatory for the proper planning to achieve a satisfactory result. (Cervelli et al., 2005) Many options are available for the correction of the anomaly including reduction mammaplasty, mastopexy, augmentation mammaplasty or a combination of procedures. (Spear et al., 2006)

Aim of the work

To review the literature concerning the different etiologies and types of developmental gross breast asymmetry and choice of the suitable approaches for each type of deformity accordingly be it mastopexy, reduction and/or augmentation. 20 Cases will be studied presenting the different types of deformities.

Part II Review Of Literature

2 2 Embryology and Anatomy of the Breast

I – Embryology of the breast

Embryologic development of the mammary gland consists of a series of highly ordered events involving interactions among a number of distinct cell types. These interactions are regulated by an array of systemic and local factors such as growth factors and hormones. Development is initially identical among males and females of the same species. (Ackerman et al., 2007) Breasts begin to form at 5-7 weeks of fetal development as a bilateral thickening of the ectoderm from the base of the forelimb to the hindlimb, in a curvilinear fashion convex towards the midline from the axillae to the medial thigh and is termed the mammary line, which involutes shortly after forming. However, in human development a limited portion in the thoracic region of the embryo remains, and forms the basis for development of the neonatal breast. (Latham et al., 2006) Thickening of the remaining mammary line forms the mammary ridge, which by seven weeks gestation reaches the milk hill stage. This is followed by the disc stage, in which the epithelial tissue invaginates into the underlying mesenchyme at eight weeks gestation. (Harris et al., 2000) This epithelial-mesenchymal signaling is probably through paracrine and juxtacrine mechanisms where the underlying mesoderm produces growth factors and hormones that interact with receptors on the overlying ectodermal cells of the primary mammary bud. Subsequently, the epithelial tissue continues to grow and invades deeper into the chest wall mesenchyme, completing the globular and cone stages by 14 weeks gestation. Epithelial tissue begins to form buds, which branch into the primitive breast alveoli in the branching stage. At 16 weeks, the branching stage has produced approximately 15-25 epithelial branches. (Einav-Bachar et al., 2004) The adipose tissue in the underlying mesoderm represents a significant store of lipids for the production of hormones and growth factors, which are then available to promote and regulate growth of the developing mammary gland. The supporting fibrous connective tissue, Cooper ligaments, and fat of the mammary gland develop from the surrounding mesoderm. When the fetus reaches the third trimester of gestation, the canalization stage of breast development begins, which is the first stage of breast development triggered by hormonal influences. (Latham et al., 2006; McKiernan and Hull, 1981) Placental sex hormones mediate the canalization of the previously formed epithelial branches to complete the formation of the primitive mammary ducts. The final stage of fetal breast development is called the end-stage vesicle and comprises differentiation of breast parenchyma into lobules, with development of the nipple-alveolar complex. This stage begins at 32 weeks and continues to birth. Canalization and branching of the breast tissue continues well into early childhood. (Einav-Bachar et al., 2004) By birth, the neonatal mammary tissue has become functional and may secrete colostrum for the first week of life. This fluid consists of cellular debris and is commonly termed witch‘s milk. It may alarm parents but is not considered a pathologic finding. (Latham et al., 2006)

3 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

Breast tissue in childhood grows at the same rate as the body, but remains non- secretory as long as estrogen levels remain low. Abnormally high levels of estrogen in prepubertal patients, however, can cause the immature breast tissue to proliferate and mature, resulting in the development of either gynecomastia or precocious puberty. (Latham et al., 2006; Pelligrini and Wagner, 1983)

II – Embryology of the musculature

The cells of the myotomes divide into an epimere and hypomere. The epimeres give rise to the skeletal muscles of the back. The hypomeres differentiate into the skeletal muscles in the lateral and anterior regions of the thorax and abdomen. The hypomere splits into 3 layers, which, in the thorax, represent the external intercostals, the internal intercostals, and the innermost intercostals or transverse thoracic muscle. In addition, in regions of the developing limb buds, the myotomes contribute to muscles of the limbs. This paraxial mesenchymal tissue also gives rise to the anterior chest and abdominal wall musculature. Several genetic and molecular techniques have been utilized to determine the source of myogenic progenitor cells and their developmental influences. Skeletal muscle differentiation requires a family of transcription factors known as myogenic regulatory factors. Most congenital muscle diseases and structural abnormalities have at least been mapped to chromosomal regions. Myogenic progenitor cells (MPC) of the somite originate from the dermomyotome and differentiate to form a primary myofiber scaffolding. Continual muscle growth occurs through the addition of secondary myofibers from fetal myogenic progenitors. Secondary fibers acquire the characteristics of fast fibers, whereas the primary fibers tend to become slow fibers. By the end of the third month, cross-striations typical for skeletal muscle appear. (Harris et al., 2000)

III – Implication of embryology to asymmetry

The shape of the breast depends on the relationship between the glandular tissue and the skin-subcutaneous envelope. The mammary gland has an ectodermal origin: as the ectodermal anlage grows it penetrates the subcutaneous tissue forming the mammary lobes. The pattern of penetration of the glandular tissue in the subcutaneous tissue depends on the disposition of the superficial fascial system (SFS) that is a network of connective strands that encases the fat layer. (Gasperoni and Salgarello, 1997) In addition, the presence of supernumerary breast tissue indicates incomplete involution of the milk line, resulting in the formation of accessory mammary tissue from the redundant clusters of ectopic primordial breast cells. Approximately one third of affected individuals have more than one site of supernumerary breast tissue development. Most of this accessory breast tissue has no physiologic significance, but some may enlarge with the onset of puberty, pregnancy, or lactation, and can be the site of breast carcinoma. Approximately 67% of accessory breast tissue occurs in the thoracic or abdominal portions of the milk line, often just below the inframammary crease and more often on the left side of the body. Another 20% occurs in the axilla. The remaining locations include anywhere along the milk line or in the buttock, back, face, and neck. Supernumerary tissue present in any location other than along the milk line represents a migratory arrest of breast primordium during chest wall development. (Latham et al., 2006) Amastia and hypoplasia may be associated with scalp defects, ear abnormalities, 4 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST renal hypoplasia, and cataracts in patients with the rare autosomal dominant Finlay- Marks syndrome. Hypoplasia also may occur in patients with Turner syndrome (ovarian agenesis), congenital adrenal hyperplasia, and delayed menarche where the administration of oral estrogen therapy usually promotes glandular development. (Sadove and Van Aalst, 2005) Anomalies such as Poland’s syndrome consists of a variable constellation of anomalies that include congenital absence of the sternal head of the pectoralis major. Other muscle anomalies may also exist. The tendency towards unilaterality of Poland syndrome (right more common than left side) has prompted speculation that the anomaly may be due to interrupted or insufficient subclavian blood supply during limb bud development that occurs in the second through the fifth week of gestation. (Borschel et al., 2007; Fokin and Robicsek, 2002)

A – Anatomy of the breast

The mammary glands are a primary symbol of femininity. It begins development early in embryologic life and only culminates in the postpartum lactation of the adult female. (Bohmert and Gabka, 1997) All breasts are usually asymmetrical. These asymmetries can range from subtle variations, recognizable only to the surgeon to major differences. (Edstom et al., 1977) Understanding the anatomy is crucial prior to performing an operative procedure. Comprehension of breast anatomy enhances the surgeon’s ability to perform surgery safely and effectively. (Wuringer, 2005)

I – The breast base

The mound of the adult female breast extends from the second rib above to the sixth rib below. Medially, it borders the lateral edge of the body of the sternum, and laterally it reaches the mid-axillary line. At its superolateral extremity, the breast tissue projects as a tongue into the axilla along the lower border of the pectoralis major (the axillary tail of Spence). The main bulk of the breast tissue is usually localized to its upper outer quadrant. (Jones, 2006)

II – Breast parenchyma and Skin appendage

As a skin appendage, the breast is closely related to the skin, its quality, thickness and elasticity affect breast appearance. The skin enveloping of the breast is subject to hormonal, expansible, weight, gravitational, & aging influences. After breast development the skin can become stretched, especially in the lower breast area and in the areas of relative breast fullness. With thinning skin as well as loss of elasticity, striae, actual tears and separations of the thinned dermis with thinning of the epidermis are often noted in the supraareolar & periareolar regions in skin that is inherently thin, has stretched rapidly or extensively or after weight loss or postpartum involution. (Bostwick J III, 2000) The amount of fat within the breast varies; this fat is responsible for most of the bulk, contour, softness, consistency, and shape of the breast. It is selectively deposited within the breast and is influenced by genetic & hormonal factors. The percentage of body fat also influences the amount of breast fat, although some women seem to selectively deposit more fat within their breast. The breast with considerable fat content feels soft, 5 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST whereas the breast with predominance of stromal & glandular components is often firm, irregular, and nodular in composition. Patient who undergo a significant weight loss often notice a change in the consistency of their breast as they begin to feel the nodularity of the normal breast tissue that previously was undetectable or not palpable within the fatty tissue. The actual glandular, secretory, milk producing component of the breast is situated within a connective & fatty tissue stroma. These glandular & stromal tissue respond to systemic hormonal & genetic influences. About 20 main lactiferous ducts connect and drain the individual breast lobules to the nipple. The breast lobules are distributed radially about the breast; each of these breast lobules is composed of hundreds of potentially secretory acini & each has a separate interlobular duct connecting to the lactiferous ducts. The nipple is a focused part of the parenchyma from a functional & sensory perspective. Contained within the nipple are special lactiferous ducts that act as conduits for glandular secretions. (Bostwick J III, 2000)

III – Fascia and Suspensory ligaments of Cooper

The breast is essentially a skin appendage contained within layers of the superficial fascia. The superficial layer of this fascia is near the dermis and is not distinct from it. The deep layer of the superficial fascia is more distinct and is identifiable on the deep surface of the breast. There is loose areolar tissue between the deep layer of the superficial fascia and the fascia that covers the pectoralis major that continues to cover the adjacent rectus abdominis, serratus anterior, and external oblique muscles. This fascia has its origin on the clavicle and sternum, extending toward the lateral border of the muscle to form the axillary fascia and continues down to cover the latissimus dorsi muscle. The deep fascia covering the lower aspect of the pectoralis major muscle is well defined, as is the fascia of the serratus anterior muscle. This deep fascia is continuous with the fascia of the external oblique and rectus abdominis muscles. The upper portions of the external oblique and rectus abdominis muscles and their overlying fascia are beneath the lower portion of the breast. The digitations of origin of the external oblique muscle are associated with the lateral inferior fibers of the pectoralis major muscle and laterally with the serratus anterior muscular digitations. (Graf et al., 2003) Fibrous processes of this layer of fascia extend to the skin and to the nipple and are more developed over the upper part of the breast, where they form the suspensory ligament of Cooper. Connective tissue (Cooper’s ligament) extends from the deep fascia to the dermis & runs throughout the breast parenchyma, attaching to the dermis of the overlying skin. These suspensory ligaments also reach to the posterior layer of the superficial fascia & connect onto the deep muscle fascia, because the deep attachments are not taut, they allow greater breast mobility on the deep fascia during motion and activity. These suspensory ligaments can be stretched & elongated by pregnancy, by aging, or by weight fluctuation. Loss of elasticity in these connective tissues contributes to breast ptosis & excess breast mobility. (Bland, 2007)

6 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

IV – Nipple areola complex

V – Infra mammary fold

This represents the lower boundary of the base of the breast and it is relatively constant in position corresponding to the sixth intercostal space. However, in elderly females and in large breasts, the inframammary crease may slide downwards to the level of the seventh rib (Bohmert and Gabka, 1997). Also the inframammary fold, is usually well above the antecubital fossa at the mid to lower 1/3 of the upper arm. (Massiha, 2001)

B – Anatomy of the Musculature

The breast lies over the musculature that encases the chest wall. The muscles involved include the pectoralis major, serratus anterior, external oblique, and rectus abdominis fascia. The blood supply that provides circulation to these muscles then perforates through to the breast parenchyma, thus also supplying blood to the breast. By maintaining continuity with the underlying musculature, the breast tissue remains richly perfused, thus preventing complications arising from aesthetic or reconstructive surgery requiring the placement of a breast implant. (Mathes and Nahai, 1997)

Pectoralis major The pectoralis major muscle is a broad muscle that extends from its origin on the medial clavicle and lateral sternum to its insertion on the humerus. The thoracoacromial artery provides its major blood supply while the intercostal perforators arising from the internal mammary artery provide a segmental blood supply. The medial and lateral anterior thoracic nerves provide innervation for the muscle, entering posteriorly and laterally. The action of the pectoralis major is to ﬂex, adduct, and rotate the arm medially. The pectoralis major is extremely important in both aesthetic and reconstructive breast surgery, since it provides muscle coverage from the breast implant. The muscle provides additional tissue between the implant and the skin, thus decreasing the palpability of the implant. (Ellis, 2007)

7 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

Serratus anterior The serratus anterior muscle is a broad muscle that runs along the anterolateral chest wall. Its origin is the outer surface of the upper borders of the ﬁrst through eighth ribs and its insertion is on the deep surface of the scapula. Its vascular supply is derived equally from the lateral thoracic artery and branches from the thoracodorsal artery. The long thoracic nerve serves to innervate the serratus anterior, which acts to rotate the scapula, raising the point of the shoulder and drawing the scapula forward toward the body. Because the serratus anterior underlies the lateral aspect of the breast, in aesthetic surgery, blunt elevation of the pectoralis major laterally inadvertently elevates a small portion of the serratus muscle. (Ellis, 2007)

Rectus abdominis The rectus abdominis muscle provides the inferior border to the breast. It is an elongated muscle that runs from its origin at the crest of the pubis and interpubic ligament to its insertion at the xiphoid process and cartilages of the ﬁfth through seventh ribs. It acts to compress the abdomen and ﬂex the spine. The 7th through 12th intercostal nerves provide sensation to overlying skin and innervate the muscle. Vascularity of the muscle is maintained through a network between the superior and inferior deep epigastric arteries. (Skandalakis et al., 2004)

External oblique The external oblique muscle is a broad muscle that runs along the anterolateral abdomen and chest wall. Its origin is from the lower 8 ribs, and its insertion is along the anterior half of the iliac crest and the aponeurosis of the linea alba from the xiphoid to the pubis. It acts to compress the abdomen, ﬂex and laterally rotate the spine, and depress the ribs. The 7th through 12th intercostal nerves serve to innervate the external oblique. A segmental blood supply is maintained through the inferior 8 posterior intercostal arteries. (Skandalakis et al., 2004) C – Blood supply and venous drainage of the breast

The blood supply of the breast parenchyma is closely related to the blood supply of the under lying muscles; knowledge of both is crucial when planning aesthetic & reconstructive breast operations, the blood supply to the breast is also primarily responsible for the blood supply of the overlying skin via perforators & the subdermal plexus. The principles applicable to muscles & musculocutaneous flaps also contribute to an understanding of the blood supply to the breast because the breast is essentially a skin derivative & its blood supply is analogous to musculocutaneous flaps. (Sadove and Van Aalst, 2005) The blood supply to the breast comes from numerous arterial sources. A substantial collateralization of arterial flow is present within the breast, making it possible for the entire normal breast to survive on a fraction of its usual total arterial input, provided that the breast parenchyma incisions do not transect a major portion of the blood supply to a particular segment. However, if all the arterial flow to a segment of the breast is divided, necrosis of portions of the breast, & especially the fat, will result. (Latham et al., 2006)

8 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

Fig 2.1: Arterial supply of the breast. (Sadove and Van Aalst, 2005)

The external mammary artery: It is a major artery entering the upper lateral portion of the breast. It originates from the axillary artery & entering the breast in the lower axillary region to supply its upper lateral portion. This vessel is large, about 2 to 3 mm in diameter, & can nourish the entire breast under normal circumstances.

The internal mammary segmental perforating vessels: These provide another primary source of arterial inflow. These vessels penetrate the breast via perforators through the medial intercostal spaces through the intercostal muscles & through the pectoralis major muscle origin between the 2nd & 6th intercostal spaces. The internal mammary perforators go to the pectoralis major muscle, the breast, & the overlying skin. The 2nd & the 3rd internal mammary perforator share also the largest, providing 1ry blood flow into the upper medial breast area. Although the size of the internal mammary artery & the internal mammary perforators vary in each individual, the upper perforators are usually predominant. During supero-medial pedicle breast reduction the upper medial and central breast parenchyma is preserved to ensure continued inflow from these important sources and to preserve a natural fullness & a satisfactory cleavage in the upper medial breast. (Latham et al., 2006) The intercostal perforators also provide a major source of blood flow to the breast. These large arterial perforators are accompanied by sensory nerves & veins perforating through the intercostal spaces through the lateral margin of the pectoralis major muscle through serratus anterior muscle digitations. They primarily supply the lateral breast segmentally from the 3rd through the 6th intercostal spaces. Additional lateral intercostal

9 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST perforators enter the lateral breast parenchyma at the lateral margin of the latissimus dorsi muscle. They send branches to the latissimus dorsi muscle as well as to the lateral breast and lateral breast subcutaneous tissue and skin. Blood flow to the central & lower breast is also supplied by another group of intercostal perforators that enter the lower medial & central aspect of the breast parenchyma from the nipple level (4th interspace) downward. These perforators, often 1 to 2 mm in diameter, are a primary source of blood supply to the central breast in inferior central pedicle reduction mammoplasty. Some of these intercostal perforators branch upward through the lower fibers of the origin of the pectoralis major muscle. These anteromedial and anterolateral arteries have branches that course upward through the breast tissue to the nipple-areola. Others enter centrally through digitations of the external oblique muscle origins. These lower intercostal pectoralis major perforators communicate within the muscles with the other major vessels in the intramuscular network. They then enter the breast and develop further communications with vessels from the internal mammary artery, external mammary artery, and pectoralis major perforators from the thoracic aorta. (Bostwick J III., 2000) A superficial subdermal venous plexus just superior to the superficial fascia & a deeper venous system closely related to the deeper parenchymal & muscular arteries provide the venous drainage of the breast. They superficially originate & form a periareolar vascular venous plexus; these veins interconnect across the midline, draining superiorly & medially. This superficial venous system connect with the deeper veins of the breast through the breast parenchyma. Their subcutaneous pattern is effectively visualized with infrared photography. Recent studies of the venous drainage of the breast demonstrate the presence of valves that direct the blood flow from the superficial to the deep system. (Ellis, 2007)

Nerves (Sarhadi et al., 1996)

Sensory innervation of the breast is dermatomal in nature. It is mainly derived from the anterolateral and anteromedial branches of thoracic intercostal nerves T3-T5. Supraclavicular nerves from the lower fibers of the cervical plexus also provide innervation to the upper and lateral portions of the breast. Perception of breast sensation has two aspects: the general sensitivity to touch with two point discrimination of pressure, vibration, heat, and cold similar to the rest of the body and the unique special sensual responsivity characteristic of central breast especially nipple-areola stimulation. Skin sensation to touch, temperature, and pressure can be preserved even if the specific sensation to the nipple-areola is diminished or absent. The abundant sensory innervation of the skin of the breast has considerable overlap and comes from the intercostal segmental nerves entering from medial, midlateral, and lateral directions. Supraclavicular filaments from the cervical plexus extend downward beneath the platysma muscle to innervate the upper portions of the breast skin collateralization. They enter the subcutaneous tissue and supplement innervation of the upper breast. The lateral intercostal nerves along the lateral edge of the latissimus dorsi provide sensory innervation for the lateral portions of the breast skin collateralization. They enter the subcutaneous tissue & supplement the innervation of the upper breast. Significant overlaps exists among these nerves, the anterolateral and anteromedial nerves, and the clavicular nerves coming down from the cervical plexus.

10 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

Primary sensory nerves of the breast skin also enter from the 3rd to the 6th anterolateral intercostal nerves. These nerves pass through the interdigitations of the serratus anterior muscle at the lateral margin of the pectoralis major muscle. They cross superﬁcially from the intercostal nerves beneath the lower portions of the ribs. The 2nd to 6th anterior medial intercostal segmental nerves supplies the medial breast and presternal area and enters the breast parenchyma with the internal mammary perforators. They also extend to the central breast, and their 3rd, 4th, 5th segmental nerves contribute to nipple- areola sensation along with those from corresponding anterolateral branches.

Breast Histology

Common to breast, axilla, and external auditory canal are epidermis, dermis, and subcutaneous fat. In the case of the axilla and external auditory canal, apocrine glands are mostly clustered in the deep reticular dermis; however, some apocrine glands may be seated in the subcutaneous fat. In the breast, apocrine glands may reside in the deep part of the dermis, but the vast majority of them (mammary glands) are stationed in the subcutaneous fat. The apocrine nature of the glands in the subcutaneous fat of the breast is not identiﬁable readily in non-secretory tissue, but it is obvious in the lactating breast. If the breast is deemed to be an organ, separate and distinct from the skin and subcutaneous fat, merely because of the presence of an apocrine glandular component that is dependent on hormones, then a similar argument can be made both for the axilla and the external auditory canal. (Latham et al., 2006)

Fig 2.2: Histology of the breast. (Muntan et al., 2000)

11 CHAPTER2 EMBRYOLOGY AND ANATOMY OF THE BREAST

The nipple projects from the anterior surface of the breast and is devoid of hairs because no follicles exist there. The nipple consists of epidermis and dermis, and, except for follicles, all epithelial and non-epithelial adnexal structures found in normal skin are also present. (Skandalakis et al., 2004) Apocrine (lactiferous) ducts enter infundibula, just as do apocrine ducts in the axilla and in the external auditory canal. Just as every part of the skin has histological features that enable it to be identified with specificity, so too it is for the breast, which has a nipple with infundibulosebaceous units, rather than infundibulofolliculosebaceous units, associated with it, numerous fascicles of smooth muscle throughout the dermis, and unique arrangement and morphologic appearance of apocrine glands and ducts in the subcutaneous fat. In the fat free area under the areola, the dilated portions of the lactiferous ducts (the lactiferous sinuses) are the only sites of actual milk storage. (Ackerman et al., 2007) The suspensory ligaments of Coper form a network of strong, irregular shape connective tissue strands or bands connecting the dermis of the skin with the deep layer of superficial fascia, passing between the lobes of the parenchyma and attaching to the parenchymal elements and ducts. (Skandalakis et al., 2004) According to Bayati and Seckel (1995) there is a ligament that originates from the 5th ribs periosteum medially and from the fascia between the 5th and 6th ribs laterally, and inserts into the deep dermis of the submammary fold and is believed to be a condensation of the rectus abdominis fascia medially and the fascia of the serratus anterior and external oblique laterally this ligament known as the inframammary crease was revealed different from Cooper’s suspensory ligaments. This dermal structure (The Cooper’s Ligaments) consists of a collagen network arranged in arrays that run parallel to the skin surface along the axis of the inframammary crease fold and is held in place by the condensation of the superficial fascial system. (Muntan et al., 2000)

12 3 Breast development and physiology

Breast development and involution

Breast development and involution can be seen as a process of dynamic change throughout reproductive life and declining fertility. Breast development in girls begins at about ten years of age and might initially be asymmetrical. Breast tissue extends into the lower axilla. The functional unit of the breast is the terminal duct lobular unit. Milk- producing lobules drain into a series of branching ducts that open onto the nipple. (Ameryckx et al., 2005) Breast asymmetry may result from growth disturbances or from a range of acquired conditions. Classifying this symmetry as errors in growth and development is technically more precise than classifying it as congenital, since not all of these conditions are apparent at birth. These growth disturbances may be unilateral or bilateral and may involve the nipple areolar complex, the breast mound, or both. Errors in growth and development in terms of breast asymmetry include absence of structures, excess structures, variation in size and shape.

Control of breast development

Various hormones strongly inﬂuence the development of breast tissue in the prepubertal and pubertal phases. Estrogen stimulates the growth of lactiferous ducts and ﬁbroadipose tissue. Progesterone stimulates the development of lobular tissue and alveolar budding. (Summers, 2004)

Growth factors: There is some early evidence of the role of TGF-α and –β in the mediation of development of ducts and alveoli. TGF-α not only promotes growth in the developing alveoli, but also may mediate apoptosis and involution to facilitate differentiation. In addition to its effects on ductal growth, TGF-β may also inhibit lactation. (Harris et al., 2000)

Placental and maternal hormones: The breast tissue in the full-term newborn begins as a discrete, palpable nodule. The nodule may persist for the ﬁrst 6 to12 months and later involutes. (Wu et al., 2002) Excessive prolactin can also stimulate newborn breast tissue to secrete milk (witch’s milk).

Pubertal hormones: Puberty is noticed by the development of a pubertal breast (thelarche) and the growth of pubic hair. (Sun et al., 2002) Estrogen, progesterone, adrenal corticoids, prolactin, insulin, thyroxine and growth hormone have coordinating activities in breast development. The pituitary gland controls the endocrine system which affects the development of the breast. Progesterone has its greatest effect on the alveolar system. Prolactin effects major physiologic changes such as ﬁnal differentiation of alveolar epithelial cells into mature-milk-producing cells. Adipose tissue and the lactiferous ducts grow in response to estrogen.

13 CHAPTER 3 BREAST PHYSIOLOGY AND DEVELOPMENT

The Tanner stage describes the pubertal development of breasts into ﬁve stages (Table 3.1). Breast development normally is complete by 2 to 4 years after thelarche. (Beller et al., 1991)

Fig 3.1: Tanner Staging of the breast (Beller et al., 1991)

Stage Characteristics 1 Elecation of the breast papilla only 2 Elevation of the breast bud and papillae as small mound Enlargement of the areola diameter Areola becomes pinker 3 Further enlargement of the breast areola with no separation of their contours. Montgomery’s tubercles appear. 4 Further enlargement with projection of areola and papilla to form a secondary mound above the level of the breast. 5 Projection of the papilla only, resulting from the recession of the areola to the general contour of the breast

Table 3.1: Tanner staging of breast development. (Beller et al., 1991)

Delayed breast growth

Delayed breast growth is considered a lack of development by age 13. These patients require an extensive evaluation and referral to an endocrinologist for potential causes for delayed development such as eating disorders, Turner syndrome, chronic illnesses such as Crohn disease, or a sexual differentiation disorder. (Wu et al., 2002) In addition aberrations of breast development Juvenile hypertrophy is breast enlargement before puberty and is a common occurrence. Exaggerated growth of breast tissue can result in large breasts that young girls might ﬁnd embarrassing. (Fallat and Ignacio Jr, 2008)

14 CHAPTER 3 BREAST PHYSIOLOGY AND DEVELOPMENT

Physiology of the female breast

The breasts begin to develop at puberty; this development is stimulated by the same estrogen of the monthly sexual cycles; they stimulate growth of the mammary gland plus deposition of fat to give mass to the breasts. In addition far greater growth occurs during pregnancy, and the glandular tissue only then becomes completely developed for production of milk. (Guyton and Hall, 1996) Breast tissue is responsive to hormonal changes. Hormonal factors also need to be understood in relation to menopause. It is also important to be familiar with the changes affecting the breast parenchyma in order to understand breast conditions that are so common they can be considered to be aberrations rather than disease. (Barter, 2008)

I – Physiology changes during the Menstrual cycle

Breast morphology is profoundly affected by cyclical variations in hormonal levels during the normal menstrual cycle. Histological changes have been reported in both stroma and epithelium. During the proliferative phase of the menstrual cycle, increasing levels of oestrogen stimulate breast epithelial proliferation. The epithelium exhibits sprouting with increased mitotic activity, and increased nuclear density. These microscopic changes are attributed to increases in size and number of intracellular organelles, especially the Golgi apparatus, ribosomes, and mitochondria. (Barter, 2008) Similarly in the luteal phase of the cycle progestogens induce epithelial changes. The breast ducts dilate and the alveolar cells differentiate into secretory cells. In the secretory phase, there is an increase in the size of the lobules, and ductules, and the stroma becomes loose and edematous. The basal cells show prominent vacuoles. (Rudland et al., 1998) Immediately before the onset of menstruation there is a peak in mitotic activity, with lymphocytic inﬁltration and apoptosis following the onset of menstruation. Premenstrual breast fullness and tenderness can therefore be explained by increasing interlobular edema and the proliferation of ductules and acini under hormonal inﬂuence. (Guyton and Hall, 1996)

II – Physiology changes Pregnancy and Lactation

During pregnancy marked proliferation of ducts, alveoli, and lobules occurs under the influence of luteal and placental hormones. Prolactin is released progressively during pregnancy and also stimulates epithelial growth and secretion. In the first 3 to 4 weeks of pregnancy marked ductal sprouting with some branching, and lobule formation occurs mainly under the influence of estrogen. At 5 to 8 weeks breast enlargement is significant, with dilatation of superficial veins, and increasing pigmentation of the nipple/areolar complex. (Rosen, 2001) Secretory activity starts in the early stages with supranuclear vacuolation. In the second trimester, lobule formation becomes dominant under the influence of progesterone. From the second half of pregnancy onward, the breasts increase in size due to increasing dilatation of the alveoli, as well as hypertrophy of myoepithelial cells, connective tissue, and fat. (Guyton and Hall, 1996)

15 CHAPTER 3 BREAST PHYSIOLOGY AND DEVELOPMENT

At parturition an immediate drop in placental hormones occurs allowing the effects of prolactin to become dominant. This causes the breast epithelial cells to change from a presecretory to a secretory state. With the establishment of lactation, there is even greater distension of the glandular lumina, with obliteration of the stroma. Large fat vacuoles are visible in the secretory cells. After pregnancy and lactation, involution occurs at a varying rate between individuals, and after a period of about 3 months the breasts return to normal. (Barter, 2008)

III – Postmenopausal Changes or Involution

The term “involution” is used specifically to describe the changes that occur in the breast due to the menopause. These changes begin some years before the cessation of menstrual periods and may start as early as in the 30s in nulliparous women. There is a gradual decrease in the lobular architecture, involving both the stroma and epithelium. The stroma becomes dense, converting into hyaline collagen, resembling normal connective tissue. The basement membrane of the acini becomes thickened, and the epithelium atrophies and becomes flattened. The lumina become narrow with the cessation of secretions. Some acini coalesce with the formation of small cysts. These may later shrink spontaneously and be replaced by fibrous tissue, but may also continue to accumulate fluid and enlarge, presenting symptomatically. The interlobular ducts shrink and some disappear altogether. (Bland and Copeland, 2004) The above changes are not uniform and may vary in degree from segment to segment. The stroma gradually is replaced by fat, and the breast becomes softer. (Bland and Copeland, 2004; Nicholas et al., 1990)

16 CHAPTER 4 AESTHETICS OF THE BREAST

4 Aesthetics of the breast

The goal of plastic surgery of the breast is to recreate a natural appearance that is satisfying to the patient (Westreich, 1997). Despite the fundamental nature of this outcome, breast aesthetics is poorly understood and difﬁcult to measure. Aesthetics refers to physical characteristics of the breast that determine the subjective evaluation of appearance. (Kim et al., 2008)

Principles of Breast Aesthetics

Breast aesthetics consist of the following:

1. Shape

2. Size

3. Anterior projection of the breast

4. Base of the breast

5. Inframammary crease

6. Supramammary crease

7. NAC

8. Symmetry

9. Scars

10. Segments of the breast Fig 4.1 Aesthetics of the female breast Shape

The ideal aesthetic breast is projecting, with adequate volume above and below the nipple-areola complex, more below than above. The nipple-areola complex should be located at the point of maximal breast projection. The areola has a slight projection on the surrounding breast tissue, and the nipple has a more noticeable projection of approximately 3 to 7 mm. Each junction of the breast with the chest, upper abdomen and axilla is an important reference point for the surgeon when he is considering breast modification or reconstruction. Contour changes of the breast and surrounding tissue should have a pleasant flow rather than a sharp delineation. (Kim et al., 2008) In profile view the flow should extend downward from the clavicle to the breast and forward the nipple-areola, which points slightly upward and outward. A mildly convex inframammary area flows to a junction with the upper abdomen at the inframammary line. The breast profile from the clavicle to the second and third ribs is practically

17 CHAPTER 4 AESTHETICS OF THE BREAST

vertical. The breast begins its projection at the level of the second and third ribs and flows outward to the nipple, which is located at the level of the fourth and fifth rib interspace. On oblique view the breast flow from the clavicle above and joins and participates in the anterior axillary fold: this fold consists of the pectoralis major muscle and tendon, axillary breast tissue and subcutaneous tissue. The breast is fuller in its lateral and inferior portions. (Bostwick J III., 2000)

Size

Breasts come in all shapes and sizes, some more aesthetic than others. Although the ideal size will vary according to personal and cultural preferences, there are more consensuses on what constitutes the ideal shape. Although breast size is subject to individual taste and societal preference, it is also true that disproportionately large or small breasts do not complement a woman’s ﬁgure. The ideal breast volume varies between 200-350 cm3. (Bricout, 1996)

The Anterior Projection of the Breast

This is measured from the mid-axillary line behind to the most anterior point of the breast volume in the front. In a normal breast without ptosis, it does not exceed a third of the basal diameter of the breast implantation. It is an oblique line and cannot be an exact measurement of projection in the mathematical sense, since this would require the construction of a perpendicular on the chest wall passing through the breast meridian, and it became more inaccurate the more the breasts diverge. (Bricout, 1996)

The Base of the Breast

The base of the breast corresponds to the implantation of the breast on the thorax. These limits are particularly well defined below (inframammary crease) and medially (except in the very rare cases of synmastia). They are less definite above (supramammary crease) and laterally, and more difficult to assess when the patient is obese. They correspond to a patient examined in the standing position, since the inframammary crease in particular is fixed in relation to the skin plane, while the breast is relatively mobile as a whole in relation to the costo-muscular plane, to which it is only weakly adherent. (Bricout, 1996)

The Height of the Breast

This corresponds to the distance between the supra and infra-mammary creases and thus measures the vertical diameter of the base of the breast which is relatively constant as the two reference points are relatively constant in position. (Bricout, 1996)

The Inframammary Crease

The inframammary crease is a very important landmark with regard to aesthetics of the female breast. This breast-abdomen juncture, the inframammary crease begins medially near the sternal midline and curves gently downward to the mid-breast line; it then curves upward

18 CHAPTER 4 AESTHETICS OF THE BREAST

slightly and diffuses near the anterior axillary line at the lateral breast border and the lateral chest. (Bostwick, 2000) The inframammary crease is a fixed clement in relation to the cutaneous layer and is anatomically determined since according to Bricout, 1996 it corresponds to the deep attachment behind the gland of the superficial fascia, which here leaves the subcutaneous layer. The inframammary crease marks the transition from the thoracic skin below to the breast skin above. The importance of this fact becomes apparent in the techniques for reduction of the hypertrophic breast where it is mostly that the scar be placed transversely at the level of the inframammary fold. Any exaggerated maneuvers to place the inframammary crease higher up, in the mammary skin, by transforming the mammary skin of the inferior part of the breast into thoracic skin are doomed to failure. This is because the inframammary crease returns to its original position after a few weeks or months, while the transverse scar ascends on the lower slope of the breast to become more apparent than if it had been placed correctly in the crease initially. In spite of the fact that the inframammary crease is fixed in relation to the skin, it is mobile with the remainder of the breast over the chest wall. This can be seen after surgical cure of hypertrophy. At that time, the breast is relieved of its excessive weight and with its base reduced in extent. Then the breast re-ascends with the crease on the chest wall because of the skin retraction associated with its elasticity. (Muntan et al., 2000)

The Supra-mammary Crease

This marks the upper limit of the base of the breast, still it is not evident in the standing position and even in the supine position. To demonstrate it in the reclining patient, the breast has to be displaced upwards. It is constant in position at the level of the second intercostal space in the mid-clavicular line. (Lalardrie and Jouglard, 1974)

The Nipple-Areolar Position and Appearance

Lines of contour all flow to the nipple-areolar, the focal point of the breast. Nipple- areolar position, size, color, texture, inclination, and symmetry define breast form. Reference points for determining nipple-areolar location extend from the sternal notch and midline to the umbilicus, the mid breast line and the midclavicular point. The nipple is situated on the breast line approximately 19 to 21 cm from the clavicle. This line begins on the mid clavicular point and continues through the nipple to the inframammary crease. A horizontal line at the level of the nipple further defines the upper and lower breast quadrants. When a woman is upright approximately two thirds of the breast volume is below this transverse line and one third above it. The nipple is usually situated 9 to 11 cm from the mid-sternal line and approximately 13 cm from the midaxillary line. The distance from the nipple to the infra-mammary fold is 7 to 8 cm. The vertical measurement over the breast from clavicle to inframammary crease is 26 to 29 cm; and the lateral width is approximately 18 to 22 cm. An areolar diameter of 35 to 45 mm is usually judged attractive, as is a nipple diameter of 5 to 8 mm and a nipple projection of approximately 4 to 6 mm. (Bostwick J III., 2000)

19 CHAPTER 4 AESTHETICS OF THE BREAST

Breast Symmetry

Ideally, a woman’s breasts are uniform in color and symmetrical in size, shape, and nipple-areola position. The breast’s position on the chest wall and its symmetry with the opposite breast must be considered. On frontal view the breasts are situated on the thorax in an anterolateral position. Because the curvature of the normal thoracic cage affects breast projection thoracic cage asymmetries may result in apparent breast asymmetries. Although minor asymmetry is the rule rather than the exception, gross asymmetry is not only distracting but of practical importance to the patient in terms of bra-cup size and appearance in clothing. When a woman seeking breast surgery is being counseled preoperatively, minor asymmetries must be pointed out. Most women are very accepting of these asymmetries preoperatively, but this is not the case after aesthetic breast surgery. (Sadove and Van Aalst, 2005)

Fig 4.2 Showing triangle of Penn with equilateral distances A-B (SNN) = 21cm. B-B (Inter Nipple Distance) = 21cm. In addition B-C (Mid sternum – areola and B-D (NIMF) – Stark and Olivari (1991)

Scars

Although patient’s perception is that plastic surgery means no visible scars, in reality that is not possible. Rather, the goal should be to keep the scars minimal in length and as inconspicuous as possible as we achieve enhanced shape. There is no question that shape is far more important than scars. So as that shortening of scars and maintenance of optimal shape are mutually attainable goals. Symmetry and size are related more to the surgeon’s judgment, artistic sense, and surgical skill than to operative technique. When breast implants are used, the shape of the breasts is largely dependent on the dimensions, volume, and shape of the implant. Shape and scars, on the other hand, are very much dependent on operative technique. Optimal breast shape and minimal scars are possible through a variety of techniques. (Nahai, 2005)

20 CHAPTER 4 AESTHETICS OF THE BREAST

The Segments of the Breast

If the patient is examined standing with the breast seen in proﬁle, four segments can be deﬁned on what is generally called the thoraco-mammary line. The study of these segments is useful in the evaluation of the position of the areola and nipple in relation to the breast size and degree of ptosis. (Bricout, 1996)

• Segment I: This is also called the infra-clavicular thoracic segment. It extends from the inferior border of the clavicle to the upper limit of the mammary gland, also known as the supra-mammary crease. It varies in thickness with that of the subcutaneous fatty layer and of the pectoral muscles; apart from these two factors, it also varies in its obliquity downwards and forwards with the shape of the chest wall.

• Segment II: This is also called the supra-areolar segment. It extends from the supramammary crease, to the upper limit of the nipple-areolar plaque. In a normal breast without ptosis, and in the standing position, it corresponds to two-thirds of the height of the breast base. Ideally, it is slightly convex and faces forwards and slightly upwards. In fact, segment II very rapidly become slightly concave, at least in its upper part, this reverse of curvature being of developing ptosis.

• The nipple-areolar plaque: This is imposed between segments II and III. It faces slightly upwards and outwards. These orientations which corresponds to the normal breast, is not that to be aimed for at the end of an operation to correct hypertrophy, where the areola should face forwards, or even very slightly downwards, and outwards. In practice, the inevitable post-operative structural changes, which stabilize in around two months, are evidenced by an inevitable relaxation of the skin envelope to an extent varying with its quality. To prevent ptosis, it is necessary that at the end of the procedure the reduction of the skin envelop should correspond to a moderate degree of over-correction. Which achieves precisely this orientation of the areola subject to other criteria to be considered.

• Segment III: This is also called the sub-areolar segment. It extends from the lower border of the nipple-areolar plaque to the inframammary crease. It corresponds to the inferior third, of the extent of the breast, and even in a breast without ptosis it is more convex than segment II.

• Segment IV: This is also called the inframammary thoracic segment. It is represented by the thoracic skin beyond the lower limit of the breast.

The anatomic separation between segments III and IV is very deﬁnite. Since it corresponds to the inframammary crease, the lower limit of the breast and especially to the point where the superﬁcial fascia of the subcutaneous plane passes the retro-areolar plane.

21 CHAPTER 5 BREAST ASYMMETRY

5 Breast asymmetry

The female breasts are often not perfectly symmetrical. Small variations of the two breasts are accepted and can be considered normal. Sometimes the patients are not even aware of this slight unevenness. When the breasts show more pronounced irregularities in shape, volume, and position, then the asymmetry becomes an aesthetic and psychological problem. (Gliosci and Presutti, 1994) The perfect symmetry of homologous organs is the exception rather than the rule. A significant variation difference in breast volume deforms the female ﬁgure. Such deformities can lead to severe psychological problems depending on the mental stability of the patient; because of this, the plastic surgeon is often asked to correct this situation. (Stark and Olivari, 1991)

Deﬁnition of breast asymmetry (excluding acquired forms)

It may be primary or secondary to thoracic deformity; be it bony or muscular. However, an association of these two clinical signs is often observed. (Denoel et al., 2008; Sanders, 2004) Breast asymmetry is deﬁned as an asymmetric morphology of shape, volume, or position of the breast, the nipple-areola complex, or both. (Araco et al., 2006) Although minor asymmetry is the rule rather than the exception, gross asymmetry is considered when there are discrepancies of bra-cup size and appearance in clothing as well as major differences in breast shape. (Denoel et al., 2008)

Incidence

The incidence of breast asymmetry is not well known. (Gliosci and Presutti, 1994) The frequency of manifestation varies in different ethnic backgrounds, with the highest incidence (1:17) seen in Japanese to the lowest (1:52) seen in Hungary. Hyperplastic abnormalities were the most common category, with the most common anomalies. (Gautam et al., 2007)

Classifications

Classiﬁcation of breast asymmetry is often based on etiological or morphological characteristics of deformity. The classiﬁcations reported in the literature are based primarily on deformity of shape, but other parameters such as breast volume and symmetry often are underrated. (Persichetti et al., 2005)

I – Mammary asymmetry is common and has been classiﬁed by Maliniac in 1959 into 4 categories:

1. Bilateral asymmetrical hypertrophy

2. Hypertrophy on one side with amastia or micromastia on the other side

3. Unilateral hypertrophy with the other side normal

4. Unilateral amastia or hypomastia with the other side normal

22 CHAPTER 5 BREAST ASYMMETRY

II – Corso in 1972 established a classiﬁcation according to the origin of the hypoplastic breast;

1. True congenital type (probably due to end-organ failure)

2. Postoperative type

3. The so-called pseudo-hypoplastic breast, often characteristic of patients with unilateral congenital (or postoperative) deformity of the rib cage or of the thoracic or cervical spine.

It is easy to understand that, following burns, radiation, or the removal of a tumor in childhood underdevelopment of a breast may occur. (Ayer and Montandon, 1981)

III – Vandenbussche (1984) propose a classiﬁcation system for Asymmetries of the breast.

1. Congenital malformation a) with skeletal deformity b) with deformity of the areola c) with systemical disease

2. Primary asymmetry a) without adipositas b) with adipositas c) asymmetry and macromasty

3. Secondary asymmetry a) tumor b) menopause

4. Tertiary asymmetry a) after X-ray b) post-trauma c) after operation for breast cancer

IV – Developmental asymmetries are classified by Regnault in 1988 into six categories that follow the classification of Simon modified to include the presence of ptosis. (Stark and Olivari, 1991)

1. One breast hypoplastic, the other normal

2. Both breast hypoplastic and unequal in size

3. One breast hypertrophic, the other normal

4. Both breasts hypertrophic and unequal in size

5. One breast hypoplastic, the other hypertrophic;

6. Hypoplasia of thorax, pectoral muscle, or breast, unilateral. (Gasperoni et al., 1988; Regnault and Daniel, 1984)

V – The classiﬁcation of Elsahay and Bohmert 1989 was used for preoperative planning. (Stark and Olivari, 1991)

23 CHAPTER 5 BREAST ASYMMETRY

• Unilateral macromasty

• Unilateral micromasty

• Macro- and micromasty

• Bilateral asymmetrical macromasty

• Bilateral asymmetrical micromasty

Aetiology of breast asymmetry

Asymmetry can result from many causes, including abnormal development, various syndromes such as Poland’s syndrome, tumors, operations, radiation therapy, and trauma. Congenital developmental anomalies are the most common causes. (Sojitra et al., 2005) Minor breast asymmetry is quite common and may be detectable to some degree in most females. It is usually of no consequence. Most often the breast on the side of the dominant hand is slightly larger. However, substantial differences in breast size can result in a major cosmetic or self-image problem. (Simmons, 2007)

Developmental anomalies

According to Simmons (2007) developmental breast asymmetry was classiﬁed in to three categories:

1. The nipple-areola complex

2. The breast

3. The chest wall

And for the purpose of this study a fourth category was added

4. Combined

I – The nipple-areola complex

Polythelia

Polythelia is the most common anomaly of the human breast. It occurs in 1-2 % of the population. Failure of the embryonic milk/mammary ridge to regress beyond the pectoral area results in accessory nipples anywhere along the ridge. (Merlob, 2003) Not every supernumerary areola has a nipple, but every supernumerary nipple has an areola. (Schmidt, 1998)

Athelia

Congenital absence of one or both nipples and areolas of the breast is rare. (Stines and Tristant, 2005) This may result from a developmental failure of the lower cervical and upper thoracic somites. (Ishida et al., 2005; Grolleau et al., 1999) According to Ishida et al. (2005), athelia is always associated with other anomalies, but usually associated with amastia. The inverted nipple is not an athelic phenomenon, it is the result of the persistence of ﬁbers

24 CHAPTER 5 BREAST ASYMMETRY from the original invagination of the mammary pit (dimple). (Lawrence and Lawrence, 2005)

Rudimentary nipples

They are actually quite common in males and females, so when a pigmented macular or papular lesion is seen along the milk ridge (axilla to groin), this is a likely diagnosis. Occasionally an ectopic nipple will form off the milk ridge. (Simmons, 2007)

II – The breast

Polymastia

The etiology of these anomalies appears to be a failure of appropriate involution of the mammary ridge. Less commonly, but more problematical, is when accessory breasts actually form along the milk ridge. This is usually not appreciated until puberty or pregnancy. Engorgement during pregnancy and lactation can be painful and unpleasant, especially in the axillæ. Usually, it occurs sporadically, but familial aggregation has been reported. It could be secondary to the non-expression of a single major gene regulating the normal regression along the ectodermal mammary ridge during embryonic life. An extensive range of congenital and hereditary anomalies has been reported in association with accessory mammary tissue, including gonadal, cardiovascular, gastrointestinal, haema- tologic and skeletal alterations. (Ameryckx et al., 2005; Aslan et al., 2004; Urbani, 2004)

Fig 5.1: Polymastia of the Left side of the patient (Aslan et al., 2004)

Hypoplasia

Unilateral or bilateral, of the breasts is far more common than true amastia and manifests as small normal breast(s) (Simmons, 2007). Unilateral hypoplasia seems to be the most common type of developmental breast deformity, with a variation in end-organ response as the most likely cause. Other genetic factors presumably are implicated in the etiology of hypoplasia of the breasts. (Ameryckx et al., 2005)

Amastia

Congenital absence of the breast, amastia, is also rare and usually unilateral. Amastia may also result from trauma. Surgery in the form of a breast biopsy or even chest tube placement in the pre-pubertal child can result in failure of that breast to develop. Developmental amastia was divided by trier et al 1965 in to three categories:

• bilateral amastia

25 CHAPTER 5 BREAST ASYMMETRY

• unilateral amastia

• bilateral amastia with congenital ectodermal defects

According to Merlob (2003), 40 % of cases of congenital amastia are associated with other congenital malformations (skeletal, facial, renal and genital). (Ameryckx et al., 2005)

Synmastia

Which is a very rare condition. (Salgado and Mardini, 2004)

Hyperplasia

Virginal or juvenile hypertrophy which occurs during puberty where one or both breasts may grow rapidly and sometimes massively is distinguished from macromastia (large breasts) by rapid growth. While generally a clinical diagnosis, if the enlargement is unilateral, a mass lesion of the breast may need to be considered. The histopathology is non-speciﬁc, but interestingly may mimic that of gynaecomastia seen in males (Simmons, 2007). The aetiology of this condition is yet unknown. In almost all cases, it develops sporadically, but a few cases of familial nature have been reported. (Govrin-Yehudain et al., 2004) Levels of FSH, LH and oestradiol are generally normal. The mechanism involved in the arrest of peripubertal growth of the breast has not been elucidated, but failure of this normal process could explain the phenomenon. Local hypersensitivity or an increased number of oestrogen receptors, or the existence of altered local growth factors, is probably implicated as well. (Ameryckx et al., 2005) Surgery may be necessary, not only for cosmetic purposes, but because of secondary effects of the massive breast(s) and/or rapid growth that can damage overlying skin. Sometimes one surgical procedure is inadequate. Breast hypertrophy which should be differentiated from hyperplasia is common in middle and older aged women, particularly with the increased incidence of obesity. However, younger women and even teenagers may be affected. (Gutowski, 2006)

Breast herniation

Unusual herniation of part of the breast through a defect in the superﬁcial fascia of the anterior thoracic wall, which normally invests the breast. The clinical and surgical aspects that differentiate this type of hernia from the tuberous breast deformity include no constricting rings, no breast hypoplasia, and no hypertrophy of the nipple-areola complex. When encountered with such problems it is important to rule out the presence of associated chest wall or upper-limb girdle deformities because congenital breast deformities might be part of a more generalized defect, especially with unilateral lesions. (Yaghan et al.,2008)

Tuberous breasts deformity was ﬁrst described by Rees and Aston (1976) based on the resemblance to a tuberous plant. Tuberous breasts have limited dimensions at the base with an overdeveloped nipple areolar complex. It is basically caused by incomplete development of the mammary gland, usually in the two inferior quadrants, and probably as a result of adhesion of the two layers of breast fascia followed by formation of a constrictive ring around the areola.

26 CHAPTER 5 BREAST ASYMMETRY

Fig 5.2: Depiction of normal and tuberous development. (Latham et al., 2006)

This leads to herniation of glandular tissue into the subareolar space, which is free of fascia i.e. the site of least resistance and thus to hypertrophy of the areola. While thought to be primary, it can occur in delayed puberty or during reproductive hormone therapy in the incompletely developed breast. (Persichetti et al., 2005) Heimburg and colleagues (1996) developed a practical means of classifying the severity in relation to the symptoms in each breast quadrant:

• Type 1. hypoplasia of the lower medial quadrant

• Type 2. hypoplasia of the lower medial and lateral quadrants with sufficient skin in the subareolar area.

• Type 3. hypoplasia of the lower lateral and medial quadrants with a deﬁciency of the subareolar skin.

• Type 4. Severe breast constrictions with minimal breast base

This classiﬁcation was later simpliﬁed by Grolleau and colleagues (1999). Where the severity of the deformity is divided into three grades:

• mainly in the inferomedial quadrant (grade I)

27 CHAPTER 5 BREAST ASYMMETRY

• in the two inferior quadrants (grade II)

• or affecting the whole breast (grade III). (Foustanos and Zavrides, 2006)

The etiology of this anomaly includes several theories that have been proposed based on anecdotal experience:

1. Grolleau and colleagues (1999) proposed an anomaly of the fascia superﬁcialis, primarily in the lower pole regions, which is abnormally adherent to the dermis and the muscular plane, and by restricting the breast expansion, forces the breast to preferentially expand forward, enlarging the areola. (Grolleau et al., 1999) Additionally, the deformity may be a result of associated involution of the mammary ridge, as the inferior portion of the deformed breast possesses a decreased number of milk ducts.

2. Alternatively, Mandrekas et al., (2003) proposed that the deformity is a result of a constricting ring at the base of the breast causing the vertical and horizontal deﬁciencies. Breast growth leads to eventual herniation into the areola. (Mandrekas et al., 2003)

3. The condition may also result from the use of exogenous steroids. (Fallat and Ignacio Jr, 2008)

4. Tuberous breast deformity may be unusually associated with Hurler-Scheie syndrome in adolescent girls. The cause of this unusual association may be related to the underlying defect in connective tissue catabolism in this disorder. (Barone et al., 2000)

The incidence of tuberous malformation types could be summarized in table 5.1 as follows (Persichetti et al., 2005):

Breast type Incidence rate % Normal-volume tubular breast 16.6 Hypertrophic tubular breast 40 Tuberous breast type I 3.3 Tuberous breast type II 10 Tuberous breast type III 20

Table 5.1: Tuberous breast incidence

Understanding the underlying malformation - i.e., the fact that the inferior quadrants lack tissue - is more important than classiﬁcation. (Paciﬁco and Kang, 2007)

III – Chest wall

Chest wall deformities most frequently encountered are those of the manubrium, including pectus carinatum, pectus excavatum, and a prominent costocondral junction. Rib torsion, rib rotation, sunken chest deformity, and ﬂaring of the lower costal cartilages are also seen. In addition, to Poland’s syndrome. (Smeenk and Aronson, 2008) It is important to recognize chest-wall asymmetries in women with breast asymmetry which is nearly always present in patients with Poland’s syndrome along with rib torsion, rib rotation, or sunken chest. (Fonkalsrud, 2004)

28 CHAPTER 5 BREAST ASYMMETRY

Fig 5.3: A patient having pectus excavatum as obvious through photography and CT study. (Park et al., 2008)

Torsional chest wall rotation is associated with spinal scoliosis, and breast asymmetry may accompany this deformity. (Rohrich et al., 2003) Breast asymmetry associated with scoliosis is due to both a difference in breast volume and thoracic deformation bound to scoliosis. However no clear deﬁnition of scoliotic pathology and its relation with breast asymmetry has been described. A notable feature is that young female adults characteristically manifest ipsilateral breast hypoplasia on the side of depressed chest wall. (Denoel et al., 2008) Bony lesions of the ribs lying beneath the breast might be mistaken for a breast mass. (Park et al., 2008)

IV – Combined

Poland syndrome

First described by Alfred Poland in 1841, the syndrome is also termed “acro-pectoral renal ﬁeld defect” since renal anomalies are often involved. Its incidence is 1 in 7,000 to 1 in 10,000. The effects are seen more often on the right side, with a ratio of 5:3 with a male predominance in a ratio of 3:1. Patients can also present with ipsilateral breast and nipple hypoplasia and/or aplasia. Poland syndrome is more common on the right side. (Abhinav et al., 2007) It is a genetic malformation syndrome that occurs in the second through ﬁfth week of embryonic development in one of the limb buds. (Latham et al., 2006)

29 CHAPTER 5 BREAST ASYMMETRY

Fig 5.4: Poland’s syndrome: A diagram showing associated skeletal deformities (Abhinav et al., 2007)

The familial form is very rare (equal male to female ratio and no predominance of the right side), with only about 20 cases reported in the literature. It is thought to be associated with delayed mutation of an autosomal dominant gene. Apart from these few cases, Poland’s syndrome is a sporadic disorder, nearly two-fold increased risk in infants born to mothers who smoked during pregnancy. (Martinez-Frias et al., 1999) Poland’s syndrome can coexist with many other congenital syndromes, but particular associations with Mobius syndrome and Klippel-Feil syndrome have been noted. (Latham et al., 2006; Fokin and Robicsek, 2002) Components of Poland’s syndrome are (Freitas et al., 2007):

1. Hypoplasia of breast and nipple

2. Scarcity of subcutaneous tissue over pectoral region

3. Absence of pectoralis major muscle (costosternal portion)

4. Absence of pectoralis minor muscle

5. Deﬁciency of additional chest wall muscles including latissimus dorsi, external oblique, serratus anterior

30 CHAPTER 5 BREAST ASYMMETRY

6. Aplasia/deformity of costal cartilages or ribs II to V

7. Alopecia of axillary and mammary regions

8. Unilateral brachysyndactyly (50%)

Although the syndrome is widely variable in presentation, all Poland’s patients lack at least the sternocostal head of the pectoralis major muscle (and most lack the pectoralis muscle). It is very rare for all components to be present in any one patient. (Freitas et al., 2007) Breast anomalies in Poland’ syndrome range from total amastia to mild hypoplasia. The nipple is often abnormal, with athelia, hypo-pigmentation, or even polythelia being reported, the uninvolved side is usually normal. However, one case of contralateral macromastia has been reported. (Fokin and Robicsek, 2002) The breast anomalies are often associated with abnormalities of the underlying ribs and shift of the heart towards the unaffected side, whereas left-sided Poland’s syndrome is associated with an increased incidence of dextrocardia. (Freitas et al., 2007) The theories of etiology for this syndromes are as follows:

1. The most widely accepted view involves an interruption of the embryonic blood supply to the upper limb bud in the second through ﬁfth week of embryonic development. (Fokin and Robicsek, 2002) This causes hypoplasia of the subclavian artery. Depending on the degree of hypoplasia, or which branches of the subclavian artery are affected, the wide variety of anomalies associated with the syndrome can result.

2. Another etiologic theory proposes a much earlier disruption at 16 to 28 days involving the lateral plate mesoderm. (Fokin and Robicsek, 2002)

3. Intrauterine insults, trauma, infection, and teratogens have also been proposed as etiologic possibilities. (Latham et al., 2006)

Klippel-Trenauney syndrome

It is a congenital abnormality consisting of cutaneous capillary malformations (commonly port wine stain in appearance), unilateral soft tissue and bony hypertrophy and varicose veins. It is rare and occurs equally across gender and race. Although the majority of Klippel-Trenauney patients will complain of physical disturbances, only 25% will approach the surgeon for cosmetic reasons. (Baldwin et al., 2006)

Other syndromes associated with breast asymmetry

1. Ullrich-Turner syndrome [45, X/46, X, i(Xq)] characterized by the agenesis of breast, nipple, pectoralis major muscle and hair follicles on the same side. (Ameryckx et al., 2005)

2. AREDYLD syndrome that comprises bilateral amastia, ectodermal dysplasia, lipoatrophy and diabetes mellitus. (Pinheiro et al., 1983)

3. The syndrome of ureteral triplication consisting of bilateral amastia, pectus excavatum, umbilical hernia, persistent ductus arteriosus, low ear implantation, hypertelorism, cubitus valgus and syndactily. (Rich et al., 1987)

31 CHAPTER 5 BREAST ASYMMETRY

4. A complex condition characterized by the congenital absence of the mammary glands and hypoplasia of the nipples, a Wolff-Parkinson-White syndrome, spina biﬁda and absence of axillary hair. (Martinez-Chequer et al., 2004)

Fig 5.5: A patient photo showing breast deformity in Klippel-Trenauney syndrome. (Baldwin et al., 2006)

Pathopysiology of breast asymmetry

Asymmetry of the breasts is common, especially during the course of normal pubertal development. It may be discrete or marked and may be physiologic or a result of hypoplasia, aplasia, hyperplasia or a tumor of one of the breasts. It is more apparent during puberty, arising from development eventually equilibrates, resulting in nearly symmetric breasts towards the end of puberty. However, if persistent by the late teens asymmetry is unlikely to change. (Ameryckx et al., 2005) In cases of juvenile hypertrophy local hypersensitivity or an increased number of oestrogen receptors, or the existence of altered local growth factors, are implicated in the etiology. Furthermore, the mechanism involved in the arrest of peripubertal growth of the breast has not been elucidated, but failure of the normal process could explain the phenomenon. In addition, end-organ failure has been implicated as a cause; either due to a decrease in number of estrogen receptors or unresponsiveness. (Koerner et al., 2001) Infections, traumata, operations and radiotherapy during childhood can damage the breast bud and affect normal breast development. All of these should be excluded as causes for the smaller breast. Anorexia nervosa of early onset can interfere with thelarche as can secondary ovarian failure and may be a cause of micromastia. Other causes such as Genetic factors presumably are implicated in the etiology of hypoplasia of the breasts. An association with connective tissue disorders and mitral valve prolapse has also been reported. (Ameryckx et al., 2005) Amastia, or absence of the breast tissue and nipple, is extremely rare and usually part of a variety of major malformations affecting one half of the body.

32 CHAPTER 5 BREAST ASYMMETRY

Congenital aplasia of the mammary gland and nipple can affect both mother and child. It seems to be genetically determined and has been associated with several syndromes. (Freitas et al., 2007) Previously reported types include a group of deformities characterized by restricted growth of the breast at its base due to the presence of dense fibrous constricting rings or adhesions between the base of the breast and the deep layer of the superficial fascia. The commonest being the tuberous breast deformity, otherwise known as the “snoopy” deformity. (Pacifico and Kang, 2007) In addition, congenital amniotic folds in the thoracoabdominal area may lead to asymmetry. This aetiology has not been previously described in reports of breast asymmetry however it commonly results in marked asymmetry and deformities. (Tepavicharova-Romanska, 2002)

Fig 5.6: Congenital amniotic fold in the thoracoabdominal area (Tepavicharova-Romanska, 2002)

33 CHAPTER 5 BREAST ASYMMETRY

PSYCHOLOGICAL IMPACT

Importance of the breasts in females

The female breast is regarded as a symbol of femininity and it plays a decisive role in a woman’s sense of physical and emotional vitality. (Bohmert and Gabka, 1997)

Female psychology and body image perception

The patient’s prospective body image is a central part of the initial consultation. The Degree of satisfaction with the breast should be assessed. Studies through out the body and cosmetic surgery bodies show that there is little relationship been ones physical appearance and her subjective body image. Women who report signiﬁcant distress with comparatively normal breasts may be suffering from BDD. Some women may level he extent of their preoccupation with their breasts by presenting the surgeon with numerous photographs of models or celebrities with breasts they desire. Such behavior likely only hints at the hours that the patents have spent thinking about their breasts. Preoccupation with an imagined or very slight defect in physical appearance that causes signiﬁcant distress points to BDD. (Sawer, 2006)

Psychological impact of breast asymmetry

Morphologic anomalies of the breast can cause considerable psychological distress, particularly among adolescent girls. The relationship between physical appearance and psychological body image is a central aspect of a patient’s quality of life, such deformities can lead to severe psychological problems depending on the mental stability of the patient; because of this, the plastic surgeon is often asked to correct this situation. In cases where psychological factors dominate in patients with major variation of breast volume, an operative procedure may be indicated at an early time. (Kim et al., 2008) Therefore the patient should be very clearly informed of the high risk of a recurrence and the possible need for secondary surgery and of realistic outcomes. (Stark and Olivari, 1991) Patients with breast asymmetry are different from patients with hypertrophy or hypomastia and that surgical treatment does, in fact, improve their quality of life and psychological impact from correction of the deformity, stated an increase in the patients self-conﬁdence and a real improvement in their social lives. (Foustanos and Zavrides, 2006) Asymmetry can cause physical, psychological, and cosmetic distress. There are reviews and classiﬁcation systems regarding breast asymmetry in the literature. As the amount of deficient tissue varies, it should also be mentioned that since the malformation occurs during the sensitive phase of puberty, it is very likely that deformity will result in psychosexual problems. Unshapely, tubular and small breasts can be severely inhibiting for a person seeking social contacts. It is not primarily the size of the beasts that girls are embarrassed about, but rather the fact that the breasts have very unnatural shape. (Kim et al., 2008)

34 6 Surgical Management of Breast Asymmetry

Timing of surgical management

Surgical correction of breast asymmetry involves not only an acceptable aesthetic result but also physical, social, and psychological consequences on the patient’s quality of life. (Neto et al., 2007)

Timing for treatment of asymmetry

Breast correction during puberty should be avoided wherever possible, the recurrences occur in patients operated on at this age group. If, however, psychological factors dominate in patients with major variation of breast volume, an operative procedure may be indicated at this time. The patient should be very clearly informed of the high risk of a recurrence and the possible need for secondary surgery. (Gurley, 2003) Another opinion states that surgical intervention for anomalies should be tailored and timed to the individual patient’s situation and need not wait until adolescence is completed. (Simmons, 2007)

Timing for treatment of associated deformities (priorities)

However surgical correction during childhood of congenital or developmental deformities of the chest may be important for preventing progressive scoliosis, cardiopulmonary exertion restrictions, and adverse psychological development. (Rocha et al., 2008) Otherwise, Surgery should be delayed until the end of puberty, when breast growth is complete; until the age of 18 to 19 years to allow full development of the contralateral, unaffected breast. (Sadove and Van Aalst, 2005) The timing also differs according to the method of treatment.

Case evaluation

Correct diagnosis is critical in patients requesting breast surgery in order to provide realistic postoperative expectations.

History

A thorough preoperative assessment including a family breast cancer pedigree, other breast cancer risk factors, drug and smoking history. (Malata and Bostwick J. III, 1999) Past surgical history of breast and chest surgeries, bleeding or bruising tendencies, pulmonary or heart disorders, and prior thromboembolism should be noted. The date of her last menstrual history should be requested. In addition a history of diabetes mellitus and previous irradiation should be obtained. (Shiffman, 2009) The affected individual may present for consultation at any age, often early in childhood as a result of parental concern. It is important to be able to counsel the patient and her family regarding the nature of the problem, its prognosis for future development, and the appropriate indications and timing of surgical intervention. Preoperative consultation is essential to understand the patient’s motivation, objectives, and expectations so that a careful operative plan can be made. (Reilley, 2006)

35 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Physical examination

Meticulous physical examination is mandatory during the assessment of breast asymmetry. A careful examination is undertaken both in the sitting and supine positions with the arms over the head; noting the skin type and changes, size and site of scars, size and shape, asymmetry, nipple and breast ptosis, and breast and axillary masses. (Fallat and Ignacio Jr, 2008) The usual error is the incorrect positioning of the patient. It is essential that the patients lay or sit their hands on their hips (i.e. iliac crests) to obtain the adequate shoulder level. The anterior inframammary costal hump observed in patients seems to be an essential clinical sign in breast asymmetry bound to scoliosis. There are other objective clinical signs that evoke a potential association between scoliosis and breast asymmetry. (Denoel et al., 2008) Assess soft tissue (both skin and parenchyma) for compliance and volume. Use the pinch test as a diagnostic tool to plan choice and position of implants. For planning purposes, an estimate of the weight to be removed from each side is made. (Shiffman, 2009)

Informed consent

Informed consent requires that the patient receive enough information about the surgical procedure proposed and the alternatives as well as the possible risks and complications of each so that a knowledgeable decision can be made. (Shiffman, 2009)

Photographic measurements

Early studies used the aid of a clear acrylic sheet marked as a grid with the patient behind the screen, which is functionally equivalent to calculating distances on a digitized/digital photograph. (Kim et al., 2008) For subjective assessment of breast aesthetics, Prints produced from digital images, digital images displayed on a computer monitor, or conventional photographs are acceptable and allow for measurements calculated on digital/digitized photographs. They rely on many of the same ﬁducial points described for anthropometry, but some anatomical landmarks may not be visible in photographs (e.g. the inframammary fold). They also rely heavily on the anatomy of the nipple-areola complex, which may not reﬂect independent features of the breast mound.

Fig 6.1: A photo taken to a patient with breast asymmetry and onto which breast measurements are applied (Left and right respectively). (Maxwell, 2001)

Metric evaluation

Accurate metric evaluation is fundamental to treatment. Recording of the following measurements should be done:

36 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

1. Sternal notch and/or midclavicular to nipples

2. Nipples to midline

3. Extent of ptosis: either the degree and/or measurement from nipple to inframammary fold and inframammary fold to lowest point of breast

4. The areolar diameter.

(Shiffman, 2009)

Investigations

Imaging techniques

Mammogram: Preoperative mammograms are indicated for Breast and axillary masses. (Stines and Tristant, 2005) X-ray: X-ray of whole spine in standing position is indicated with the measurement of the Cobb’s angle to rule out idiopathic scoliosis. Three-dimensional imaging: Spiral CT with 3-D reconstruction can provide a valuable preoperative assessment prior to chest wall reconstruction, but MRI has the advantage of providing multi-planar views, and avoiding exposure to ionizing radiation. TTM chart and computer programs specially designed to calculate the ideal aesthetic parameters for the patient in her speciﬁc condition, even if she is thin or over weight and in implant selection. (Kim et al., 2008) Several technologies such as stereophotogrammetry in signiﬁcant chest wall deformities. (Denoel et al., 2008), laser scanning, three-dimensional digital photography, and light digitizers can be used to create three-dimensional images. (Sawer et al., 2005) For breast surgery, three-dimensional imaging permits evaluation of differences in volume, surface area, shape, size, contour, and symmetry. (Sawer et al., 2005) A single three-dimensional image yields more information regarding breast appearance than multiple conventional photographs, including data regarding some elements of breast appearance, such as volume, that are not available from two-dimensional images. (Denoel et al., 2002)

Laboratory investigations

Routine investigations with special emphasis that renal anomalies may impair renal function or cause renovascular hypertension. Thus patients with pectoral muscle anomalies accessory nipples and amastia should be screened for coexisting renal problems. (Sadove and Van Aalst, 2005)

Objective Evaluation of the patients with breast asymmetry

Asymmetry is determined by comparing right and left breast Objective evaluation should consider: First, the initial evaluation should focus on the chest wall itself for symmetry and shape. Any chest wall abnormalities (such as degrees of pectus excavatum or carinatum) should

37 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Fig 6.2: Representative images of illustration and measurement capabilities. (Left) Laterally rotated image and coordinate axes. (Right) Image of breast using the mesh mode and surface of the breast. Breast projection and volume enclosed between the base and the surface are estimated quantitatively. (Denoel et al., 2002)

Fig 6.3: MRI with axial reconstruction for 3D application in volume rendering. (Pozzobon et al., 2008) be noted and discussed with the patient using mirrors or photographs to illustrate. Any asymmetry or degree of rib ﬂaring should be discussed. (Rohrich et al., 2003) Second, the presence and degree of breast ptosis should be documented. Any degree of ptosis greater than grade II that may suggest a possible role for concomitant mastopexy should be discussed. Third, breast asymmetries should be identiﬁed. These asymmetries include breast mound volume, inframammary fold position, presence of base diameter constriction, and asymmetries of the nipple-areola complex size and position. (Spear, 1998) Fourth, the most important landmark is the inframammary fold and the associated breast width. This determines the natural limits of the breast. Size is ultimately determined by the base diameter of the breast, whereas shape is determined by projection in relation to base diameter. The levels of the inframammary folds should be evaluated and asymmetries should be noted. (Rohrich et al., 2003)

38 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

The objectives of the patient are summarized in table 6.1:

Breast part Points of examination Nipple-areola complex Size Position Chest wall Pectus excavatum / carinatum Rib ﬂaring Breast proper Mound Shape & volume Base constriction Inframammary fold Position

Table 6.1: Evaluation of patients with breast asymmetry. (Rohrich et al., 2003)

Non surgical treatment

Treatment of breast asymmetry is essentially surgical where Breast surgery continues to gain popularity. Unfortunately; most patients with signiﬁcant breast asymmetry have a minimal response to conservative treatment and only see improvement after breast surgery. Nevertheless, Treatment modalities include physical, psychological and pharmacological which commonly are in conjunction with surgery. (Gutowski, 2006)

Physiotherapeutic

Strengthening the back, helps deal with postural, gait and functional abnormalities. Chest physiotherapy in patients who suffer from congenital chest wall deformities. (Smeenk and Aronson, 2008)

Psychological

Psychological and social functioning counseling is required, and reassurance should be given to both the parents, who are often quite upset and the patients. (Neto et al., 2007)

Pharmacologic

Oestrogens

Treatment of idiopathic hypoplasia with high doses of oestrogens is useless and should be avoided. Its effect, if any, is strictly transient and may cause iatrogenic galactorrhoea. Treatment of the endocrine disturbance enables the breast to resume its development. Oestrogen replacement required because of gonadal dysgenesis, premature ovarian failure or deﬁcient GnRH secretion should be started at a very low dose and increased slowly, to avoid the development of tuberous breasts. (Ameryckx et al., 2005)

Tamoxifen

Selective oestrogen receptor modulator, which acts as an antagonist of oestrogens in the breast, was found to be the most effective remedy for arresting recurrent breast enlargement after surgical intervention. The drug may cause depression, hypertriglyceridaemia, thrombocytopenia and, after prolonged use, a risk of endometrial cancer.

39 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Considering the young age of most patients, it is not indicated as a ﬁrst line, that is, longterm treatment. (Latham et al., 2006)

Dopaminergic drugs

These drugs have some stabilizing effect in cases of gravid gigantomastia, but not in the juvenile form. (Arscott et al., 2001)

Surgical management

Indications for surgical treatment

These include the following indications:

1. Either aesthetic or psychological reasons, and sometimes these overlap: Breast augmentation and reduction procedures are no longer regarded as being purely cosmetic measures. They are now accepted forms of medical treatment for physical and psychological disorders. (Zuckerman and Abraham, 2008)

2. Somatic indication: Abnormally large breasts can cause actual structural symptoms particularly pain in the breast and back.

3. Social indication: personal or job-related problems resulting from breast deformity.

4. Poland’s syndrome: Chest wall depression, inadequate protection of the mediastinum, Paradoxical movement of the chest walls, Aplasia / hypoplasia of the breast, especially in females as well as Cosmetic defects. (Freitas et al., 2007)

Approach to surgical management of developmental breast asymmetries

It is no longer acceptable for surgeons to merely create a breast mound that does not resemble the premorbid appearance. Symmetry is a result that most women expect and many surgeons strive for. This can sometimes be accomplished with the initial operation; however, secondary procedures are often required. (Nahabedian and Galdino, 2003) Current estimates are that 60 to 70 percent of women undergo one or two procedures to obtain symmetry. (Losken et al., 2002) As previously stated, most surgeons rely on their personal experience and visual assessment skills, which are sufﬁcient in the majority of cases. However, there are situations in which objective quantitative information regarding the breast could potentially beneﬁt the surgeon. (Araco et al., 2006) There are many degrees of breast asymmetry, including differences in breast mound volume and position, contour, and projection, inframammary fold position, base diameter, as well as nipple areolar size and position. (Losken et al., 2002)

Basic management protocol

Basically, all cases are preoperatively assigned to one of six groups, each of which has a different treatment regimen. (Araco et al., 2006)

• Bilateral asymmetrical hypertrophy (group 1) & unilateral hypertrophy (group 2) are treated with reduction mammoplasty (bilateral or unilateral, respectively).

40 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

• Hypertrophy with amastia or hypoplasia of the contralateral side (group 3) is treated with both reduction and augmentation mammoplasty.

• Unilateral amastia or hypoplasia (Poland’s syndrome, group 4) is treated with a monopedicle transverse rectus abdominis musculocutaneous ﬂap.

• Asymmetric bilateral hypoplasia (group 5) is treated with augmentation mammoplasty.

• Unilateral mammary ptosis (group 6) is treated with mastopexy and augmentation mammoplasty.

The tuberous breast is included as a different category because of its high prevalence and the difficulty in achieving an acceptable aesthetic shape. (Araco et al., 2006) This classification did not introduce new surgical techniques but helped the surgeons correctly ascribe patients to each group and to find the consequent operation. Obviously, it did not substitute clinical judgment, but it helped the decision making process and served as the beginning of a standardized and scientific approach to breast asymmetries. (Losken et al., 2002)

Speciﬁc surgical management methods

Bony cage deformity

Treatment of these anatomical deviations varies from physiotherapeutic to (minimal invasive) surgical techniques.

1. For manubriosternal prominence, pectus carinatum, and prominent costro-chondral junctions, the usual maneuver is to camouﬂage the bony middle chest by placing them as high and medial as possible with a wide base. (Fonkalsrud, 2004)

2. For pectus excavatum a) If the width is greater than 8 cm and depth is greater than 4 cm, this needs to be addressed by the use of a possible silicon implant, however if the defect is deeper with associated sternal rotation, thoracotomy with rigid ﬁxation of the pectus is indicated. The silicon implant can be customized after moulage preparation either in an initial ﬁrst stage or in a combined procedure with the breast reconstructive surgery. b) If less than 4 cm in depth, it may be advantageous providing a deeper and more prominent cleavage. (Beier et al., 2009; Fonkalsrud, 2004)

3. For sunken anterior chest, if a discrepancy of more than 3 cm exists it is important to treat it using customized implants, which should act as a base for further surgery. This overcomes the problem of volume and projection asymmetries. (Smeenk and Aronson, 2008)

4. For scoliosis, customized and prefabricated and custom made chest-wall implants which will ensure symmetry and improved cosmesis should be used. (Bricout, 2005) Other options include bracing and spine surgery. (Denoel et al., 2008)

41 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Poland’s syndrome

Surgical management depends on the extent of the anomaly as follows:

1. With loss of the anterior axillary fold due to partial or complete absence of the pectoralis major, Latissimus dorsi transfer is particularly suitable for the reconstruction of the anterior axillary fold. Free gracilis ﬂap can be used if the expected donor-site defect on the back appears to be too large. (Borschel et al., 2007)

2. As for breast volume

• An expander/silicone implant is the method of choice for augmenting breast volume. When contralateral hypoplasia is also found bilateral breast implants of different sizes may be used to augment both breasts.

• Autologous tissue replacement can be a good option if a large volume is needed.

Careful intraoperative assessment of the recipient vessels prior to ﬂap transfer is mandatory. Especially in Poland’s syndrome as Poland’s chest-wall deformity may include anomalies of the vascular system, preoperative vascular assessment with duplex ultrasonography should be considered in all patients, and use of preoperative angiography or venography in selected patients also appears justiﬁed. (Bricout, 2005)

3. Severe chest wall deformities

• They require resection of the concavity with possible mesh reinforcement or with multiple osteotomies to reconﬁgure the area or to place a chest wall implant. This is preferred by some authors to recreate the pectoral sweep as muscle ﬂaps have been noted to progressively evolve into atrophy.

• Split rib grafts taken subperiostially from the unaffected side, other bony allograft or autografts, mesh patch, or a combination.

• Can also be corrected with a microvascular free tissue transfer of the transverse rectus abdominis myocutaneous ﬂap or latissimus dorsi myocutaneous ﬂap. This helps cover the infraclavicular hollowness and partially cover the breast implant. (Longaker et al., 1997; Rocha et al., 2008)

4. Associated anomalies with Poland’s syndrome

a) Hand anomalies Reconstructive surgery ranges depending on the degree of commitment. Syndactylies should be corrected early, preferably in the ﬁrst year of life, before abnormal compensatory functional patterns have developed and deformity has progressed. (Latham et al., 2006)

b) Nipple-areola complex is usually involved and is usually sited superiorly, hypoplastic or even absent. Can be treated by bilateral periareolar incisions with skin resection on top of the normal nipple-areola complex and on the bottom of the affected complex. In severe cases of hypoplastic nipple-areola complex, the whole complex is used to reconstruct the nipple, and a peripheral tattoo is done to achieve areola symmetry. (Da Silva et al., 2007)

c) Postoperative physiotherapy helps prevent muscle atrophy. (Borschel et al., 2007)

42 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Fig 6.4: Chest wall implant. (Longaker et al., 1997; Rocha et al., 2008)

Tuberous breasts

There are no standard procedures for surgical correction. Each surgeon needs to select the most suitable procedure in order to achieve and optimal result. A critical point in understanding tuberous breast deformity is the fact that the superficial layer of the superficial fascia is absent in the area underneath the areola. In addition to the presence of a constricting fibrous ring at the level of the nipple-areola complex inhibiting the normal development of the breast this ring is denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. (Foustanos and Zavrides, 2006) Rees and Aston (1976) were among the first to describe the principals for treatment of the deformity, correctly recognizing that an implant alone would not correct the areolar

43 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT herniation and suggested that the breast tissue be released or scored to expand the base, with lowering of the inframammary fold. Further more, they found multiple principles to correct severely deformed breast:

• Type 1: These deformities are addressed with reduction mammoplasty if the breast volume was adequate, or with augmentation mammoplasty if the breast was hypoplastic.

• Type 2: Treated with simple augmentation, especially if the breast tissue was unfurled and allowed to re-drape at the time of augmentation. However a ‘double bubble’ deformity was noted in which a mound of breast tissue appears to rest on top of the implant.

• Type 3 and 4: Tissue expansion and treatment of the subareolar region is recommended for improved shape and symmetry.

However, tuberous breast remains an area in which plastic surgery continues to improve. (Persichetti et al., 2005)

Breast herniation

The congenital hernia is unusual herniation of part of the breast through a defect in the superﬁcial fascia of the anterior thoracic wall. Simple closure of the defect seems to be adequate treatment. (Yaghan et al., 2008)

General methods of surgical correction

All surgical measures have the common goal of improving the appearance of the breast to conform what the patient ﬁnds aesthetically pleasing. (Gutowski, 2006)

Changes may involve the following:

1. Reducing size

2. Alerting the shape without reducing substance

3. Enlargement

4. Establishing symmetry

I – Breast Augmentation

Breast augmentation surgery may appear simple to some surgeons, but it has many potential complications. The main indication for breast augmentation remains to be hypoplasia or breast asymmetry. The surgeon should help the patient select the incision site, the implant type,

44 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

the implant size, and the implant placement in relationship to the breast muscles. (Strasser, 2006) However, the principles of implant selection remain the same. There are several methods for determining the size as well as the base diameter of the implant allowing proper preoperative assessment of implant volume and symmetrizing both sides. Several theoretic methods exist to calculate the final prosthesis volume on the basis of anthropometric measurements of the chest and or the contralateral breast. Nevertheless, in clinical practice such assessments often prove inadequate and do not correlate with the actual needs and expectations. (Stevens et al., 2006) A method suggested by Tezel and Numanoglu (2000) includes applying the principle of Archimedes. The breast is inserted into a graduated cylinder filled with water, the spillover of which will correspond to the gland volume in terms of cubic centimeters. This method, initially carried out with direct contact of the water with the breast skin, was then improved using polyethylene bags that were prefilled within the measuring cylinder. The patient was then invited to wear a bra having a size adequate to the new post prosthesis status to anticipate the final result. (Tezel and Numanoglu, 2000) In addition to a set of expanders, or “phantoms”, that are completely identical to permanent prostheses in shape and volume are used. They are connected to a valved tube that can be filled with sterile physiologic solution, permitting expansion of the breast to reproduce the exact desired shape and size. The expanders are provided within a kit containing low-, high-, and medium-profile round and anatomic shapes. When the volume and type of prosthesis is chosen, the inflatable expander is rapidly deflated and extracted from the mammary cavity to be replaced with the definitive prosthesis. (Hamas, 2000)

Breast prosthetic materials They are saline-inﬂatable, silicone gel (cohesive І, П, Ш) combined saline-inﬂatable and silicone gel, and breast expanders. Consider the use of textured, polyurethane vs. smooth implants and anatomic shaped vs. round prostheses. The most important determinant of the aesthetic quality of the result is the size of the implant. Inappropriate size selection leads to problems with shape and the need for revision, this is avoided with saline implants especially in cases with asymmetry. (Maxwell, 2001) Implant base diameter is important consideration as implant volume in treating asymmetry. Both dimensional and volumetric asymmetries need to be addressed. (Maxwell, 2001)

Placement of incisions Implant placement incisions whether conventional or endoscopic can be placed in the following locations (Bostwick J. III et al., 1996):

1. Axillary

2. Periareolar

3. Transareolar

4. Inframammary

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5. Umbilical

Location of Implant The location of implant can be in any of the following locations (Querci della Rovere et al., 2008):

1. Retromammary

2. Retromammary subfacial

3. Subpectoral

4. Complete submuscular

The choice is usually determined by patient and surgeon preference but at times may be limited by anatomic considerations. The implant is placed either between the breast tissue and pectoralis major muscle or deep to the pectoralis major muscle. Subpectoral placement provides for better tissue visualization with mammograms and may minimize implant “wrinkling”. (Graf et al., 2003)

Augmentation approach The approach of breast augmentation differs according to the degree of asymmetry. This is shown in table 6.2.

Breast Asymmetry degree Approach of augmentation Normal asymmetrical Inframammary augmentation (subpectoral / subglandular) breasts Periareolar augmentation Severe asymmetry Inframammary or periareolar augmentation with release of lower pole on smaller side Constricted breast Extensive lower pole release ± expansion Surgical release of parenchyma and skin combined with postoperative expansion adds to the ability to address asymmetries involving breast constriction.

Table 6.2: Approach of augmentation in breast asymmetry. (Chang et al., 2001)

Principles Certain principles while performing performing the breast augmentation surgery should be followed and may help avoid future problems. They should be considered as guidelines for the surgeon. They are as follows:

1. The implant size should ﬁt the patient’s body according to her height and weight.

a) The patient, however, has the right to choose the size she feels she wants.

b) It helps using one of the methods to determine size, such as placing bags filled with saline, beans, peas or filling placing filled gel implants in the bra. This can give an

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approximate implant size for the surgeon that helps is symmetrizing both breast and is satisfactory for the patient.

c) It is important to make sure that the size decided upon is not inﬂuenced by the spouse.

d) The surgeon should question the patient’s decision to have very large implants (over 500ml). (Reilley, 2006)

2. In chronic smokers who will not stop smoking necrosis may occur and surgery should be avoided.

3. The new inframammary fold should be well developed in the pocket and made at equal level with the contralateral breast.

4. The implant should be centrally placed behind the nipple.

5. The muscular attachments to the ribs and sternum in submuscular implants may need to be completely transected or avulsed in order to ﬁt the implant. This will allow adequate pocket size.

6. Bleeding in the pocket should be carefully controlled. Blood is known to cause capsular contracture.

7. Postoperatively it is better to ﬁx the implants in proper position for a few days with a bra and wrappings. This helps the inframammary fold to remain in its proper position.

8. Breast augmentation should not be performed in a lactating patient.

9. Never use closed compression caspsulotomy.

10. Delay corrective procedures on the breast augmentation patient for at least 6 months after surgery.

11. Know when to stop performing corrective procedures. (more than 3 or 4) “Perfection is the enemy of good”

12. Sterile technique with the use of some antimicrobial solution to wash the implant and possibly the pocket is essential. (Shiffman, 2009)

Dissection down to the pectoral fascia should be as follows: • If a subglandular approach is chosen simply dissect the gland off of the muscle until an appropriate pocket has been fashioned.

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• If a submuscular approach is to be performed retraction of the breast in a cephalad direction, entering the subpectoral plane at the lateral border of the pectoralis major muscle then creating the cavity.

Always use sizers in the operating room to verify or modify choice of implants on the basis of the intraoperative aesthetic effect of the prostheses. (Gutowski, 2006)

II – Breast Reduction

The goals of breast reduction in breast asymmetry are aesthetic and functional. The ideal procedure should enhance the form of the breast. By reducing and reshaping the breast with the nipple-areola complex in the appropriate position through minimal scars and with minimal risk of nipple-areola loss. (Bohmert and Gabka, 1997) Postoperative dissatisfaction with breast reduction is not limited to scars and shape. There for greater emphasis has been placed on improvement and maintenance of shape with minimization of scars. Asymmetric breasts should not be approached with any ﬁxed measures in mind, because several techniques can be applied, depending on proportions and adaptations to the contralateral deformity. In very small breasts, one should try using a single vertical incision and may ﬁnd it necessary to include a prosthesis on the contralateral side, without having to reduce the larger breast. When one breast has a nice shape with small ptosis, one should adapt the contralateral breast to the good one avoiding the use of prothesis whenever possible (Goldwyn, 1990)

General principles of reduction mammaplasty

A number of operative procedures are available for breast reduction with a variety of pedicles to maintain the nipple and areola, a variety of techniques to shape the breast, and varying lengths of incisions. The operative technique involves the three structural components of the breast: the content, namely the mammary gland or mass, the skin, and the meeting point, namely the areola and nipple complex, which forms the keystone of the mammary vault. (Khan, 2007)

The mammary mass (contents) Regarding the mammary mass, some pre-requisites are needed to ensure a positive result for reduction mammoplasty

1.Correct residual mammary volume Mammoplasty surgeries are performed to obtain residual breast volumes, whatever the extent of the hypertrophy and the possible degree of asymmetry, which are equal, harmonious related to the reduction of the breast base and adapted to the general physique of the patient.(Lalardie and Jouglard, 1982)

2.Absolute vascular security Vascular security is no problem as the breast is richly supplied by vessels of different origins. However, what is really of concern is the vascular security of the areola and nipple complex. (Khan, 2007; Lalardrie, 1983)

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3.Cutaneo-glandular undermining It is now seldom desirable, for not only does it destroy the embryological and anatomical cutaneo-glandular unity, but it also severs the elements essential to glandular suspension namely Cooper’s ligaments.

Also with cutaneo-glandular cleavage, the gland is deprived of the main venous drainage system, that is the superficial venous plexus and the gland relies only on the deep venous drainage system that is less efficient than that of the superficial one.

4.The type of glandular resection There are different methods of resection of the breast mass depending on the technique used for reduction. They can be external, upper, lower, etc. Whatever the method of resection employed, it is better to preserve as much of the parenchyma of the breast attached to the nipple especially in young patients. (Bostwick J III., 2000)

The skin (container) Regarding the skin management in reduction mammaplasty, certain points are beyond dispute. (Lalardrie, 1983)

1. A perfect balance of skin and glandular volume Skin excisions are necessary primarily to adjust the skin envelope to the reduced breast volume and secondarily for breast support. Excess skin is removed to conform to a smaller or more uplifted breast contour. Removal and tightening of the breast skin should not be done to control and shape the breast, the actual volume and contour of the breast parenchyma is more important for this function. (Bostwick J III., 2000)

2. The need to reduce the length of the scars The current debate in reduction mammaplasty centers essentially on the scars, the most important remaining problem posed by mammaplasty, and more precisely on their position length and quality. Asymmetry due to scars is yet a problem. Minimizing the extentof the scars and making them least obvious, they must be properly sited, as short as possible and of good quality. (Bricout, 1996)

3. The type of skin excision There are various techniques of skin excision in breast reduction surgery and should be viewed as separate from the techniques of parenchymal excisions. In small breasts the skin reduction may be a wedge in the middle below the areola, but in larger breasts it has to be combined with a shortening of the vertical scar line, resulting in an inverted T-scar, but with shorter legs in the inframammary fold.

Alternatively, the wedge could be placed laterally, leaving a straight lateral scar. It can also be made more crescent-like, resulting in an L-shaped scar with one leg in the lateral part of the inframammary fold and the other vertical, below the areola. (Strombeck, 1983)

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The various techniques of skin excision in breast reduction are mainly chosen according to the degree of reduction needed i.e. each technique is more suitable for a speciﬁc degree of breast reduction. (Bostwick J III., 2000)

For minimal breast reduction requiring minimal nipple elevation with closure of the nipple defect and vertical excess skin resection , a vertical scar technique is used utilizing closure with a single vertical scar that extends up to 7 to 8 cm below the areola and occasionally 1 to 2 cm below the inframmary fold. These scars will shorten postoperatively with skin and wound contracture. (Lejour and Abboud, 1990)

Two special points regarding the inframammary incision are worth mentioning. The ﬁrst point is the extent of this incision, which should be hidden below the breast when the patient is standing. This means that it should not extend too medial. And laterally should not be extended beyond the anterior axillary line as beyond this line the scar will be obvious and not covered with the overlying breast mound.

The second point is the level of the inframammary skin incision. Most of the surgeons advise placing it 1 to 2cm above the original inframammary crease as this will shorten the length of the incision and creates a new inframammary crease that is higher on the chest wall to conform to the new reduced breast base and the contralateral breast base.(Bostwick J III., 2000)

The areola and nipple complex The main points that are related to the management of the areola and the nipple complex in reduction mammoplasty are the following:

1. The size of the nipple areola complex

Most patients with breast hypertrophy also have expanded enlarged areolas. although there will be a natural decrease of the areolar diameter when the underlying breast volume is reduced, it is often recommended to further reduce the diameter of the areola at the time of breast reduction to make it proportional to the new breast size.the preference of the patient for areolar diameter is considered in planning; usually a diameter of 4-4.5cm is considered attractive for the reduced breast and 4.5- 5.5cm for larger breasts.

Reduction of the areolar size should be proportional to the new breast volume and to the contralateral NAC. The scar around the areola should be a ﬁne line. (Bostwick J III., 2000)

2.The method of transposing the nipple areola complex

There are 2 methods of taking the areola nipple complex to their new site in cases of reduction mammoplasty.

a) This can either be by transposing them as a free graft, or

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b) Taking them on a vascularized pedicle as a ﬂap to the desired position. (Bricout, 1996)

The areola nipple complex can be raised on different types of flaps there are two types of flaps that can be used, namely subdermal pedicle or central breast mound techniques. (Bostwick J III., 2000) a) The subdermal pedicle techniques depend on the fact that the nipple areola complex is supplied by blood vessels that are passing circumferentially around the breast in a subdermal position (Lalardie and Jouglard, 1982). There are various techniques that utilize this principle each of them is different from the others in designing the base of the dermal flap carrying the NAC the dermal flap can be superiorly based (Weiner et al., 1973), inferiorly based (Ribeiro, 1975) or a vertically oriented bipedicled dermal flap (McKissock, 1972), it can be also a horizontally bipedicled flap (Strombeck, 1960). The dermal flap can also be laterally oriented (Skoog, 1963) or superomedially oriented (Hauben, 1985). (Baran et al., 2001) b) The second type of NAC bearing flaps are those based on the central base mound. This technique is based on the assumption that the major branches of the arterial supply of the breast enter the breast parenchyma near its base and then ramify to supply the gland , the skin and the NAC so that raising thick skin flaps and excision of the breast parenchyma from the periphery of the gland staying 1 to 5 cm short of the deep layer of the superficial fascia covering the pectoralis major muscle will preserve the blood supply to the skin and NAC. (Walton and Gonzalez, 1994)

3. Preservation of sensation of the nipple areola complex after reduction mammaplasty

Techniques that preserve the breast on its deep posterior or medial attachment usually have a predictability satisfactory nipple areola innervation. Although the sensation may be decreased in the postoperative period it often returns a few weeks later. The innervation of the skin of the upper chest comes from the cervical plexus. When a free NA graft is used the graft is placed on this de-epithialized skin within a few weeks of the operation most patients report a return of sensation with reinnervation of the nipple through the skin graft dermal bed. (Bostwick J III., 2000; Costa et al., 2008)

4.The position of the NAC

Three important measurements are important regarding the position of the NAC at the end of breast reduction surgery

a) The distance between the complex and the suprasternal notch.

b) The distance between the mid line and the complex.

c) The distance between the complex and the infra mammary crease. (Costa et al., 2008)

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The new nipple location should be located on the mid breast line approximately 19- 21cm from the sternal notch with the weight off the breast. This distance has to be modified according to the patient height to be more than 21 cm in very tall women and less than 19 in very short ones, this distance must be also modified when the breasts are very large (planned resections of 2 pounds per breast), a distance of up to 25cm can be used to allow for the stretching effect of the breast weight off the skin. In addition it should be modified in order to suit the contralateral NAC in cases of asymmetry where a compromise might result in a more visually acceptable result. (Keskin et al., 2008)

The distance between the nipple and the middle line should be from 9-11cm and should be centered on the mid breast line. In some patients the mid breast line is too lateral especially in patients with huge breasts. In these cases the new position of the nipple should be related to the midline and not to the mid breast line. In these cases the mid breast line will correspond to a line that is drawn from the mid clavicular line to the anterior superior iliac spine. (Costa et al., 2008)

The distance form the nipple to the inframammary crease varies as the breast enlarges. The length varies form 7cm for 32b breasts to 10cm for 42c breasts. The distance from the nipple to the inframammary crease must be progressively longer as the breast volume increases. (Bostwick J III., 2000)

If care is not taken to safe guard a short vertical subareolar distance (not exceeding 4- 4.5cm at the end of the procedure, even by attaching the inferior pole of the breast to the chest wall at the level of the crease, secondary glandular ptosis may develop with slipping of the inferior pole of the gland under the horizontal scar. This can happen even if it was initially correctly seated in the crease. (Bricout, 1996)

III – Mastopexy

Frequently, breast augmentation will result in a lifting of the breast in addition to an increase in breast volume. Some women, however, desire only a lift without an increase in the size of the breast. A mastopexy covers a wide range of procedures to elevate the breast. Mastopexy with or without augmentation and reduction mammoplasties are surgically performed using the following pioneer pedicle techniques and their modiﬁcations:

1. Lateral dermal bipedicle (Strombeck, 1960)

2. Lateral dermal pedicle (Skoog, 1963)

3. Superior dermal pedicle (Pitanguy, 1962)

4. Vertical dermal bipedicle (McKissock, 1972)

5. Inferior dermal pedicle (Courtiss and Goldwyn, 1977)

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6. Circumareolar

7. Free nipple graft

Principles of mastopexy (Payne and Malata, 2003)

• A small lift of the nipple-areolar complex may be accomplished by a circumareolar incision and minimal skin resection.

• A moderate lift will require the addition of a vertical scar below the areola for more skin resection. However, in experienced hands, moderately enlarged breasts can also be reduced by the periareolar central pedicle technique without any additional incisions.

• Larger lifts may require the same incisions as a breast reduction to allow for removal of large amounts of breast tissue.

• In cases where a patient requires a significant mastopexy and augmentation, it may be reasonable to stage the procedures so that a breast lift is done first and the breast implants are placed after final skin healing and soft tissue settling has occurred. This may decrease complications and provide a more symmetric result.

Techniques

1. For minimal ptosis creation of a nipple-areola complex 4 cm in diameter based on a central ﬂap. Another eccentric incision is designed around the existing nipple and the new localization of the nipple-areola complex.

The eccentric area around the nipple is deepithelized and the breast tissue is undermined to an extent, depending on the size of the breast.

The wound is then closed with a purse-string suture placed at the edges of the deep dermis of the breast skin to reduce the size of the eccentric incision, and regular subcuticular sutures, placed in the breast skin and areola without tension.

This suture technique will usually control the enlargement of the nipple-areola complex and allows immediate skin recontouring with minimal skin scar (Rovere et al., 2008)

2. For the patient moderate ptosis Bass (1978) states that the deep double-layered closure reduces the tension on the areolar suture line and minimizes postoperative enlargement of the constructed areola. (Rovere et al., 2008)

3. Goes (1996) performs the periareolar mastopexy or reduction technique using polyglactinepolyester mesh to obtain a controlled conical shape of the breast, since a skin

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envelope alone does not prevent early ptosis as well as areola enlargement (Latham et a., 2006)

4. Spear et al. (2006) also state that the concentric mastopexy procedure has an application for mild nipple ptosis, glandular ptosis, and areola asymmetry, as well as tuberous breast. Similar techniques such as doughnut mastopexy might be effective in reducing the size of the areola in similar above-mentioned selective cases, by leaving only a periareolar scar. (Spear, 2006)

Symmetrising procedures

Nipple-areola complex

The goal of nipple areolar reconstruction is the creation of nipple and areola similar in appearance to the opposite breast. The basic requirements for this reconstruction are a ﬂat, circular graft that matches the colour, texture and diameter of the opposite nipple and a composite graft that matches the diameter, projection, colour, and texture of the opposite nipple. Reconstruction of the nipple-areola complex should only proceed once the patient and surgeon are satisﬁed with the shape and volume of the reconstructed breast. It is virtually impossible to recorrect the nipple position. (Farhadi and Pierer, 2007)

NAC reconstruction procedures

I – Nipple reconstruction procedures include the following:

1. Nipple grafting from the contralateral breast If the contralateral nipple has sufﬁcient projection, It is cut in half horizontally, and after deepithelialization of the recipient site, it is sutured in the correct position using simple interrupted sutures. The donor-site defect can be closed primarily or can remain open to allow reepithelization to occur from the lactiferous ducts (Damen et al., 2009).

2. Local ﬂaps

A number of local techniques have been described such as:

a) Star ﬂap

b) Propeller ﬂap

c) Skate ﬂap rarely if ever used.

3. Full thickness grafting from the labia minora which is psychologically unpleasant to the patient. 4. Alternative approaches as full thickness grafts harvested from the ears have also been described in literature.

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5. Correction of nipple projection and re-elevation. If nipple projection declines over time ﬁller injections of bioimplants such as collagen or hyaluronic acid (or another permanent ﬁller) have proven to be successful for re-elevation, however, patient should be informed that repeat injections may be needed (Borschel et al,. 2001)

6. Nipple reduction may also be performed if one nipple is larger than the other.

Areolar reconstruction Asymmetry of the areolar diameter is another frequent occurrence. It is vital to choose an area of skin that is relatively hairless. Otherwise transfer to the breast region can cause both functional and cosmetic problems.

1. Tattooing has almost completely replaced the more complex procedure of full thickness grafting. It yields good results. However the drawback is that the tattooing fades and later touch-ups are needed. (Damen et al., 2009)

2. Full-thickness skin grafting which in addition to the color resemblance to the original areola provides for more permanent projection like reconstruction better than tattooing. Options are the following:

a) The medial thigh area near the groin crease may be used.

b) Areolar skin from the contralateral breast.

c) Excess skin from the upper eye lid, however it may not be able to cover the entire areola in a single piece. (Latham et al,. 2006)

Relocation

The goals of nipple-areola repositioning are safe movement of the nipple and areola as well as reconstruction of the breast tissue to achieve asymmetry without compromising the vascularity of the nipple and areola. The speciﬁc technique for moving the the nipple- areola depends on its size, shape, and position and the age of the patient. The surgeon should have a spectrum of procedures available and apply the appropriate technique to each patient. Methods include the various pedicles and nipple and areola graft technique (Fahradi and Pierer, 2007).

Liposuction

Liposuction alone can be an effective technique, but relies on skin elasticity and retraction. The nipple can raise to a higher position if liposuction is performed above the areola, but this can lead to loss of upper pole fullness. The breast tend to be ﬂatter and have residual ptosis. Liposuction has a lower risk of complications. Nipple necrosis is less likely, and sensation and breast feeding are more likely to be preserved. However this procedure

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does not work well in the most ideal indication; teenagers with normal body weight. As teens tend to have thick ﬁbrous glandular breasts with minimal fat. (Nahai, 2005)

II – Inframammary fold (Massiha, 2001)

In any breast reconstruction case, a properly positioned and newly created IMF is necessary to ensure a more predictable result. Patients with tuberous breast deformity tend to have a high IMF, which may need to be lowered below the inferior boundary of the contralateral IMF so autologous tissue does not sit high on the chest wall. On the contrary, if the previous expander/implant was positioned too low, it must be repositioned prior to ﬁnal ﬂap inset. (Schusterman, 2004)

Technique

With different aesthetic problems related to lowering of the inframammary fold. The key is division of the costochondral insertions of the pectoralis muscle in its inferior and medial aspects. Perform continued dissection in the subglandular plane, and make a conscious attempt to continue the inferior aspect of the dissection above the pectoralis fascia.

III – Other procedures for augmentation mammaplasty

Breast augmentation with autologous fat

Liposuction was introduced in 1983 by Fisher et al. (1983). The fat retrieved from liposuction ultimately began to be used to augment tissues. Since the introduction of tumescent liposuction by Klein in 1987, there has been less blood loss in liposuction, and more fat retrieval. Fat transfer to the breast is relatively easy. Before transfer fat should be washed thoroughly to remove blood products. Injection of fat should be through tunnels at various levels outside the breast gland and fat should not be injected into pools, and after then should be massaged so that it will not necrose and calcify. (Shiffman, 2009)

Fat transfer with platelet-rich plasma

The use of additives such as PRP appears to further enhance the success and rate of graft acceptance in both small volume and large volume applications. PRP has proven to provide such improvements, and it can be inexpensively isolated and applied to breast augmentation in asymmetry, with long lasting natural contouring and volume increases are attainable. (Shiffman, 2009)

The brava external tissue expander

The brava system is an alternative method for symmetrizing breasts. It should be used in women where one cup enlargement is sought and those happy with the shape of their breast seeking only an increase in volume as an alternative to an implant. (Shiffman, 2009)

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Microsurgical tissue transfer

Microsurgical reconstruction of chest-wall and breast asymmetry in Poland’s syndrome and hypoplastic breast augmentation yields excellent results with a high degree of patient satisfaction. (Longeraker et al,. 1997) Lai et al described difficulty in breast augmentation in Asian women secondary to small body habitus. With a small amount of breast tissue and thin chest wall. To circumvent this problem they undergo bilateral TRAM flaps. In addition autologous tissue has a natural feel and appearance. It offers a life time reconstruction with the ability to adjust to patient weight change and aging. They also help remove excess tissue in areas that the patient desire while providing adequate volume for breast reconstruction. (Gurley, 2003) Free flaps donor sites include the following:

• Transverse rectus abdominis ﬂap (TRAM)

• Superﬁcical inferior epigastric artery ﬂap (SIEA)

• Deep inferior epigastric artery ﬂap (DIEA)

• Superior gluteal ﬂaps

• Inferior gluteal ﬂap

• Latissimus dorsi ﬂaps

The abdominal tissue is the preferred donor site for DIPE and SIEA. The superficial vessels are always explored during abdominal flap harvest. This allows harvesting of the tissue without opening the anterior rectus sheath. The breast incision is most frequently inframammary, which allows adequate exposure to the internal mammary vessels via exposure by removal of the 4thrib cartilage. The incision length varies according to preoperative breast size and skin laxity. This can be extended laterally and if the thoracodorsal vessel is used as a recipient vessel then an axillary incision can be used. A submammary pocket is created which places the flap in a neutral position. A tissue expander can be placed within the pocket to stretch the skin during flap harvest. Anastomoses are performed to recipient vessels sometimes using the synovis microvascular anastomotic coupler system. Postoperatively, the patients may need excision of the skin paddle and suction-assisted lipectomy for final contouring of the flap (Bostwick, 2000).

Pedicled ﬂaps (Bostwick, 2000)

These include the following ﬂaps:

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1. Latissimus dorsi ﬂap

2. TRAM

3. The lateral intercostal artery perforator (LICAP) pedicled ﬂap

IV – Stem cell therapy (Lewis and Visbal, 2007)

Organ-specific tissue stem cells are considered to be a rare population of long-lived cells that are defined operationally by the ability to self renew and to give rise to all other cell types in a given tissue. They not only function in organ formation in the embryo, but also participate in tissue repair, regeneration, and remodeling in the adult organism (Molofsky et al. 2004; Wicha et al. 2006). In the mammary gland, regenerative stem cells, and division-competent progenitor cells derived from them, are the driving force behind gland development and function. (Behbod and Rosen 2005). Elegant transplantation studies initiated nearly five decades ago (Daniel et al. 1968; DeOme 1958; Faulkin and Deome 1960) demonstrated that the adult mouse mammary gland contains relatively growth-quiescent epithelial stem cells that are distributed throughout the entire gland. These stem cells could be activated to self-renew upon transplantation of small duct fragments or dissociated cells, and were capable of regenerating morphologically normal, functional ductal trees for multiple transplant generations. However, current genetic data do indicate that inhibition of hedgehog signaling is important for control of proliferation and histoarchitecture, and that activated hedgehog signaling can regulate important aspects of the behavior normal epithelial stem and progenitor cells.

Final Intraoperative appearance (Malata and Bostwick J. III, 1999)

Finally, intraoperative appearance should be critically assessed in every quadrant: medially, laterally, superiorly, and inferiorly. Final assessment should be accomplished with the patient in a sitting position. These simple steps will allow for more predictable, reproducible, and satisfying results in dealing patient with breast asymmetry.

Postoperative course and evaluation

Follow-up

After breast augmentation, reduction, or mastopexy, most women will only need the same follow-up, examination and mammogram screening of their breast as women without prior breast surgery. Postoperative changes on physical examination may include palpable implants, particularly on the inferior and lateral portions of the breast. Minor breast lumps after

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surgery may be due to suture granulomas, internal scars, and fat necrosis. These tend to improve over time as healing resolves. In rare cases, inclusion cysts or small abscesses may present years after surgery. Any suspicious masses after the normal healing period should be evaluated as any other breast lump. It is certainly reasonable to obtain the opinion of the original plastic surgeon in these cases. Routine mammogram screening guidelines should be applied to women with breast implants. They should be referred to mammography centers that have experience with screening such patients and will obtain the appropriate Eklund views. It is reasonable to obtain a baseline mammogram 1 year after breast reduction surgery as there may be benign calciﬁcations present from fat necrosis after the surgery. (Malata and Bostwick J. III, 1999)

Complications of treatment

General complications

• Bleeding, infection, and seroma formation may be expected after extensive surgery.

• Thromboembolism is a risk. Proper history taking is mandatory with prophylaxis in high risk patients.

• Recurrence of asymmetry is highest in younger patients repaired at an early age.

Speciﬁc complications

1. Recipient-site complications encountered included venous congestion, hematoma, cellulitis and partial fat necrosis hernia. (Gautam et al., 2007)

2. Complications related to implants include rupture, migration, infection, rippling, sensory changes to the nipple-areola complex, synmastia, “double-bubble” deformities, capsular contracture and extrusion (Borschel et al., 2007; Baldwin et al., 2006)

3. Breast reduction and mastopexy complications include minor wound separation, partial or total areolar necrosis or asymmetry, hypertrophic scar, dog-ears, vertical-scar widening , residual wrinkling of skin, (mild) breast asymmetry, bottoming out inevitable late complications such as abnormally enlarged areola-nipple complexes may occur in the hands of inexperienced plastic surgeons. (Farhadi and Pierer, 2007)

Post operative evaluation

It is not always possible to achieve precise symmetry. We do not yet have an exact scientiﬁc method to determine how much tissue should be excised or what the size of the prosthesis to implant should be to perfectly balance the two breasts. Usually the surgeon makes these decisions based on his experience and surgical judgment. (Beer et al., 2001)

59 CHAPTER 6 BREAST ASYMMETRY MANAGEMENT

Linear measurements and MRI are objective methods for evaluating postoperative symmetry, and when used in association, can help plastic surgeons to achieve favorable results in mammary asymmetry treatment. (Neto et al., 2007)

Revision surgery

Surgical revision might be necessary in patients due to postoperative complications, recurrence of asymmetry or minor touch up procedures. These procedures may range from minor surgical debridement, ﬂap advancement, and scar revision for hypertrophic scar to secondary nipple-areola reconstruction or secondary reduction. However most operations are minor procedures (ofﬁce surgery under local anesthesia) performed to obtain an aesthetic result that is acceptable to both patient and physician. (Munhoz et al., 2009)

Part III

Methodology

61 7 Patients and Methods

Patients

Twenty cases of breast shape malformations observed in the last 3 years, both retrospective and prospective, between April 2005 and March 2009. The records of the patients with asymmetrical breast deformities treated in Al Kasr al Ainy Hospital and other private hospitals were reviewed as well as all female patients above the age of 12 years requesting correction of breast asymmetry. Chronic heavy smokers, high risk breast cancer patients, patients suffering from major uncontrolled medical illness and those suffering from asymmetry due to trauma, breast masses, burn or previous procedures were excluded from this study. In the bilateral cases one breast often showed a more severe malformation compared with the other side, therefore the breast shape malformation was usually asymmetric.

Methods

Patients were evaluated by history, physical examination, investigations and photography. And the techniques used were differential reduction, differential augmentation ± mastopexy, reduction augmentation, as well as reconstruction of tuberous breasts and Poland’s syndrome deformity. The follow-up period ranged from 5 to 38 months (median 23 months).

History

Thorough history with stress on main complaint, physical, psychological as well as family history of breast cancer, in addition to family history of asymmetry should be obtained. In the prospective study we had patients routinely answer the following 6 questions:

• When was the asymmetry ﬁrst noticed?

• Does anyone else in the family have a similar problem?

• Was there an episode of trauma to the breast?

• Are the breasts still growing?

• Has there been any change in bra size in the last year?

• Has there been a history of depression or aberrant behavior?

Their characteristic body language–slouched posture and downcast eyes–conveys that they are uncomfortable with themselves were observed in addition to recording patient age and proﬁle whether teenage, during child bearing period or post-menopausal as well as height and weight. 62 CHAPTER 7 PATIENTS AND METHODS

Physical examination

Breast examination was performed while the patient was sitting, upright, leaning forward and lying supine. Apart from the standard breast examinations certain criteria have been stressed on:

Degree of asymmetry

• Examine the entire thorax as well as the breasts.

• Look for signs of pectus deformities, spinal deformities as scoliosis, rib ﬂaring, chest wall hypoplasia, and muscular abnormalities.

• Measure and record the sternal notch to nipple distance and the base width of each breast.

• Determine if there is a discrepancy of inframammary fold levels.

• Roughly estimate the gram size difference between the breasts.

Degree of hypertrophy of each breast

The degree of hypertrophy of each breast is roughly estimated by the cup size that ﬁts the breast. The degree of hypertrophy is assessed according to the following scale:

1. Mild hypertrophy with cup size B.

2. Moderate hypertrophy with cup size C.

3. Major hypertrophy with cup size D.

4. Gigantomastia with sizes E and above.

It was estimated by breast volume in grams. Patients were classiﬁed according to their breast volumes as follows (Jones, 2006):

1. Mild hypertrophy: Less than 200 gm.

2. Moderate hypertrophy: 200-500 gm.

3. Major hypertrophy: 500-1500 gm.

4. Gigantomastia: More than 1500 gm

63 CHAPTER 7 PATIENTS AND METHODS

Degree of ptosis of each breast

It is deﬁned by the relation between the level of the nipple and IMF and classiﬁed as follows:

1. Minor if it is at or just below the IMF.

2. Moderate deformity if it is within 3cm below IMF.

3. Severe ptosis if it is more than 3cm below IMF.

Linear measurements of both breasts

They include the following measurements:

1. Sternal notch to nipple

2. Midclaviculr point to nipple

3. Nipple to inframammary fold

4. Intermammary distance

5. Breast base diameter.

Skin quality (excess)

Excess skin was graded into minimal, moderate, or loose. (Naha, 2005)

Skin quality (elasticity)

The skin was assessed whether it was normal or inelastic as tested by stria, skin thickness and skin recoil. (Nahai, 2005)

Skin parenchyma relationship

The relationship between the skin and breast parenchyma was assessed and classiﬁed into ﬁrmly adherent or loosely adherent. (Nahai, 2005)

Intertigo (Fungal infections)

Any intertigo was treated with topical antifungal and patient should be free from the disease at least one week prior to the operation.

64 CHAPTER 7 PATIENTS AND METHODS

Fig 7.1: A diagram showing measurements for breast asymmetry (Maxwell, 2001)

Investigations

Routine investigations including full blood picture, liver function, fasting blood sugar, and stressing on renal functions wee performed. Preoperative mammogram for patients older than 35 years was also performed. The location and length of the possible scars were shown and described to the patients whose desires inﬂuenced the choice of the technique.

Photography

Preoperative photos were taken and reviewed with the patient to point out conditions such as extent of asymmetry. Representative before and after photos also should be reviewed to insure that the patient understands the scars and has realistic expectations. Both standard frontal, oblique and side views were routeinely shot pre- and postoperatively.

Consent

Standard consents were taken from the patients and parents in patients under 21 years, with a special stress on the possibility of recurrence especially in teenage patients and need for resurgery.

Final preoperative patient classiﬁcation

After the previously mentioned methods, Patients were classiﬁed as follows:

1. Asymmetrical hypertrophy (unilateral or bilateral)

2. Asymmetrical hypoplasia (unilateral or bilateral) 65 CHAPTER 7 PATIENTS AND METHODS

3. Hypertrophy / hypoplasia

4. Combined (e.g. with scolicosis, Poland’s, etc)

Operative procedures

Techniques used in this study were reduction , mastopexy, augmentation, correction of tuberous breast deformity and Poland’s syndrome deformity. In patients that required a different operation on each breast, the more difficult or less controllable side was operated on first. For example, if the patient needs a mastopexy and reduction, the mastopexy was performed first to have a model to match with the reduction. With special concern to the markings as they act as a guide in shape adjustment throughout the operation for more predictable results.

Reduction mammoplasty

Preoperative markings and planning of the superior pedicle reduction

Step 1: Patient placed in the semi-sitting position or standing. The supra sternal notch (S.S.N.), the midline and the inframammary fold (I.M.F.) were marked ﬁrst. The breast axis is drawn from the suprasternal notch downwards. It passes through the center of the breast’s apex. It does not necessarily pass through the nipples as their position may vary and are frequently asymmetric in these big breasts. The axis is a very important landmark as we plan on it for the ideal site of the future nipple, the symmetric resection of the excessive tissues, as well as the site of the ﬂap and its pedicle.

Step 2: A point is placed, on the breast axis, at 19 cm from the supra sternal notch which represents the upper border of the neo-areola. It should be on exactly the same horizontal level to the opposite side. From that point, a vertical ellipse is marked as follows: The breast is rolled outwards or laterally to trace the inner limb then rolled inwards to mark the outer border of the ellipse. Its lower extremity stops at an inch above the infra mammary fold. Riding on top of this ellipse is the key hole pattern for the areola while at its lower end is traced the site of the transverse limb of the inverted T above the infra mammary fold.

Step 3: The site of the ﬂap is marked. It begins inside the circle of the new areola an goes for about 4cm distal to the nipple. Its width should be, around 10 cm.

66 CHAPTER 7 PATIENTS AND METHODS

Fig 7.2: Diagram of the preoperative markings.The various important items illustrated for proper planning of the procedure mainly: S.S.N. Supra sternal notch, I.M.F. Infra mammary fold, Breast axis. of the inverted (T) at one inch from the inframammary fold (Gheita, 2009)

Surgical technique All patients operated upon under general anesthesia and received prophylactic broad-spectrum antibiotics at the beginning of the procedure.

1. The patient is placed in the semi sitting position on the operating table.

2. A very superﬁcial ring incision (epidermal) around the nipple is made with a diameter of 4cm marking the size of the new areola. The key hole pattern is placed on top of the ellipse and a superﬁcal incision of the epidermis made, not to interrupt the subdermal plexus coming from above.

3. The dermoglandular ﬂap carrying the nipple areola complex is de- epethelialized according to the tracings.

4. At the lower extremity of the traced ellipse, by scissors dissection, and blunt with the fingers, the hand is passed behind the breast separating it from the pre pectoral fascia.The fist of the hand is then introduced centrally into the breast core to reach behind the nipple.This plane opens easily, is relatively avascular, the dissection is blunt, and it aims at preserving, to the maximum, the vascular subdermal plexus coming superiorly from the axillary and acromio-thoracic branches. This maneuver facilitates the separation of the flap, which is anteriorly situated, from the posterior leaf which will be amputated.

5. The flap is separated from the surrounding. It is elevated carefully to preserve its vascularity in the subdermal plexus. The palm and the fingers of the left hand serve as a monitor for the thickness of the flap which should be about 2cm. The uppermost part of the breast above the new areola site should be left attached to the chest wall to preserve the maximum vascularity coming from above. Now with the flap elevated, the ellipse of

67 CHAPTER 7 PATIENTS AND METHODS resection is deepened and a wedge of excessive breast tissue is removed in a monoblock fashion thus achieving an amputation of the ptotic lower part of the gland, which is below and behind the areola. This monoblock resection achieve better symmetry of the breasts, less blood loss, shorter operating time and less complications. That created space behind the site of the new areola (keel) will accommodate these extra long ﬂap without compression.

6. The keyhole pattern is closed. The vertical limb of the inverted T i.e. the distance from the areola down sutured for a distance of 4cm. The dermo-glandular ﬂap folded upon itself, the nipple areola complex delivered and ﬁxed at its new location.

7. The whole breast is elevated. At an inch above the infra mammary fold a parallel incision is made. It extends medially and laterally to the inner and outer folds of the breasts. It meets the incision coming from the vertical sutures underneath the areola.

8. The inner and outer excessive breast tissues also called inner and outer ﬂaps are reduced in size as needed. We call these the “breast stabilizer” as by modifying their size we can modify, at the end of surgery, the desired breast’s size as well as its shape. Thus achieving symmetry in asymmetric conditions. These dermo glandular ﬂaps sutured to each other give support and stability against early re-ptosis.

9. The breast is then closed starting from the middle line at the junction of the inverted T with the horizontal line and any remaining dog ears removed. The horizontal suture should fall above the infra mammary fold inside the breast aiming at a better qualityscar. No drainage was required.

Dressings and follow-up Elastic adhesive plaster is used in the form of a ﬁgure of 8. Stitches were removed after 14 days.

Mastopexy

The technique used was also the superior pedicle technique, tracings are similar to those of the superior pedicled reduction procedure, however the operative technique differs in that only skin excision is performed without glandular resection and the infra- areolar segment is then plicated back to back, with everting sutures to give projection of the breast and support elevation of the areola and nipple. In cases where an augmentation was indicated or desired slipping of a prothesis in the retromammary space was performed prior to skin resection so as not to end with a tight encasing envelope and skin deﬁciency.

Augmentation

The preferred approach is the periareolar intraareolar or the submammary approach in cases a small areola or big implants. The prosthesis used were gel filled round mammary ones (whether smooth of textured). The retromammary pocket fashioned was 2cm larger that the actual circumference of the implant as a capacious pocket is believed to prevent against capsular contracture and with a good and meticulous haemostasis.

68 CHAPTER 7 PATIENTS AND METHODS

The base of the implant breadth is measured from the the sternal edge to the anterior axillary fold across the chest. This will define the diameter of the base and the nipple should be in the center of the prothesis. The volumes were chosen according to and relative to the height of the patient, the chest and shoulder frames as well as patient preference. In cases of slight asymmetries equal volumes are chosen for both breasts, as in larger volumes asymmetry is less apparent. With larger differences the volumes are chosen according to the proportion of asymmetry and regarding the actual given volumes that are assessed preoperatively and considering the base diameter difference. In addition the asymmetry can be utilized to augment parts of the deformed breasts, by taking lateral parenchymal flaps to augment medial compartment deficiencies. Case 17

Tuberous breast deformity

Types 1 and 2: A circumareolar reduction of the areola with areolar telescoping onto the breast, followed by mastopexy and insertion of an implant in a sub-glandular pocket to allow for base enlargement of the breast.

Types 3 and 4: Entailed circumareolar reduction of the areola delineation with undermining between the breast and skin to release the sites of tightness of the breast capsule. This is performed by multiple capsulotomies on the anterior surface of the lower half of the breast and extending also to part of its retromammary surface. Allowing also the pushing down of the inframammary crease by releasing the high tight inframammary crease to accommodate for the released breast and/or the slipped in prosthesis. Augmenting the breast base and already hypoplastic volume to a more suitable breast volume and contour and also working as a stretcher on top of which the capsulotomies would be prevented from healing and retightening of the breast again.

Fig 7.3: Intraop. Areolar reduction by depethelialization & breast undermining

69 CHAPTER 7 PATIENTS AND METHODS

Fig 7.4: Anterior surface capsulotomy of inferior half of the breast & undermining

Poland’s syndrome

In Poland’s syndrome we used a two-stage approach using initial tissue expanders then silicone gel implants. Reconstruction of the areola was performed by areolar skin from the contralateral breast during contralateral breast reduction.

Liposution

It was utilized in a single case presenting with hypertrophy and synmastia.

70 CHAPTER 8 RESULTS

8 Results

Patients

The malformation was unilateral in 1 case and bilateral in 19 cases. Ages of the patients ranged from 14 to 54 years (median, 31.3 years).

Of the 20 treated breasts, seven patients had asymmetrical hypertrophy (35% ), 3 patients had hypoplastic asymmetries (15%), 3 patients had asymmetrical ptotic deformities(15%). 3 patients had tuberous deformities (15%), 2 patients suffered from hypertrophy/hypoplasia, 1 patients had combined deformity (5%) and one case suffered from Poland’s deformity (5%). Asymmetry was present in all the patients (100%). Areolar prolapse was noted in 2 tuberous breasts (10%). There were no other anomalies present apart from scoliosis, and no family history of breast malformation was recorded. The data present in this paragraph are summarized in table 8.1.

Classification Number of Patients Hypertrophic asymmetries Asymmetrical hypertophy 7 patients Hypoplastic asymmetries Asymmetrical ptosis 3 patients Asymmetrical hypoplasia 3 patients Tuberous breast deformity 3 patients Hypertrophy Hypoplasia 2 patients Combined cases With scoliosis 1 patients Poland’s syndrome 1 patient

Table 8.1: Classiﬁcation of breast asymmetries & patient numbers

Minor deformities are normally unrecognized by the patients and were observed in patients with breast hypoplasia seeking augmentation, while patients with tubular breast are very concerned of their aspect and come directly to the surgeon.

Preoperative evaluation

The preoperative evaluation of breast asymmetry and associated conditions is summarized in tables 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8.

Operative plan

The operative plan for the different types of deformities are shown in tables 8.9, 8.10, 8.11, 8.12, 8.13 and 8.14

71 CHAPTER 8 RESULTS

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Postoperative care, complications and Follow-up

Complications Number of patients Hematoma 0 Seroma 1 NAC necrosis 0 NAC malposition 0 Wound dehesince 1 Wound infection 1 FAT necrosis 0 Cyst formation 0 Delayed wound healing 0

Table 8.16: Complications of Breast asymmetry operations

Secondary surgery Number of patients Scar revision 2 Excision of dog ears 0 Resurgery 2 Liposuction of lateral bulge 1 Poor aesthetic outcome 0 Cyst formation 0

Table 8.17: Secondary surgeries and number of patients undergoing them

Long term results Good Satisfactory Poor Shape 14 6 Size 18 2 Scars 17 3 Symetry 18 2

Table 8.18: Long term results in patients with breast asymmetries surgery

84 CHAPTER 8 RESULTS

Postoperative aesthetic Good Satisfactory Poor results Shape 15 5 Size 19 1 Scars 19 1 Symmetry 18 2

Table 8.19: Postoperative aesthetic results for patients with breast asymmetry

Breast asymmetry Case number Satisfied Moderate Unsatisfied Hypertophic asymmetries Case 1 Yes Case 2 Yes Case 3 Yes Case 4 Yes Case 5 Yes Case 6 Yes Case 7 Yes Hypoplastic asymmetries Asymmetrical ptosis Case 8 Yes Case 9 Yes Case 10 Yes Asymmetric hypoplasia Case 11 Yes Case 12 Yes Case 13 Yes Tuberous breast deformity Case 14 Yes Case 15 Yes Case 16 Yes Hypertrophy-hypoplasia Case 17 Yes Case 18 Yes Combined cases Scoliosis Case 19 Yes Poland’s syndrome Case 20 Yes

Table 8.20: Table showing the degree of patients satisfaction following Breast asymmetry surgeries

Patient photos

Patient photos are on the pages that follow.

85 CHAPTER 8 RESULTS

Case Presentations

Asymmetrical Hypertrophy

Case 1

a) A case showing asymmetrical b) Preoperative markings Hypertrophy

c) Postoperative results after employing a superior pedicle reduction

Fig 8.1

86 CHAPTER 8 RESULTS

Case 3

a, b) Gigantomastia in a 16 year old patient

c, d) Postoperative after a superior pedicle reduction

Fig 8.2

87 CHAPTER 8 RESULTS

Case 5

a,b) Bilateral asymmetrical hypertrophy

c,d) Postoperative after reduction mammaplasty

Fig 8.3

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Case 6

a,b)Bilateral asymmetry hypertrophy

c,d) Postoperative after reduction mammaplasty

Fig 8.4

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Case 7

a,b) Preoperative showing congenital synmastia and asymmetry

c,d) Postoperative after initial liposuction of 400cc

Fig 8.5

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Asymmetrical Hypoplasia (ptosis)

Case 8

a) A case of asymmetrical breast ptosis

b) Postoperative after mastopexy Fig 8.6

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Case 9

a) A case of asymmetrical ptosis

b) After mastopexy and augmentation

Fig 8.7

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Case 10

a) Case with asymmetrical ptosis

b) After using equal implant volumes concealing the difference

Fig 8.8 93 CHAPTER 8 RESULTS

Asymmetrical Hypoplasia (Hypoclostic Breasts)

Case 11

a) Patient with asymmetrical hypoplasia

b) After different implant volumes on either side were inserted

Fig 8.9

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Case 12

a) Patient with right sided aplasia

b) Postoperative with use of an implant on the aplastic side

Fig 8.10

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Asymmetrical Hypoplasia (Tuberous Breasts)

Case 14

a) Photo showing grade 3, 4 tuberous breasts

b) After postoperative correction by implants and telescoping of reduced areolae

Fig 8.11

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Case 15

a,b) A patient with grade 4 tuberous breasts

c,d) After postoperative correction by capsulotomis and reduction and telescoping of the areolae

Fig 8.12

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Case 16

a) A case showing right sided grade 1 tuberous breast and left sided hypoplasia

b) After augmentation mammaplasty concealing the differences

Fig 8.13

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Hypertrophy/Hypoplasia

Case 17

a) Asymmetrical hypertrophy and constricted left breast

b) Discrepancy of the IMF levels

c) Postoperative correction with reduction on the right side and mastopexia on the left

Fig 8.14

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Combined Case 19

a) Pateitn with asymmetrical hypertrophy of the right side and ptosis of the left side

b) Preoperative markings

c) Postoperative after right side reduction and left side mastopexy

Fig 8.15 100 CHAPTER 8 RESULTS

Case 20

a) A patient with Poland’s Syndrome

b) After skin expansion prior to implant placement

Fig 8.16

101

Part IV Discussion and Conclusion

102 CHAPTER 9 DISCUSSION AND CONCLUSION

9 Discussion

Discussion

Asymmetry exists in a continuum, with the perfect symmetry on one end and severe asymmetry on the other. Breast asymmetry presents a problem in surgical management for the discrepancy in size, volumes, shapes and contour and even the sites of differences or excess in these breasts. In addition to some associated discrepancies of breast bases on which the breasts are seated as thoracic cage abnormalities and unevenness. Hence, the difficult differentiation of the breast problems which root to even the origin of their etiologies that has to be understood in order to deal with the associated pathologies that cause these abnormalities. Different classifications (Perrsichetti et al., 2005) were proposed in the literature about the different configurations of breast asymmetries and many ways of management reflect the difficulty with which this problem is tackled. (Reilley, 2006) There are no hard and fast rules regarding the timing of surgery. Frequently, to be sure that breast growth is fully completed, a pediatrician may advise the patient to wait until she is in her late teens. However, there are many patients in whom such a delay would be cruel. Earlier surgery is offered to the patient with the understanding that fine-tuning of the result may be required later. Maintaining symmetrical result over time, particularly with the changes in size and shape that naturally occur during pregnancy, is a challenge. However, to delay correction until child-bearing is completed seems unreasonable. (Latham, K. et al., 2006) The study here is conforming with that asymmetrical hypertrophy of the breasts forms most of the cases of asymmetry, and also that slight degree of asymmetries in volume in the big sized breasts often pass unnoticeable than in smaller sized breasts up to 10% of discrepancies in breast size might pass as normal range in the big sized breasts and also slight discrepancies in the breast base especially the inframammary crease as up to 1cm difference in level is accepted in the normal range (Table 8.1). Not one classification already advanced did fulfill all types of etiologies of breast asymmetry and even did not design the fine paths along which we could already manage these cases with clearer understanding. Each abnormality should be well understood as regards its etiology and the entailed pathology with the different degrees of the severity of affection in order to define the localization of the deficiency or excess and accordingly managed with the available reconstructive and esthetic breast techniques to achieve higher precision and satisfaction. There are no new operations to learn. Each patient may be unique, but to achieve symmetry, familiar procedures including augmentation, mastopexy, reduction, and variations such as augmentation/mastopexy or plus/minus reductions are used. Mastopexy or reduction may be achieved with whichever technique. It seems obvious that when performing an asymmetric reduction, the larger breast needs to be reduced first. This strategy prevents inadvertent over- reduction of the smaller side with the possible scenario of being unable to reduce the larger side to match it without compromising nipple areola circulation. In patients that require a different operation on each breast, the more difficult or less controllable side should be addressed first. (Reilley, 2006) In classifying breast asymmetries and since the hypertrophic group form the most common type, they should be gathered in one category and easier to deal with by reductions especially if it is performed by one technique that is the superior pedicle technique tailored and adapting the discrepancies with ease, as evident in our studied cases (Table 8.9, 8.10 and 8.11). It is much better to use the same technique on both breasts than different techniques on both sides also it is much better in these cases to be operate on both sides by the same operator.

103 CHAPTER 9 DISCUSSION AND CONCLUSION

Pedicles Central Inferior Superior Lateral Medial Free Graft (posterior) All degrees of Minimally, hypertrophy moderately and The pedicle is massively based on the Minimal & enlarged upper pole moderate breasts. The that suspends Moderate & When minimally, pedicle base the NAC in The pedicle massive Unpredictable moderately presents a constant place base presents hypertrophy other pedicle and Applied for problem as it The ptotic a problem as May produce blood supply massively is the ptotic part is excised it is the tissue medial specially in enlarged tissue that reliving the that needs to excessive massive breasts needs to be breasts from be removed bulge hypertrophy removed its unwanted to achieve a otherwise it part and good result is pulled preserving the down by upper pole gravity fullness and projection Doubtful graft loss or partial Safety Safe safe safe Safe Safe discromia and flattening Not Reliable Not reliable Reliable shape (flat,square (flat,square Produces the Not Reliable Not reliable Reliable Reliability shaped shaped best conical breasts) breasts) shape Sensation ++ ++ ++ - ++++ - Breat + +++ + + + - feeding Long vertical Long vertical Scars Long long limited long component component Bottoming Very Does not Common Uncommon Uncommon Uncommon out common occur NAC riding Does not Common Common Could occur Could occur Does not occur up occur

Poor - Potential + Good ++ Very Good +++ Excellent ++++

Table 9.1: Comparing different types of pedicles

In cases done great feasibility and adjustability of the method was due to that the operation position was in the semi-sitting position for instantaneous comparison of the results and adjustment of the technique on both sides. What is important in these reductions is not what to remove but what to leave behind so that the remaining breasts would be symmetrical. Taking into consideration that the measurements taken on the heavier side would be adapted to the effect of gravitational stretch with more recoil back when the excess tissue weight is taken off, that is to say that the nipple levels should be measured at a slightly lower level than on the lesser sized breast and also the length of the infra-areolar segment a little larger than on the smaller sized breast to allow for this recoil. The amount of glandular resections should be tailored differently in order to allow for a comfortable closure of the breasts without undue tension which would jeopardize the results. This reveals the advantages of superior pedicle technique over other pedicle techniques with their inherent disadvantages like bottoming out and high riding areola and poor aesthetic fill-up of the upper segments of the breast and resulting in square flattened breasts with long scars. In 104 CHAPTER 9 DISCUSSION AND CONCLUSION addition, the lack of adaptability to the pattern of asymmetry by their presentable designs which do not tailor well the asymmetry and amounts of resection and the unevenness of the remaining breasts. If the patient needs a mastopexy and reduction, the mastopexy is performed first to have a model to match with the reduction. The other categories of breast anomalies as aplasia, hypoplasia, atrophy, achieving symmetry may be possible with unilateral surgery, but frequently bilateral surgery is required. It is critical to grasp the concept that the more similar the procedures performed on each breast, the more likely there will be symmetry over time. An inframammary incision for implant insertion is recommended to preserve the opportunity for future breast feeding. This particular group of patients is more accepting of breast scars than those having purely aesthetic surgery procedures. The interareolar approach is also used in larger areola for better aesthetic results. There are more implant options, including saline (adjustable), gel (cohesive I, II, III), or combinations. Anatomic or round devices when a unilateral enlargement is needed. For the perenity of the results we used round implants making their pockets generous to avoid contracture and symmetrical without the possibility of getting upper pole implant dislodgment which is common in antomic shaped implants. Asymmetric augmentation may involve 2 different sized implants with differential fill volumes, and patients with chest wall asymmetry may also require the use of different profile implants. The value of using implant sizer in these patients cannot be overstated. It is important to re-state that in small discrepancies equal sized prosthesis are used, masking the difference coinciding with the fact that asymmetries are more apparent in smaller volumes than in larger volumes. (Table 8.12) Tuberous breasts with their different grades, which are special entities of hypoplastic breasts as was already shown were treated with multiple capsulotomies, areolar reduction and telescoping and implant placment. In one case where an implant was not used there was a recurrence of slight constriction peripheral to the areola 6 months post operatively thought to be due to the healing of the capsulotomies and recontracture. Recurrences were associated with cases not treated by implants, due to the lack of support offered by the prosthesis and maintenance of stretch of the capsulotomies avoiding re-contracture in addition, to widening the base of the breast; which is an inherent abnormality in those cases. (Table 8.13) The third entity were breasts showing unilateral hypertrophy and contralateral ptosis, hypoplasia or aesthetically acceptable breasts, treated by unilateral reduction and contralateral mastopexy, augmentation or not treated at all with matching the reduced side to the acceptable breast. The best results were achieved when both breasts were treated using superior pedicled techniques offering the same technique for treating both breasts and allowing a more stable long time result. Whereas, those treated by reduction on one side and augmentation on the other often require resurgery because the behavior of the two breasts are not similar at long term. (Malata and Bostwick J. III, 1999) (Table 8.14) Volumes removed from bilateral asymmetric hypertrophic breast were amounting to more than 1000gm and even upto 1500gm from each breast where as in the mixed cases of hypertrophy hypoplasia or unilateral hypertrophy the volumes removed did not surpass the 500gm indicating that in this later type of hypertrophy they do not reach huge sizes which will serve us well in symmetrizing the reduction of one side with the augmentation of the other side. (Tables 8.11 and 8.14) We start as usual by the reduction on one side then augmentation on the other side to match. Except in cases where there is a shortage of the skin envelope on the hypoplastic side accordingly we have to commence with the augmentation on that side first or insert an expander first to reach the acceptable volume followed by placement of the prothesis allowing us to match the reduction of the contralateral side to it. Other anomalies of the chest wall as Poland’s syndrome with its associated deficiency of chest musculature and bony cage deformities with an array of other similar syndromes. In these cases of course understanding the etiology and the pathology entailed in the light of the

105 CHAPTER 9 DISCUSSION AND CONCLUSION

descriptions already studied in this work, will deﬁne in each case how to deal with the deﬁciencies in the light of the available reconstructive breast procedures armamentarium. In this series cases were treated with a two staged approach were skin expansion was followed by placement of a prosthesis and contralateral reduction. (Table 8.15) Other factors of management requiring tissue transposition or custom made prosthesis for discrepancies of the chest wall are indicated in extreme cases view to possible added scars and complications as in the less sever forms where the patient is satisfied by the expansion augmentation alone. Non surgical management was not employed as hormonal treatment for all the cases came to us late or in the cases of sever tuberous breasts the breasts was encased in to a fibrous sheath and would be unable to distend further.

Conclusion

The key to successful treatment are deﬁning the nature of the breast asymmetry, respecting the patient’s aesthetic goals, and performing a well thought out surgical plan. Following are some guiding principles:

• When the patient experiences the problem as a problem this is the proper timing of operation • Reduce the larger breast first • Work on the more difficult side first • The more similar the procedures (on each breast) the more long-lasting the result in addition similar scar patterns allow for similar behavior and effect on the skin • Accept that there will be some deterioration of the result over time • In the hypertrophic group, the superior pedicle technique tailors and adapts the discrepancies with ease, while the patient in the semi-sitting position it allows for proper alignment of the inframammary folds and the N/A complex • In the hypoplastic group, bilateral implant placement with different volumes to allow both breasts to behave in a similar pattern achieving a long term symmetry • Symmetrizing procedures for the N/A complex are of utmost importance, but can be delayed until proper healing of both breasts occurred

Always referred to the equilateral triangle of Penn that is the triangle with the summit at the suprasternal notch and the sites going down from that to both nipples which is about 21cm each and the inter nipple base of the triangle also with a similar distance. This particular triangle is the real landmark on the road to symmetrization between the 2 breasts for nipples leveling, supraareolar distances and also infra areolar distances. In addition the infra mammary distance should not surpass 5 cm so reaching aesthetically pleasant breasts on a clear pattern of reconstruction. In inserting the prosthesis the inframammary crease is not lowered except in limited indications because it is easy to lower it but very difficult to relocate it in the proper position and with possibility of having asymmetries in this precious area. The nipple and areola should be in the center of the prosthesis. We have used mostly round prosthesis for the creation of the pockets was easier and expectedly no liability of having asymmetric pockets like in other types of prosthesis and no dislodgment of the upper poles of other prosthesis. In mastopexies we used a superior pedicle technique which adapts well for cases of asymmetries giving a uniform result and easy to adapt if augmentation is combined. Tight closures are to be avoided also it adapts well if a contralateral superior pedicle reduction is performed. In this way the same procedures and resulting scars would give uniformity of the results. 106

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116

Part V

Summary

117 CHAPTER 10 SUMMARY

10 Summary

Breast asymmetry presents a problem in surgical management for the discrepancy in size, volumes, shapes and contour and even the sites of differences or excess in these breasts. In addition to some associated discrepancies of breast bases on which the breasts are seated as thoracic cage abnormalities and unevenness, hence, the difficult differentiation of the breast problem which root to the origin of their etiologies which have to be understood in order to deal with the associated pathologies that cause this abnormalities. Breast asymmetry’s only hope for treatment is the surgical treatment. This study was done between April 2005 and March 2009 with the intention of choosing a specific method correction for each subtype of breast asymmetry. The study was held in Kasr Alainy hospital on 20 female patients having different types of breast asymmetry. The patients were examined and evaluated preoperatively and according to the type of breast asymmetry, a specific surgical plan was devised. The patients were then followed up in the early postoperative period for possible complications and for at least one year after surgery to check about patient satisfaction and second look surgeries. We used mastopexy, reduction and augmentation whether alone or in combination in order to correct breast results. Categorizing the patients and doing a tailored plan for each patient was the key to successful outcome. The study concluded that there is no technique is superior over the other and that there are guidelines to be followed to achieve patient satisfaction.

118 CHAPTER 10 SUMMARY

Arabic Summary

119 CHAPTER 10 SUMMARY

١٠ ﻣﻠﺨﺺ

إن ﻋﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ ﻳﺸﻜﻞ ﻣﻌﻀﻠﺔ ﻓﻲ اﻟﻌﻼج اﻟﺠﺮاﺣﻲ، ﻧﺘﻴﺠﺔ اﻟﺘﺒﺎﻳﻦ ﻓﻲ ﻗﻴﺎس و اﺣﺠﺎم و اﺷﻜﺎل و ﻣﺤﻴﻂ او ﺣﺘﻰ ﻓﻲ أﻣﺎآﻦ اﻻﺧﺘﻼﻓﺎت او اﻟﺰﻳﺎدات اوﺗﻨﺎﺳﻖ اﻟﺤﻠﻤﺘﻴﻦ ﺑﺎﻹﺿﺎﻓﺔ إﻟﻰ ﻣﺎ ﻳﺼﺎﺣﺒﻪ ﻣﻦ ﺗﺒﺎﻳﻦ ﻓﻲ ﻗﺎﻋﺪة إرﺗﻜﺎز اﻟﺜﺪي اﻟﻤﺘﻤﺜﻠﺔ ﻓﻲ ﻋﺪم اﻧﺘﻈﺎم اﻟﻘﻔﺺ اﻟﺼﺪري. و ﻣﻦ ﺛﻢ ﺻﻌﻮﺑﺔ ﺗﺼﻨﻴﻒ ﺣﺎﻻت ﻋﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ ﺑﻨﺎء ﻋﻠﻰ اﺳﺒﺎﺑﻬﺎ ﻟﻤﻌﺎﻟﺠﺔ هﺬة اﻟﻤﺸﻜﻠﺔ. و ﻳﻌﺘﺒﺮ اﻟﻌﻼج اﻟﺠﺮاﺣﻲ هﻮ اﻟﺴﺒﻴﻞ اﻻﻣﺜﻞ ﻟﻌﻼج ﺣﺎﻻت ﻋﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ. و ﻗﺪ ﺗﻤﺖ هﺬة اﻟﺪراﺳﺔ ﻓﻲ اﻟﻔﺘﺮة ﺑﻴﻦ أﺑﺮﻳﻞ ٢٠٠٥ و ﻣﺎرس ٢٠٠٩ ﺑﻘﺼﺪ إﺧﺘﻴﺎر ﻃﺮﻳﻘﺔ ﻣﻨﺎﺳﺒﺔ ﻟﺘﻌﺪﻳﻞ اﻻﻧﻮاع اﻟﻤﺨﺘﻠﻔﺔ ﻣﻦ ﺣﺎﻻت ﻋﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ و ﻗﺪ اﻗﻴﻤﺖ اﻟﺪراﺳﺔ ﻓﻲ ﻣﺴﺘﺸﻔﻰ ﻗﺼﺮ اﻟﻌﻴﻨﻲ ﻋﻠﻰ ﻋﺸﺮﻳﻦ ﺣﺎﻟﺔ ﻋﺎﻧﻴﻦ ﻣﻦ اﻻﻧﻮاع اﻟﻤﺨﺘﻠﻔﺔ ﻟﻌﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ و ﻗﺪ ﺗﻢ ﻓﺤﺺ و ﺗﻘﻴﻴﻢ اﻟﺤﺎﻻت ﻓﻲ ﻣﺤﻞ اﻟﺪراﺳﺔ ﻗﺒﻞ إﺟﺮاء اﻟﺠﺮاﺣﺔ و ﻓ ﻘ ﺎً ﻟﻨﻮع ﻋﺪم اﻟﺘﻀﺎهﻲ و ﺑ ﻨ ﺎ ءً ﻋﻠﻴﻪ ﺗﻢ وﺿﻊ ﺧﻄﺔ ﺟﺮاﺣﻴﺔ ﻟﻜﻞ ﺣﺎﻟﺔ ﻋﻠﻰ ﺣﺪﻩ و ﻗﺪ ﺗﻢ آﺬﻟﻚ ﻣﺘﺎﺑﻌﺔ اﻟﺤﺎﻻت ﻓﻲ ﻣﺤﻞ اﻟﺪراﺳﺔ ﺑﻌﺪ اﻟﺠﺮاﺣﺔ ﻋﻠﻰ اﻟﻤﺪى اﻟﻘﺼﻴﺮ ﻟﺘﺒﻴﻦ ﺣﺪوث ﻣﻀﺎﻋﻔﺎت ﻣﺤﺘﻤﻠﺔ و ﻋﻠﻰ اﻟﻤﺪى اﻟﻄﻮﻳﻞ ﻟﻤﺪة ﻋﺎم ﺑﻌﺪ اﻟﺠﺮاﺣﺔ ﻋﻠﻰ اﻻﻗﻞ ﻟﻠﺘﺄآﺪ ﻣﻦ ﻣﺪى رﺿﺎ اﻟﺤﺎﻻت و ﻹﺟﺮاء ﺟﺮاﺣﺔ ﺗﻜﻤﻴﻠﻴﺔ و ﻗﺪ ﻗﻤﻨﺎ ﺑﺎﺳﺘﺨﺪام ﺗﻘﻨﻴﺎت رﻓﻊ او ﺗﺼﻐﻴﺮ او ﺗﻜﺒﻴﺮ اﻟﺜﺪي إﻣﺎ ﻣﻨﻔﺼﻠﺔ او ﻣﺠﺘﻤﻌﺔ ﻟﺘﻌﺪﻳﻞ اﻟﻨﺘﺎﺋﺞ. و ﻗﺪ آﺎن ﺗﺼﻨﻴﻒ اﻟﺤﺎﻻت و اﺳﺘﺨﺪام ﺧﻄﺔ ﻋﻼج واﺿﺤﺔ هﻮ ﻣﻔﺘﺎح ﻋﻼج هﺬة اﻟﺪراﺳﺔ. و ﻗﺪ ﺧﻠﺼﺖ اﻟﺪراﺳﺔ إﻟﻰ اﻧﻪ ﻻ ﺗﻮﺟﺪ ﺗﻘﻨﻴﺔ ﺑﻌﻴﻨﻬﺎ ﺗﻔﻮق ﻏﻴﺮهﺎ ﻣﻦ اﻟﺘﻘﻨﻴﺎت اﻻﺧﺮى ﻟﻜﻦ و ﻻ ﺑﺪ ان ﻳﻜﻮن هﻨﺎك ﻧﻬﺞ ﻳﺘﺒﻊ ﻟﺘﺤﻘﻴﻖ اﻟﺮﺿﺎ و اﻻﻗﺘﻨﺎع ﻟﺪى اﻟﺤﺎﻻت.

120 ﻋﺪم ﺗﻀﺎهﻲ اﻟﺜﺪﻳﻴﻦ: أﻧﻮاﻋﻪ و ﺧﻴﺎرات اﻹﺻﻼح اﻟﺠﺮاﺣﻲ اﻟﻤﻨﺎﺳﺒﺔ

رﺳﺎﻟﺔ

ﻣﻘﺪﻣﺔ ﻣﻦ

د. رﺷﺎ ﻣﺤﻤﺪ ﻋﺒﺪ اﻟﻘﺎدر

ﻹﺳﺘﻜﻤﺎل درﺟﺔ اﻟﻤﺎﺟﺴﺘﻴﺮ ﻓﻲ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ

ﺗﺤﺖ إﺷﺮاف

أ. د. ﻋﻼء ﻏﻴﺘﻪ أﺳﺘﺎذ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ واﻟﺘﺠﻤﻴﻞ آﻠﻴﺔ اﻟﻄﺐ، ﺟﺎﻣﻌﺔ اﻟﻘﺎهﺮة

أ. د. ﻋﻠﻲ ﻣﻔﺘﺎح ﻋﺰﻳﺰ ﻣﻔﺘﺎح أﺳﺘﺎذ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ واﻟﺘﺠﻤﻴﻞ آﻠﻴﺔ اﻟﻄﺐ، ﺟﺎﻣﻌﺔ اﻟﻘﺎهﺮة

أ. م. د. واﺋﻞ ﻣﺤﻤﺪ اﻟﺸﺎﻋﺮ أﺳﺘﺎذ ﻣﺴﺎﻋﺪ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ و اﻟﺘﺠﻤﻴﻞ آﻠﻴﺔ اﻟﻄﺐ، ﺟﺎﻣﻌﺔ ﺑﻨﻲ ﺳﻮﻳﻒ

ﺟﺎﻣﻌﺔ اﻟﻘﺎهﺮة ٢٠٠٨