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Developmental Breast Asymmetry ORIGINAL ARTICLE Developmental Breast Asymmetry WoanYi Chan, MSc, MRCS, MEd, Bhagwat Mathur, MCh (Plast), FACS, Diana Slade-Sharman, BSc (Hons), MSc , and Venkat Ramakrishnan, MS, FRACS St Andrew’s Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, Essex, UK n Abstract: Developmental breast asymmetry (DBA) can affect psychosocial well-being in the young female. Correction of breast asymmetry may present a reconstructive challenge, especially in tuberous breasts. Fifty-two cases of DBA treated between January 2002 and January 2006 were reviewed. Preoperative clinical assessment of the specific anatomical defor- mity, subsequent surgical treatment modalities, esthetic outcome, and patient’s satisfaction were evaluated. Surgical modal- ities used in our series include augmentation mammaplasty with or without tissue expansion, parenchymal scoring, nipple areola complex reduction, glanduloplasty techniques, mastopexy and reduction mammaplasty. The mean age of DBA pre- sentation was 21 years; 69% (36 ⁄ 52) patients had tuberous breasts, of which 67% (24 ⁄ 36) were unilateral and 33% (12 ⁄ 36) were bilateral deformities. Patients with tuberous breast deformity presented consistently under the age of 25 years. Esthetic outcome was rated ‘‘good’’ in 75% (39 ⁄ 52), and symmetry rated as ‘‘good’’ in 58% (30 ⁄ 52) by professional evalua- tion. Surgical treatment is tailored to the affected esthetic units of the individual breast. In our experience, symmetry is the hardest parameter to achieve, particularly in tuberous breasts. Operative treatment is of great value to the psychosocial well-being of the patient. A conceptual approach in the assessment and treatment of DBA is emphasized by this series. n Key Words: breast asymmetry, breast development, congenital breast anomalies, congenital breast deformity, tuberous breast he female breast is an important symbol of femi- asymmetries cases was carried out. The aim was to Tninity. Socio-cultural influences motivate individu- analyse the clinical patterns of DBA and the precise als to seek surgical intervention for ‘‘imperfections’’ of anatomical deformity associated with breast asymme- the breasts (1,2). Although some degree of breast try. The surgical modalities used to treat the various asymmetry is almost universal, developmental breast group of DBA were assessed by esthetic outcome and asymmetry (DBA) has a significant psychosocial effect. patient satisfaction. Breast shape, volume, size, location and shape of the nipple areola complex (NAC) affect overall breast esthetics. Correction of breast asymmetries, especially MATERIALS AND METHODS in tuberous breasts, may present a reconstructive chal- Records of all patients referred with breast asym- lenge for the surgeon. This is reflected in the plethora metry under the care of the senior author from Janu- of techniques described in the literature for treatment ary 2002 to January 2006 were reviewed for this of these deformities. These include augmentation study. Patients with breast asymmetry resulting from with or without tissue expansion, NAC reduction, trauma, burns, neoplasia, severe chest wall deformities parenchymal scoring, and a variety of glanduloplasty and involutional hypoplasia were excluded. Other techniques. (3–27) Careful assessment and an individ- exclusion criteria included cases with incomplete ualized surgical treatment plan are required for each records and patients who did not proceed to surgery case. A retrospective review of developmental breast (because of NHS funding issues or pregnancy). A total of 52 patients with DBA were suitable for Address correspondence and reprint requests to: WoanYi Chan, MSc, our review. A number of classifications of breast MRCS, MEd, St Andrew’s Centre for Plastic Surgery & Burns, Broomfield asymmetry have been described (28–38). The von Hospital, Court Road, Chelmsford, Essex, CM1 7ET, United Kingdom, or e-mail: [email protected] Heimburg et al. classification of tuberous breast (33) was used for the purposes of this study. The postoper- DOI: 10.1111/j.1524-4741.2011.01104.x ative parameters (size, shape, symmetry, NAC, scars, Ó 2011 Wiley Periodicals, Inc., 1075-122X/11 The Breast Journal, Volume 17 Number 4, 2011 391–398 and overall) assessed were graded as poor, fair, good, 392 • chan et al. or very good. Two evaluators (a plastic surgery trainee RESULTS and a plastic surgery staff nurse) assessed the patient’s A total of 88 breasts in 52 patients underwent sur- esthetic outcome in clinic. A further two evaluators (a gery. The mean age was 21 years (range 15–34 years); breast reconstruction nurse and a surgical care practi- 79% (41 ⁄ 52) of the patients were under the age of tioner) assessed six standard view pre- and post-opera- 25 years; 27% (14 ⁄ 52) were under 18 years. tive photographs. The operating surgeons were There were no common combinations of breast excluded from performing the postoperative evalua- deformity in this series. Significant tuberous breast tion. Satisfaction questionnaires were completed by deformity was present in 69% (36 ⁄ 52) of the patients, patients in the outpatient setting. of which 33% (12 ⁄ 36) of cases had bilateral tuberous Operative procedures were performed by the same breasts; 50% (44 ⁄ 88) of operated breasts had tuber- surgeon or under supervision of the senior author. ous deformity. Patients with tuberous breast deformity Seven types of surgical treatment modalities in various presented consistently under the age of 25 years. Sev- combinations were used: augmentation with subglan- enteen percent (9 ⁄ 52) had hypoplastic breasts, either dular implants alone, augmentation with tissue expan- unilateral or bilateral with differential sizes; 13% der followed by replacement prosthesis, reduction (7 ⁄ 52) patients had unilateral hyperplastic breasts. mammaplasty and mastopexy. All implants were placed subglandular to achieve good projection of the Objective Asymmetry breast and symmetry in all breast quadrants. In Volume Difference selected cases parenchymal scoring, areolar complex Objective asymmetry defined by bra size showed a reduction (‘‘donut procedure’’), and glanduloplasty difference of two to four cup sizes with two bra cup were performed. sizes being the most frequent. A mean augmentation Parenchymal scoring of glandular tissue was per- volume of 250 mL (range 95–410 mL) and a mean formed by sharp dissection in radial fashion to release reduction mammaplasty weight of 319 g (range 189– the constricted fibrous areas. Severe nipple areolar 691 g) were observed. herniation was corrected by donut excision of areolar skin. Positional Differences Glanduloplasty was performed by Wise pattern skin Metric measurements of SN-N discrepancy between incision and medial transposition of the lateral breast the breasts ranged from 1 to 12 cm (mean 3.8 cm) pillar. preoperatively and 0–1 cm (mean 0.7 cm) postopera- Of all the patients, 60% (31 ⁄ 52) were able to come tively. Although there was no statistical significant to the clinic for full evaluation. For the remaining correlation between objective metric asymmetry and 40% (21 ⁄ 52) patients, photographic assessments were esthetic outcome, the improvement in SN-N discrep- performed by two independent evaluators. ancy postoperatively was reflected in patients’ satisfac- Individual breasts were assessed for glandular vol- tion. The entire infra-mammary fold (from medial to ume, base constriction and skin deficit, level of infra- lateral) was elevated by 2–5 cm in 92% (33 ⁄ 36) of mammary fold (IMF), degree of ptosis, NAC size and tuberous breast patients; 8% (3 ⁄ 36) of patients had a herniation. Criteria for tuberous deformity were based medial raised IMF. on features described in literature: lower quadrant hypoplasia (medial, lateral, or entire), subareolar skin Treatment of Types of Deformity deficiency resulting in elevated IMF, breast base con- Seven types of deformity were found in our group striction, large NAC and breast parenchyma hernia- of patients, including tuberous breasts using the von tion (11,32–34). Heimburg (33) classification [Table 1]. Measurements of pre-and post-operative sternal Hypoplastic breasts were essentially treated with notch to nipple (SN-N) distance, NAC to IMF dis- subglandular implants alone; 13% (2 ⁄ 16) patients had tance and areola diameter were performed. Bra cup tissue expansion followed by replacement implant. size differences, augmentation volumes, and resected Tuberous type 1 breasts were treated with implants, tissue weights were also recorded. Postoperative com- mastopexy or glanduloplasty depending on glandular plications including pain and altered nipple sensation volume. Parenchymal scoring was required in selective were noted. Descriptive statistics were obtained using cases of inferomedial quadrant deficiency; 27% (4 ⁄ 15) SPSS and Sfinx Survey Plus (2). patients with type 1 tuberous breasts had no surgery Developmental Breast Asymmetry • 393 Table 1. Types of Deformity of Operated Breasts NAC. Hyperplastic breasts were corrected with Wise pattern inferior pedicle reduction mammaplasty. Number of operated breasts Hypoplasia 16 Esthetic Outcome Hyperplasia 13 Patients Ptosis 15 Tuberous type I 11 Clinical evaluation took place at a mean of 2 years Tuberous type II 14 postoperatively (range 6–53 months). Of all the Tuberous type III 8 Tuberous type IV 11 patients, 60% (31 ⁄ 52) completed a satisfaction ques- Total operated breasts 88 tionnaire and were also clinically assessed in the same clinic. These patients represented the range of breast deformities,
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