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.