Subcategories of breast asymmetry can include:
In all of these cases however our goal is to recreate a normal appearance and symmetry of the breasts. Doctors performing breast asymmetry reconstruction should be Diplomates of the American Board of Plastic Surgery, Board Certified Plastic Surgeons. This reconstruction of asymmetric breasts requires experience and judgment which takes years and years of training as well as experience during post-residency practice. We see patients commonly with breast asymmetry problems.
Example No. 1 is a patient with severe congenital breast deformity with significant asymmetry. By looking at her pre- and postop photos, it is evident preoperatively that she has a very large breast on the right which is a 36E size breast with severe Grade 3 ptosis, meaning the nipple areolar complex is greater than 3 cm below the fold. On the right she has a 36B size breast. Her reconstructive surgery included placement of a small implant only on the left breast of a 200 cc saline subpectoral through the periareolar approach, a right breast reduction using the inferior pedicle Wise-pattern technique and a left formal mastopexy.
Our second example shows asymmetry, also congenital in nature, in which the patient has developed Grade 3 ptosis on the right with a tubular breast deformity on the left. Reconstruction on the left required a simple augmentation mammoplasty procedure with a 300 cc implant on the left and 210 cc implant on the right, as well as a formal mastopexy using the inferior pedicle Wise-pattern technique on the right to lift the right breast.
Our third example shows significant breast asymmetry. The left breast is a 34B and the right 34A. The patient desired to be a small "D" and therefore a 510 cc saline implant was placed on the right in the dual plane technique with a 420 cc implant placed on the left. The patient's before and after results are shown.
Breast asymmetry for cancer reconstruction can include the use of flaps, including a TRAM (Transverse Rectus Abdominus Muscle) flap, pedicle or free flap, latissimus dorsi flap from the back with or without a silicone or saline implant as necessary.
Our goals as plastic surgeons are to create normalcy, to create proportion, not disproportion, and to allow the patients to feel good about their self-esteem. Breast asymmetry surgery is an operation similar to breast reduction surgery and leads to thankful with patients improved self-esteem for the rest of their lives.
Poland's deformity. There are three classes of Poland's deformity. Class I is considered the mild form. It is where there is hypoplasia of the breast as well as the pectoralis muscle and possibly the nipple areolar complex. There is usually a small nipple areolar complex which is elevated.
There is also absence of a sternal head of the pectoralis major muscle, which can be reduced in size.
Class II Poland's deformity is a classic form in which there is a complete absence of the sternal head of the pectoralis major muscle as well as an aplastic or hypoplastic breast as well as a small nipple areolar complex.
In the most severe form or Class III deformity, there is rib and sternal abnormality, absence of the sternocostal and sternoclavicular portions of the pec major can also be associated with hypoplastic or absence of fingers or digits.
Tubular breast deformities are seen in a significant percentage of our patients. Approximately 2% of our patients will show signs of tubular breast deformity, which will include:
This is a deformity that can be corrected. Plastic surgeons throughout the world have their own techniques on how to make a tubular breast appear to be more round. Dr. Linder's favorite result, depending upon the amount of breast tissue available, is to perform the dual plane technique if there is size "B" or smaller breast, if there is a significant amount of breast tissue and the patient has a thicker or endomorphic build with thick chest wall and thick chest muscle and hardened glandular tissue or endomorphic build, then these patients may do better with a subglandular or retromammary approach in order to round out some of the upper pole of the breast which may be flattened or refaced if the implant is placed under the muscle on these thicker chested women.
Example of Tubular Deformity
The above patients present with a tubular breast deformity, is a 34 small B breast, desires to be a full "D" and as a result, a 500 cc saline implant was placed using the dual plane technique under the muscle through a periareolar approach. Her frontal and oblique views on 15A and 15B are evident. Note, on her oblique view, the conical shape to the breast, triangular fashion with herniation of breast tissue to the nipple areolar complex, triangular-like shape breast, as in a tubular breast. Notice in her postop photo, a nice round shape to the lower pole of the breast on frontal view, there is nice upper pole fullness and her cleavage is quite good.
Case tubular breast deformity. Once again note the patient to have a very poorly defined inframammary fold, narrow shape to the lateral breast, and pseudo-herniation of breast tissue into the nipple areolar complex.
The examples will be 01A, 01B, 01C from Photo Gallery. Pectus carinatum is associated with a pigeon bowing chest deformity of the sternum in which the sternum bows outward as in a pigeon's chest deformity. The ribcage will often slope from medial to lateral. Therefore, dissection needs to be precise and careful in order to prevent intrapleural pneumothorax.
I have been able to perform subpectoral augmentation mammoplasties on these patients. Preoperative chest x-rays and CT scans are useful to identify other abnormalities of the costochondral junction sternum as well as the ribcage and chest wall itself.
Examples of Pectus Carinatum
Patients present with pectus excavatum on a regular basis to our practice in Beverly Hills.
Pectus excavatum patients can be very complicated. The deformity specifically is associated with a sternal deformity in which the sternum and sometimes the ribs and costochondral junctions and sometimes even laterally the ribs themselves, are depressed, showing a concave appearance to the sternum, which can lead to severe chest wall deformity, as well as pulmonary problems. Patients with severe pectus excavatum should seek consultation of a pulmonologist, a lung specialist, in order to determine their FEV1, total lung capacity, etc.
Implants on mild pectus excavatum can certainly be placed in the dual plane technique in order to allow for muscle coverage along the middle or medial aspect of the breast pocket. Patients with pectus excavatum that is severe, which may extend to the lateral chest wall, may do better with a subglandular or retromammary approach in order to fill in the upper pole depression, as well as to prevent pneumothorax or intrapleural spaced dissection, which can be quite dangerous.
Our example of pectus excavatum shows the patient who underwent an augmentation mammoplasty procedure with breast revision because of her absence of cleavage. As a result, the patient underwent removal and replacement with high profile silicone gel implants, medial open capsulectomy on the right only with shifting of the implant to the midline. Her after photo shows a nice camouflage of this pectus excavatum by displacing the implant on the right towards the midline.
Patients do arrive with nipple hypertrophy. They have desires to have the nipples made smaller. They can show signs of emaciation, excoriation and rashes from the nipple hypertrophy. Functionally, this can be great to reduce the size of the nipples in order to allow for a cessation of the patient's symptoms. In any case, nipples can be reduced by doing multiple different operations. Dr. Linder performs a superior pedicle flap with resection of the inferior portion of the nipple from the 3 o'clock to the 9 o'clock position in a wedge resection and then a superior flap is brought down inferiorly and sutured into place with simple 5-0 Prolene sutures which are maintained for at least 20 days.
The before and after results show a typical example of a nipple reduction procedure. Interestingly, the first example, Example 1, is the patient six months out of surgery and the second example is the patient two years out of surgery, who is now pregnant with engorgement of her breasts. The nipple reduction procedure is useful with augmentation mammoplasty when performed concurrently.