Synmastia: Prevention and Correction

Congenital and Acquired Symmastia: Experience from 100 Cases Treated

BACKGROUND

Symmastia, first defined by Spence et al. in 1984, is a medical condition characterized by the convergence of breast tissues in the midline, resulting in the absence of adhesion between the skin and subcutaneous tissue over the presternal area. It can be either congenital or acquired. Currently, there is no universally accepted treatment for symmastia. This study presents a surgical approach and preoperative and postoperative care for the correction of symmastia.

METHODS

Between January of 2014 and December of 2020, a surgical technique was performed on 100 patients, including 59 with congenital symmastia and 41 with acquired symmastia. The technique involved creating a thin skin flap and attaching it to the sternum to reconstruct the intermammary V-shaped region.

RESULTS

All patients in both groups underwent subglandular implant placement, with textured/polyurethane prostheses used in 97% of cases. Three cases did not use any implants. In the corrective surgery, patients received smaller, round implants, following the steps of the surgical approach devised by the author. The median satisfaction scores were high in both groups.

CONCLUSIONS

The surgical approach described in this study is a safe, one-time procedure with a low risk of complications and high patient satisfaction. The technique is reproducible and provides consistent outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Acquired Symmastia: Classification, Causes, and Repair Strategy

BACKGROUND

Acquired symmastia is a rare complication after breast augmentation that is difficult to fix.

METHODS

The medical records of 18 female patients with symmastia treated by our team were reviewed. Data collected included preoperative medical history, implant size, and breast base width. Surgical techniques were systematically reviewed and analyzed based on postoperative follow-up results.

RESULTS

Of the 18 patients, 15 patients had undergone implanted breast augmentation and 3 had injected breast augmentation. All 18 patients underwent comprehensive repair with various surgical techniques. Three patients showed recurrence after operation. Four patients were dissatisfied with postoperative breast size and underwent 2-stage replacement surgery.

CONCLUSIONS

Symmastia is an intractable surgical complication. Surgical classification can help assess the difficulty of surgery in advance, and the surgical strategy plan can help the surgeon to control the quality of the repair surgery.

Congenital Symmastia: A Comprehensive Review and Proposed Treatment Algorithm

ABSTRACT

Congenital symmastia is a relatively uncommon condition and poorly described in the literature. Although numerous studies have evaluated iatrogenic symmastia including its prevention and treatment, considerably less has been studied with regard to congenital symmastia. In this review, the authors seek to consolidate the literature published thus far and provide techniques and principles of management that may guide surgeons treating patients with this condition.

The Nomenclature, Terminology and Lexicon of Breast Surgery: Are We Really Saying the Same Thing?

This study investigated inconsistencies in the use of descriptors in breast surgery and recommends a novel nomenclature that will be adopted and standardized among plastic surgeons. The study used a modified Delphi methodology to first identify redundant descriptors or those with multiple interpretations, and then achieve consensus on ideal recommended nomenclature in breast surgery. The Delphi panel agreed that there was misuse of and lack of a clear definition for several terms, and recommended removal of these subjective terms. Replacement with more anatomic nomenclature was suggested. Stretch deformity, pectoral banding, and implant-gland mismatch were introduced as new terms.

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications

BACKGROUND

The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care.

OBJECTIVE

This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications.

RESULTS

In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases.

CONCLUSION

Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Iatrogenic Symmastia: Causes and Suggested Repair Technique

BACKGROUND

Various theories exist to explain the etiology of iatrogenic symmastia. Subglandular over-dissection of the medial breast pocket over the sternum, disruption of midline sternal fascia, oversized implant base diameter, and over-dissection of the medial pectoralis muscle attachments to the sternum are popular explanations.

OBJECTIVES

The authors hypothesized that the most common risk factor for iatrogenic symmastia is subpectoral breast augmentation.

METHODS

A retrospective chart review was conducted including all symmastia patients who underwent surgery from January 2008 to April 2018 by a single surgeon (C.L.M.). ASAPS members were also surveyed regarding the etiology and incidence of symmastia in their practice.

RESULTS

Twenty-three patients with symmastia were included in the retrospective chart review. All had previous subpectoral breast augmentation. In the ASAPS survey, 91 plastic surgeons reported seeing an average of 2.2 consults for acquired symmastia over the preceding year; 1.9 of the 2.2 (84.9%) acquired symmastia consults previously underwent subpectoral breast augmentation. Most surgeons attributed these patients' symmastia to over-dissection of the medial pectoralis muscle attachments to the sternum.

CONCLUSIONS

Symmastia is most often caused by pectoralis major sternal dehiscence during subpectoral breast augmentation. In the senior author's experience, all patients with iatrogenic symmastia previously had a submuscular breast augmentation. The ASAPS survey supports multiple causes for symmastia with retromuscular breast augmentation occurring in the majority of patients. Repair of symmastia should include securing Scarpa's fascia to the sternum, reattaching the pectoralis major to the sternum, avoiding another subpectoral implant, and using postoperative modalities to protect the repair.

LEVEL OF EVIDENCE: 4

Contralateral Augmentation with a Transmidline Scarless Technique During Unilateral Breast Reconstruction Using Implants

BACKGROUND

Unilateral breast reconstruction can be a challenge when attempting to achieve an aesthetically pleasing and symmetrical breast mound on the contralateral side. This study investigates the outcomes of using a contralateral augmentation transmidline scarless (CATS) technique to simultaneously augment the contralateral breast using implants.

METHODS

Between January 2004 and July 2016, patients undergoing unilateral implant-based breast reconstruction and simultaneous contralateral implant augmentation using a transmidline access were studied. Characteristics and complications using this technique were assessed.

RESULTS

Sixty-five (91.5%) of 71 patients used the CATS technique for unilateral breast reconstruction using implants with contralateral breast implant augmentation. The remaining 6 cases used a preexisting chest scar. In the assessment of complication rates between the reconstructed and augmented sides, the reconstructed side had a statistically significant higher rate of implant exposure (P = 0.04) and total complications (P = 0.02). In comparing the revision rates between these 2 groups, the need for implant change (P = 0.04) and the total revision rates (P = 0.01) were higher in the reconstructive side. Use of saline implants had a higher rate of chest wall and breast skin necrosis (P = 0.03) in comparison with silicone implants. There was not a statistically significant difference in complications when comparing timing of reconstructions (immediate versus delayed).

CONCLUSIONS

The CATS technique can be performed safely, with a desirable aesthetic outcome, and also symmetry with minimal risk of symmastia during unilateral breast reconstruction using implant-based reconstruction.

A Muscular Etiology for Medial Implant Malposition Following Subpectoral Augmentation

BACKGROUND

Implant malposition is becoming an increasingly recognized complication following subpectoral breast augmentation. Although several causes of medial malposition have been previously demonstrated, medial implant malposition secondary to unintended pectoralis muscle slips has not been previously described.

OBJECTIVE

The goal of this study is to describe a form of medial implant malposition caused by pectoralis major and minor musculature vectors on the implant.

METHODS

The primary investigator performed a retrospective review of all patients who underwent revisional breast surgery for the diagnosis of symmastia or medial implant malposition following subpectoral augmentation. Those patients with muscular-type etiology for medial implant malposition were identified.

RESULTS

Five patients with pectoralis muscle slips causing medial implant malposition were identified. The pectoralis muscle slips were successfully diagnosed on preoperative exam and corrected with specific surgical procedures aimed at balancing surrounding forces and thus correcting malposition.

CONCLUSIONS

Pectoralis muscle slips contributing to medial malposition can be found in some patients after subpectoral breast augmentation. The etiology of this deformity is unknown, but theorized to be caused by anatomic predisposition, with slips inadvertently formed during subpectoral pocket formation arising from the pectoralis minor and/or incompletely released or accessory pectoralis major muscles.

Five-step Correction of Congenital Symmastia

Congenital symmastia is distressing and difficult to treat, and traditional surgical modalities have met with limited success. We present a novel approach for a patient that failed all traditional surgical options. The anatomic deformity is analyzed using a modified version of Blondeel’s 3-step analysis (conus, footprint, and skin envelope, to which we added a fourth element “intermammary web”). Combining operative principles from breast cancer reconstruction, we describe 5 operative steps that help correct the deformity, followed by a new postoperative splinting regimen that addresses the common pitfalls that could lead to recurrence.