Advanced Art of Cosmetic Surgery     Thomas M. DeWire, Sr., MD, FACS    Specializing in Cosmetic Plastic Surgery     Richmond, Virginia, USA



breast implant augmentation revision repair correction complication symmatia bottoming-out thong bra         Advanced Art of Cosmetic Surgery:  Thomas M. DeWire, MD, FACS, Surgery Center and Spa,  3974 Springfield Road, Glen Allen, VA, 23260, Richmond, Virginia, USA

Breast Implant Procedures

Breast Augmentation Revision Surgery
Correction of Symmastia or Synmastia After Augmentation



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Correction of Symmastia After Augmentation

Symmastia describes the  phenomenon where the breast implants cross the  breast bone  to touch each other over the  midline  of  the  chest where the  cleavage area  would normally  be seen.  Attempts to "increase cleavage"  by releasing the  soft  tissues or medial parasternal origins of the pectoralis muscles lead to Symmastia  by  surgically disrupting  the normal  anatomical attachments of skin and muscle at the medial aspects of the breasts  where  the cleavage is  normally defined. This disruption allows the implants to gradually, or quickly, move medially, elevating the pre-sternal skin off the breast bone, joining the breasts at the midline, with destruction of cleavage.  Repair of the symmastia deformity is a complex and laborious procedure, necessitating reconstruction of the medial muscle origins and repositioning  of the  implants in  appropriate  position behind  the  nipples.  Often symmastia  deformities are accompanied by other related deformities, like bottoming-out and combined composite repair is required to correct them.  As these deformities are relatively uncommon, repair should be done by a surgeon with significant experience and a knowledge of the techniques required for successful repair. Unfortunately, many of the patients I have treated for symmastia have already had multiple failed attempts at repair, expending significant resources,  and adding much complexity to the final definitive repair.



Case 1:  A 40 year old woman who had  breast  enlargement with saline implants  partially under the muscle via crease incisions complicated by capsule  contractures and marked  Bottoming-Out.  She had failed two repair attempts by  her   original  surgeon.  A definitive   surgical repair of  the Bottoming- Out was  done and at that time Symmastia of the  upper sternal   area  was noted and repaired.   Capsule release was done to allow the Bottoming-Out   reconstruction to succeed.   Photos are seen  at 3 days,  3 mos,  and 9 mos,  during  which   time  significant symmastia  progressed  over the  sternum,   making it clear that the pectoral muscles had been released at  the  time of the  original  surgery,    but the deformity was masked by the implant capsule  contractures.  Release  of  the  capsule scar contractures,  replacement  of saline implants   with smooth silicone implants, and pocket tailoring to  correct  Bottoming-Out was followed by massage to maintain the open  pockets.  Now without  the  peri-implant capsule scars,    Symmastia became obvious  as  the pre-sternal  soft tissues lifted away from the breastbone, allowing the  kissing implant deformity.  Repair  approach is discussed  at  right. pre-op 


3 days post-op


Photos before  and  3 days after repair of Bottoming- Out and  repair of  upper sternal  Symmastia with  permanent sutures to reconstruct the proper  pocket  dimensions and elevate the abnormally low fold.  Ink  guidelines are seen on  the  photo  at  right.
 See: Bottoming Out Repair-2
3 months post-op

9 months post-op

Release  of  the  peri-implant scar capsule contractures in the Bottoming- Out repair was followed by maintenance massage to prevent capsule contracture recurrence.  This had the undesirable effect of allowing  the Symmastia to worsen,    making it  obvious that the    pectoral muscles had  been  cut  free from  the breastbone by  the  original surgeon  in an  attempt to "improve cleavage".
The Thong Bra to stabilize symmastia reconstruction


  4 months after symmastia repair


Photos show  the results of repair of Symmastia and use of the Thong Bra  to reinforce and   apply pressure  to  the area of repair.  A Thong  Bra and an   underwire bra  are  worn for 6-12 weeks  post-op to stabilize the pocket repair.  Displacement   massage  is still done in  an   upward manner to  main the proper pocket dimensions  and  to avoid the firmness otherwise seen with  peri-implant  scar encroachment.


Case 1 Problems Analysis of Cause Correction
Symmastia Symmastia results from ill-conceived or  overly aggressive  attempts to alter  chestwall  anatomy trying to increase cleavage in  thin patients.  Thin women  usually have little soft tissue  or  fat over the breast bone where the  breasts  normally gently  slope inward from   each  side  to  a  soft depth  of  cleavage over  the sternum.  If  this  soft tissue is  absent, the transition  to  the cleavage area may be rather abrupt and squared off, with a visible space between the breasts. This outcome is purely a result of the starting point anatomy, but is made  worse  by  use of larger implants in thin patients,  and  is  a problem for implants over or under  the  muscle, though  submuscular  implant placement allows the  muscle to  provide some softening  of the transition  to  the cleavage area from  the  augmented breast  mound.   Repair of Symmastia entails removal  of peri-implant  scar  overlying the breastbone, followed by  reattachment of  the subdermal fat  and skin to  the  breastbone  soft  tissues with dissolvable sutures to   prevent skin dimpling.  In the  case  of Symmastia  with implants over the muscle, the implants should be relocated to a submuscular plane  allowing the   muscle attachments to the sternum to prevent recurrence of  the medial implant migration of symmastia.  In cases of Symmastia with implants  under the muscle, repair of the rolled and cut edges of the scar from over the  breastbone  should  be done with several layers of permanent soft sutures to allow  partial  reattachment  of the muscle origins, thus  holding  the  implants lateral to the sternal edges.  Complete relief of medial pressure on the  repair must be maintained by  either expanding the implant   pockets laterally,  or by exchange for smaller implants.  The repair must  be  reinforced by external pressure with a Thong Bra garment, and usually by use of a bra.
Never release soft tissues or muscle origins along the border  of the sternum above the level of the 7th rib,  as  Symmastia  will  be  a frequent outcome,  and can  be  extremely difficult to correct.   Attainable cleavage is a matter  of anatomic starting-point  potential, and  cannot  easily  be  changed. 
         See Cleavage Determinants Page
Unnatural Shape  In very thin patients, large implants take on a very artificial pasted-on look,  as there  is little  fat  and soft tissue to soften the transition from the implant to the chest wall.  If  a constricting capsule forms directly around the implant  the  situation of a fake look is worsened, and rippling is more likely.  For thin patients  with implants over the muscle, there is even less soft tissue covering the implant, and the  result is  often even worse regarding  fake appearance  and  rippling. Avoid very large implants especially  over the muscle in thin patients.  Maintain  pocket dimensions that are considerably larger than the implant in the vertical dimension  to prevent the peri-implant scar from   defining the implant  dimensions, causing  a  fake  look.  This is especially  true  for textured implants that form a directly adherent scar around the implants, leading  to  considerable firmness, fake look, and rippling in many thin patients.  Implant Displacement  Massage is  a key element in preventing  scar  encroachment around implants, favoring a softer and more natural-appearing  result.
        See Post-Op Implant Massage Technique


Photos of a very severe symmastia deformity that I reconstructed are found at this link: 



    Symmastia Revision Photo Gallery
  Back to Augmentation Revision Page


Related  Breast Augmentation Links:   To Other photo Illustrated Procedures:

Important  Information  About  Implant  Breast  Enlargement

Trans-Axillary Breast Augmentation
Trans-Axillary Breast Incisions Scars
Breast Augmentation Shape Evolution
Breast Augmentation Shape Determination
Cleavage Determinants
Post-Op Implant Massage Technique
Implants Over versus Under the Muscle
Special Considerations in Augmentation
Breast Surgery in African American Women
Breast Augmentation FAQs
Breast Augmentation with Mastopexy or Breast Lift
Revision Surgery for Augmentation Problems
Important Information about Silicone Breast Implant Use
Nipple Reduction/Shaping
Mastopexy or Breast Lift
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Thomas M. DeWire, Sr., MD, FACS
Advanced Art of Cosmetic Surgery
3974 Springfield Road
Glen Allen, VA 23060
Richmond, Virginia, USA
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Symmastia bottoming-out breast augmentation complication revision repair reconstruction


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