Breast Augmentation Revision: Symmastia: Advanced Art of Cosmetic Surgery

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


	Breast Implant Procedures
	*Breast Augmentation Revision Surgery*
	*Correction of Symmastia or Synmastia After Augmentation*

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.
	pre-op	3 days post-op	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 t o 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.
		Prevention
		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 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