Breast Asymmetries

Published on 09/05/2015 by admin

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CHAPTER 36 Breast Asymmetries

Craig Rubinstein

Summary/Key Points

1. Significant breast size asymmetry is usually obvious: however less obvious asymmetries to consider include those of shape, position and the nipple itself.
2. Breast asymmetry is common, may be very distressing and all components should be carefully assessed prior to any breast surgery.
3. Breast asymmetries are often complex; there are rarely optimal simple solutions and most corrections involve a number of surgical techniques and compromises.
4. Careful surgical planning requires appreciation of all of the asymmetries as correcting one asymmetry may exacerbate other asymmetries.
5. Correction of breast asymmetry may require more than one surgery, either as staged procedures or because both breasts may change differently with time.

Patient Selection

Breast asymmetry includes differences of size, shape and position between the breasts and nipples. More specifically breast asymmetry may also include differences in: degree of ptosis, the levels of the inframammary creases, the nipple heights on the chest wall, the nipple positions laterally from the midline and the nipple positions on the breasts. Poland’s syndrome may also present as breast asymmetry and should be considered.

Nearly all breasts are at least slightly asymmetric but usually not symptomatic. Severe breast asymmetry is less common but often distressing to the patient and may be socially inhibiting. One criterion of severity is its effect on the patient and this may be reflected in a strong desire for surgical correction. Severity of asymmetry is subjective. Inappropriate emotional overtones to what is objectively a mild problem may be a warning sign of unrealistic expectations. Further surgical or psychological assessment may be needed prior to any surgical correction.

Breast size asymmetry may be the most apparent asymmetry and the principles of breast asymmetry correction may seem simple if one breast is already satisfactory. The larger breast may be reduced or the smaller enlarged. When both breasts are too big, both may be reduced removing more from the larger side. When both breasts are too small, augmentation may be bilateral but with a larger implant on the smaller side. Breast size and other asymmetries are interdependent and changing one may significantly change others. Correcting breast size asymmetry may not be appreciated by the patient if it causes or exacerbates another previously unrecognized asymmetry. For example, simply placing a larger implant in a smaller breast to match the other breast size may also change the shape of the breast causing an unacceptable shape asymmetry. It is important to appreciate all of the patient’s asymmetries. It is important to appreciate how corrections of asymmetries interact with each other and to fully explain this to the patient. To obtain the best results in correcting breast asymmetry requires understanding of the patient’s wishes and their anatomy, all of the asymmetries and planning surgery accordingly.

When breast asymmetry is mild it may seem to be of minimal consequence but still needs consideration. An unappreciated asymmetry prior to routine breast reduction or breast augmentation may become significant after surgery. The patient may even feel the surgery caused the asymmetry. It is far better to advise and discuss asymmetry prior to surgery than try to explain a previously unrecognized but now apparent asymmetry afterwards.

Chest wall asymmetries and postural asymmetries including shoulder height asymmetry, leg length discrepancies and scoliosis, may all give the appearance of asymmetry – a breast pseudo-asymmetry. Significantly they may also exacerbate or mask a real anatomical breast asymmetry. To the patient, the cause of the asymmetry is less important than that the breasts still seem to be different and need to be corrected. Augmenting the breast on the side of the chest wall deficit or using any of the other surgical strategies for the correction of a breast size asymmetry may still be appropriate.

During consultation the opening questions should elucidate the patient’s concerns and goals. The patient may even tell you what specific surgical procedures they want. This may be based on other patients, other doctors, the internet or numerous other sources, some of which may not be appropriate. A realistic management plan requires a careful comprehensive examination. Each breast should be assessed including its size, shape, position, and nipple. The examination should then include the upper limbs, shoulders, chest, breasts and general posture. It is also important to explain to the patient all of the clinical findings; including quite likely a number of asymmetries and to put them into perspective.

Nipple height asymmetry may not be mentioned or even realized by the patient before surgery. Compared to the size asymmetry, prior to surgery it may have seemed unimportant or may not have been apparent. After surgery, the patient is likely to reassess her breasts more comprehensively and more critically. A relatively minor nipple asymmetry prior to surgery may be more obvious in breasts that are now of similar size. Also, both breasts are now larger and more likely to draw critical attention making a previously unappreciated nipple height asymmetry more apparent. In addition, the surgery itself may have significantly exacerbated the actual nipple height asymmetry.

Breast shape asymmetries may be subtler than breast size asymmetries or nipple height discrepancy but should not be underestimated. It is significant that the most common concern of patients after surgery seems to be their cleavage. To a certain extent breast size and nipple height asymmetries can be masked with clothing or padding. Asymmetries of cleavage seem to be just as distressing but more obvious in certain activities and more difficult to hide.

Consideration of breast ptosis is important in the management of breast asymmetry for a number of reasons. One breast may simply be more ptotic than the other and diagnosing and treating this may be all that need be corrected. Some surgeries, such as placing asymmetric implants may exacerbate a pre-existing ptosis asymmetry. Severe ptosis may contraindicate certain surgical options such as breast augmentation without mastopexy where an aesthetically poor result is likely. Post-operatively after breast augmentation it may be important to emphasize how important it is to wear an appropriately supportive bra to prevent ptosis in now larger and heavier breasts.

Iatrogenic breast asymmetries may be the result of asymmetric surgical technique. The asymmetric surgery may be deliberate such as with asymmetric liposuction to correct a size asymmetry which may inadvertently create a shape asymmetry. Asymmetric surgical technique itself may also be inadvertent and less obvious, such as when one surgeon is not performing all of the surgery on both sides. No two breasts are ever perfectly the same and no two surgeries can ever be identical.

In the pursuit of perfection should local anesthesia be injected into both breasts together at the start of the operation with surgery not commencing on the second side for possibly an hour, or should the local anesthesia be injected into the second breast possibly an hour later just prior to its surgery? Will for example a right-handed surgeon perform slightly different surgeries on a right compared to a left breast? It is possible to obsess over probably trivial influences but where many cumulative factors are not appreciated, understood or even considered, adverse outcomes become more likely.

Digital photography is very useful in demonstrating, assessing and documenting breast asymmetry; it is worthwhile printing two sets of photographs and giving one set to the patient. Asymmetries that may have seemed less significant or even been overlooked at initial assessment may be obvious in the photograph. Some patients do not immediately realize that they are looking at themselves and may even be a little shocked at what they see. It is far better they be shocked before surgery than after. In addition, lines drawn on digital photographs can be used to clearly demonstrate certain asymmetries such as nipple height asymmetry. Parallel lines can demonstrate anatomical relationships such as postural asymmetries, chest wall asymmetries and scoliosis. Comprehensive photography is also invaluable for the medical records and a helpful reference during surgery.

For breast reductions with significant asymmetry a water displacement test provides estimation of breast volume asymmetries. Patients are instructed to place a taller narrower bowl inside a shorter wider bowl and fill the taller bowl to the brim with warm water. The patient then slowly lowers one breast into the water, removes her breast from the water and measures the overflow or measures exactly what volume of water in cc is required to refill the water to the top. This volume is documented then the process repeated for the other breast, further alternating till both breasts have each been measured ten times. For each side the ten volumes are averaged, omitting any obviously incorrect measurements. The results are a guideline but as long as taken in context with other clinical assessments often quite useful. Significant secondary benefits include involving the patient in their own assessment and also demonstrating to the patient how hard it is to accurately measure volume asymmetries.

Magnetic resonance imaging (MRI) is an evolving technique in the preoperative determination of breast volume asymmetry. Accuracy is dependent on correctly defining the breast base and thus measuring the entire breast without including surrounding non-breast tissue. Reliability is likely enhanced with good communication and cooperation with the radiologist. Marking the breast bases together, at least for the first few patients and having the same radiologist on each occasion is highly advantageous. MRI may also be useful in assessing other breast and chest anatomical abnormalities or asymmetries and is a sensitive preoperative screening test for breast cancer. It is also quite good at determining breast tissue composition to determine if there is enough fat that liposuction is physically feasible. Alternately, if the breast is predominately densely glandular, liposuction of sufficient fat may not be an option. Prior to secondary surgery after previous breast implantation MRI also seems to be more reliable than mammography and ultrasound in assessing existing breast implants. It is reliable in demonstrating the implants position on the anterior chest wall, relationship to pectoralis major, type and style. It may demonstrate evidence of rupture or deflation, silicone leakage and capsule integrity and is even reasonably accurate in measuring the volume of the implant. MRI seems to provide more information than ultrasound and unlike mammography there is no painful and potentially traumatic compression of the breast and no radiation.

It is worth emphasizing that all techniques of preoperatively assessing breast volumes are guidelines. The ultimate decisions are still made intraoperatively by carefully and frequently comparing one side with the other. Comparing section by section or quadrant by quadrant is helpful as is stepping right back and examining both breasts from a distance. In addition to examining the breasts from several angles with the patient supine it is critical to repeat this with the patient sitting up.

Timing of surgical correction for breast asymmetry including the minimal age of the patient at which surgery is optimal depends on many factors. It is desirable for a patient to be old enough to provide legal consent. If below this age, parents or legal guardians must provide consent prior to surgery. Optimally both physical and psychological maturity should have been attained in a sensible patient who is stable, both physically and psychologically. When a patient is immature, but distressed, the consequences of not operating in terms of psychological deterioration need consideration. Even where the breasts are still developing it may still be better to perform surgical correction at a younger age with the anticipation that further surgeries may be required.

Surgery may be deferred for other reasons. Patients should never be rushed, it takes time for a patient to become well informed and form realistic goals and expectations. The patient should be medically fit and keen to proceed. Sometimes it is better for a patient to wait and one common reason may be a patient who smokes. Smoking is a serious concern and a relative contraindication to surgery. In breast reduction, smoking with its adverse effects on tissue oxygenation, increases complications including wound break down, skin and nipple necrosis and infection. In breast augmentation it may also increase capsule formation. Smoking also thins the dermis increasing breast implant palpability, possibility of exposure and generally accelerates ptosis. The significant secondary consideration is that where a patient is unable to stop smoking, despite being advised how important it is, their motivation to have the surgery must be questioned. Alternately where a patient gives up smoking to have surgery there is likely to be significantly better motivation and likely better postoperative compliance.

The surgical correction of breast asymmetry is challenging enough. Optimal correction is much more likely with a well prepared surgeon performing a well prepared surgical plan on a well prepared patient.

Indications

In the correction of breast asymmetry, where a breast is too small it may be augmented. Where a breast is too big it may be reduced by liposuction alone, formal surgical breast reduction or a combination of the two. Where a breast is ptotic or the nipple too low, mastopexy may be appropriate. All of these procedures may be performed unilaterally, bilaterally, in combination, or as staged procedures.

When there is a mild to moderate breast size asymmetry the dilemma may be whether to reduce the larger or to augment the smaller. While it is important to take into consideration patient’s requests, there are other anatomical considerations. For example, in a bid ‘to avoid surgery’ a young patient in this situation may request liposuction of the larger breast. In a young patient where the breast is predominantly glandular, this may not be feasible. Augmentation of the smaller breast has significantly less scarring than surgical breast reduction but may compromise breast shape symmetry. Surgical reduction of the larger breast will likely result in better breast shape symmetry but with significantly more scarring. In determining the surgical plan there are numerous factors to be considered including the anticipated size change, skin elasticity, whether the breast is also ptotic, scar tendency and the patient’s attitudes to scars. An absolute intolerance of scars is very unusual in a well-informed patient, but if a patient refuses any scar, surgery may just not be an option. Patients are more likely to make the best decisions when they understand the advantages and limitations of each of their options.

Where at least one breast is too small, correction of breast asymmetry with breast implants in its simplest form may be the placement of a unilateral implant to make up a size deficiency. This is likely to give two very different breasts, as usually the smaller breast is less ptotic and the nipple height higher. A unilateral implant will further elevate the nipple exacerbating this appearance. Where breast asymmetry is mild to moderate (generally less than 90–120 cc), bilateral asymmetric implants may be more appropriate. The range of breast implants is also becoming more sophisticated. Until several years ago, correcting breast asymmetry with breast augmentation usually involved simply placing implants of different sizes. Now there is an almost overwhelming choice of implants with different base diameters, projections, and even shapes, that can be carefully selected for a specific asymmetry. For example, where both breasts have a similar base diameter but the volumetric difference is predominately due to difference in projection correction may employ implants with similar base diameters but different sizes due to different projections (i.e., mix and matching low, medium, and high profile implants).

It is sometimes possible to effectively correct a relatively mild size asymmetry with symmetric implants, which by increasing the size of each side decreases the relative difference between the two breasts. To understand this mathematically, a 200 cc breast is 100 cc bigger than a 100 cc breast but 200/100 cc = 2× bigger or a 100% difference. If both breasts receive 400 cc implants there is still a 100 cc difference, but now the larger is 200 + 400 cc = 600 cc the smaller is 100 + 400 cc = 500 cc and 600/500 cc = 1.2× bigger or a 20% difference. Unfortunately while theoretically valid, in practice the result may not be satisfactory. Small asymmetric breasts may not be very noticeable but when both are made significantly larger, even though there is less relative difference, as the breasts themselves become more obvious the perceived asymmetry becomes more obvious. With larger breasts this asymmetry may be more distressing and is harder for the patient to mask or hide with padding or loose clothing.

Where the asymmetry is more severe (generally greater than 90–120 cc), asymmetric implants alone may not be appropriate due to exacerbation of other asymmetries and may require additional surgical procedures. A better option may be to commence by reducing the larger breast asymmetry with liposuction or surgery. Depending on the degree of correction achieved, the implants inserted may then be symmetric or more similar in size and shape compared to if the reduction had not been performed. The advantages include better symmetry that is more likely to remain symmetrical with time. This is because the breasts are genuinely more similar with symmetric breast sizes and symmetric implants as opposed to where the apparent symmetric breast size was achieved by placing different sized implants in different-sized breasts. Another strategy is to correct half the breast size asymmetry where possible with liposuction, the other half with less asymmetric implants. It will be interesting in the long term to see which of these strategies maintains the best symmetry.

Where the nipples are already at a different height to each other prior to surgery this needs to be carefully considered. In addition to the different degrees of nipple elevation from different implants, the position of the implant will have an effect. The lower the implant the greater the nipple elevation, the higher the implant, the lower the nipple. This may be important for example in correcting two breasts of different height (i.e., different heights of the breast bases on the anterior chest wall), where placing the implants at the same height as each other may exacerbate nipple height asymmetry.

Where there is asymmetry in the lateral positioning of the nipples, placing symmetric implants equidistant from the sternal midline may result in breast shape and nipple height asymmetry. This is because each nipple may be in front of a different part of the horizontal curve of the implant with consequently different projections. Centering each implant behind the nipple may avoid breast shape and nipple height asymmetries but one breast will then be more laterally displaced resulting in another type of asymmetry.

Where a breast is too big, liposuction may promise negligible scarring, rapid recovery and the ability to ‘avoid surgery.’ Nonetheless, liposuction is a surgical procedure, should not be trivialized, and has significant limitations. Its first limitation is in the glandular breast where there may not be enough fat amenable to liposuction. Its second, very significant limitation, is that by reducing the breast volume without reducing the skin envelope it may cause or exacerbate ptosis.

Ptosis of the breast is largely determined by the relationship between the relative excess in surface area of the skin envelope and the relative deficiency in volume of the breast filling. It is of relevance to liposuction that breast volume is a cubed function (x3) as opposed to skin surface area, which is a squared function (x2). This means that changing breast volume has a lesser effect on changing skin surface area than if they were directly proportional. The math may not be intuitive but its consequences apparent by considering a rubber balloon. Analogous to liposuction, the balloon being deflated loses a larger volume of air compared to a relatively smaller decrease in its surface area. This decrease in surface area does become more significant the greater the volume of reduction and the less elastic the balloon or (of relevance here) the breast skin. The more the balloon is deflated, the more it wrinkles. The practical application is that where the volume of liposuction is conservative, liposuction alone may be appropriate. Large volume liposuction by itself will likely be complicated by skin wrinkling and ptosis.

In the less common case where the larger breast is less ptotic than the contralateral smaller breast, liposuction of the larger breast may correct both the size and nipple height asymmetries. Anticipating the volume of liposuction required to correct nipple height asymmetry would be very difficult. The most likely scenario would therefore be to correct the size asymmetry then once settled, if indicated, surgically revise the nipple positions.

Liposuction, while generally expected to exacerbate ptosis, occasionally may help correct it. Conservative liposuction of a mildly larger and slightly more ptotic breast with good skin elasticity may paradoxically correct the ptosis of the larger breast. The mechanism of this correction is likely due to the good skin elasticity acting on the reduced weight of the breast tightening up the breast skin envelope and elevating the nipple. More severe ptosis may be due to inelastic skin and/or excessive breast size and formal surgical reduction would then likely be indicated.

Breast reductions are defined by the pattern of excision, the vascular pedicle or eponymously. One excellent option for all breast sizes (up to 3 kg reduction per breast to date) is breast reduction using a Lejour type pattern with a superior pedicle, in combination with liposuction. With this technique there are reductions in surgical time and scarring and improvements in long-term shape over Wise pattern inferior pedicle techniques. This technique is certainly not perfect. It has a steep learning curve. Good definitive results are often not apparent for months and there is a high rate of generally fairly minor revisions. These concerns are usually greater for the surgeon than the patient and are usually well tolerated after good preoperative education.

Mastopexy is indicated for breast ptosis and as for breast reduction there are similar variations. Unilateral mastopexy may correct nipple height asymmetry where only one breast is ptotic. Asymmetric bilateral ptosis may require bilateral mastopexies but a more ptotic breast is also likely to be larger and therefore require a small reduction in addition to the mastopexy. Alternately, after unilateral breast reduction is performed to correct a size asymmetry, a contralateral mastopexy may be needed to maintain nipple height and breast shape symmetry.

Mastopexy–augmentation is the combination of mastopexy and breast augmentation and may be used to correct asymmetry where one or both of the breasts are ptotic and small. It is significantly more difficult and has a higher rate of complications than may be anticipated from the sum of its two components. Standing on a ball is difficult but standing on one ball on top of another ball is much more difficult, especially if the balls are a different size and shape. A staged approach, performing the mastopexy on the smaller side, the mastopexy plus reduction on the larger side then allowing it to settle prior to breast augmentation is more straightforward. Also, at the second stage further adjustments may be incorporated, including placing asymmetric implants or further surgical reductions or nipple height adjustments. In practice most patients, ‘want it all done at once’ and where appropriate good results can be achieved with good planning and careful surgery.

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