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.

Deciding which techniques of breast asymmetry correction to utilize requires careful consideration and should be made with the patient. The patient should be well informed and realistic. At least two, unrushed, comprehensive consultations including showing photographs of a realistic range of outcomes are recommended. It is worth emphasizing to patients that correction of asymmetry is rarely perfect, as ‘different breasts, having different surgeries, will have different outcomes, at different times.’ Breast asymmetry correction may require staged surgical correction and patients need to realize that there is a significantly higher likelihood of further surgeries being required in the short, medium and long term. Positive outcomes are more likely with the implementation of a carefully prepared surgical plan on a well-informed patient who has realistic goals.

Operative Technique

Breast asymmetry correction is not an ‘operative technique’ per se but rather the appropriate selection of generic surgical techniques. It is possible to adopt an almost modular approach to the surgical correction of breast asymmetry by defining all of the asymmetries and then having a number of different surgical techniques or modules to address each. These modules include breast augmentation, liposuction, breast reduction, and mastopexy. Selecting the best modules and anticipating their interactions with each other may seem complex but breast asymmetry itself is complex and for best results may need a complex solution.

Breast augmentation

A horizontal line is drawn across the upper chest at the level of the anterior axillary folds along a tape measure. This line will be a reference in assessing breast implant positioning intraoperatively. A small vertically orientated cross is then placed in the sternal notch and a short vertical line placed in the midline between the two breasts at the level of the inframammary creases. These two points are used to confirm the vertical axis between the two breasts.

The new inframammary creases should be parallel to but may be lower than the existing inframammary creases. Where the inframammary crease heights and the breast sizes are asymmetric the crease height of the smaller breast is nearly always higher. With the patient sitting up, centered on a vertical line extending down from the lateral extent of the nipple, a 4.5 cm line is marked in the existing inframammary crease of the lower (usually larger) breast. The other inframammary crease is marked similarly but is lowered to symmetry. Aesthetic judgment is required and if necessary one or both inframammary creases may be lowered. As a guideline, the nipple to inframammary crease should be approximately half the diameter of the breast implant. This is to position the nipple at approximately the apex of the breast and approximately half the breast diameter above the nipple and half below.

Ideally the inframammary incision should result in a fine scar hidden in the inframammary crease, but this may need to be compromised. Where the inframammary creases are at different heights the incisions may both be in the inframammary creases but then would be at different heights. To maintain symmetry the incision on the side of the higher inframammary crease needs to be lowered. The distances from the nipple to the inframammary crease horizontal lines are measured on each side and noted. A laser level preferably generating a ‘+’ pattern is then used, the vertical line placed along the vertical axis between the breasts, the horizontal line then being an aid to determine height discrepancies between the two inframammary creases. Laser levels are readily available and vary in their sophistication. A single line generating laser level can be used, but to ensure the line is indeed horizontal it should be self leveling or incorporate a spirit level. The inframammary creases can now be adjusted. During this time it is also worth confirming and correcting the patient such that their shoulders are horizontal and there are no postural contributions to the asymmetry.

Sometimes where one nipple is significantly higher it may be worth raising that inframammary crease a little to reduce nipple height asymmetry. Elevating one inframammary crease will be at the expense of inframammary crease, implant height, and cleavage asymmetry and is probably best avoided.

The size and style of implant to be used is checked with the surgical notes, the size and style confirmed with the patient and this is written on each side of the chest. At this point the assistant confirms the implants and takes a set of only these implants into theatre. The assistant then confirms the availability of spare implants should they be needed. The patient is then sat up and photographed with a digital camera also photographing the designated implant sizes and styles. Only then is the patient wheeled into theatre.

After skin incision, the subpectoral plane is readily and generally fairly bloodlessly dissected, commencing with diathermy and then with blunt dissection. Dissection does not extend posterior to the anterior axillary line but does extend cranially with the use of a distally curved metal urethral sound to just beneath the clavicle, and there is minimal blunt dissection medially. Only the lower sternal and medial pectoralis origin is dissected rolling a finger gently to avulse the fibers of insertion. Appropriate pocket dissection is then confirmed with the curved urethral sound. A fiber optic retractor is then used to assess the pocket for hemostasis and any small vessels are readily diathermy cauterized to ensure a dry pocket.

Where the definitive breast implant size has not been determined or needs to be checked intraoperatively temporary sizers may be helpful. Prefilled sizers, especially if similar to the definitive implants are best but may not be available. Resterilizing old implants to use as sizers is not allowed due to sterilization guidelines. Inflatable sizers have significant limitations. As the sizers inflate their shape changes from ovoid to spherical and may not correlate with the definitive implant. Similarly, where size asymmetry is to be corrected with saline implants, it is better to select appropriate volume saline implants and fill both to their rated volumes. This is to avoid the shape changes of overinflating the saline implant on the smaller side.

The definitive implant still sealed in its container is held up by the scrub nurse and confirmed deliberately for each side to be of the correct style and size.

The correct orientation of the implant is confirmed by palpating its marker disk centered posteriorly and the implant checked and should be smooth, without kinks or folds. The urethral sound is dipped in Betadine to make it slippery and then gently run along the anterior and posterior surfaces of the implant again to smooth the implant and then repeated on the contralateral side. This maneuver is also useful to check the symmetry of the pocket dissection, which, if not satisfactory, is usually readily corrected with gentle blunt dissection. Occasionally it may be necessary to temporarily remove the implant to further dissect the pocket, the implant then being replaced and the pocket rechecked.

Once the breast augmentation(s) have been performed the patient is then sat up as high as the anesthetist feels is safe. Symmetry of the breasts is checked from both sides of the bed and the foot of the bed. The horizontal reference line is used to assess symmetry. If symmetry has not been attained the implant may be manipulated in the sitting up position. Usually the patient is returned to horizontal, the implant lowered and then the process repeated until satisfactory symmetry has been attained.

Closure is of three layers with deep and intermediate interrupted 3-0 Vicryl then a subcutaneous 4-0 Monocryl. There are no external knots and drain tubes are not used.

Steri-strips are used to reinforce the wound and a plastic Opsite dressing placed over the Steri strips. Three layers of 1 inch micropore are placed horizontally along the inframammary crease, around the anterior chest extending to the mid lateral lines. The breasts are then further supported with a ‘W’ similar to the lower part of a bra cut from Mefix elastic porous dressing tape. Three layers of elastic micro foam dressing are then placed again without any tension across the upper poles of the breast to minimize excessive elevation of the implants and to minimize the potential for dead space in the early postoperative period. The dressings may not be important, but for some patients may help correct a small area of over dissection and preserve the operatively confirmed symmetry. A light bra is then placed over this, the patient sat up as soon as recovered and all the dressing remains intact for 5–7 days.

Liposuction (breast reduction)

Preoperatively the patient is sat up and a cross drawn over the breast centered over the nipple dividing the breast into four quadrants. The target liposuction volume is divided up and allocated to each quadrant with the four anticipated aspirate volumes written on their respective quadrants. Where a greater discrepancy exists between the quadrants of the two breasts more should be taken and conversely where the two quadrants are more similar less should be taken. Liposuction is not precise; however this technique can contribute to obtaining better overall symmetry.

For small volume liposuction (<150 cc) preoperative local anesthesia is usually not employed as the local anesthesia could dilute and therefore contribute to a false reading of the liposuction. The theoretical absence of vasoconstriction in the absence of local anesthesia does not seem to be a problem. After the liposuction local anesthesia (20 cc 1% ropivacaine, 20 cc 0.5% bupivacaine and 1 cc 1 : 1000 epinephrine, diluted with 300 cc saline) should be infiltrated to decrease postoperative discomfort. For larger volume liposuction local anesthesia is carefully infiltrated, symmetrically if bilateral, and not using excessive volumes that could distort the breasts.

With the patient supine a stab incision is made in the inframammary crease. A 3, 4, or 5 mm Mercedes type cannula is used endeavoring to liposuction the appropriate volume as determined and marked for each quadrant.

Quantifying liposuction is complicated in that two similar volumes may have quite different amounts of fat. The proportion of fat will be reduced where the liposuction includes more blood, serum or lipo-infiltrate including local anesthetic. The density of fat (specific gravity approx. 0.7) is less than these fluids (specific gravity approx. 1 or a little more) so that for the same volume the greater the weight the less fat and hence less genuine lipo-reduction. Put simply, 100 cc that weighs 70 g may be nearly pure fat, but as this weight approaches or surpasses 100 g the liposuction comprises less, or possibly even minimal, fat. After allowing the liposuction canisters to settle, the volume of fat can also be measured between the volume markings on the canister. To enhance accuracy this should be performed with the canister level as confirmed with a leveling device.

Where the amount of fat is small and the volume difficult to ascertain accurately, the liposuction canister can be placed on a digital scale. If higher levels of accuracy are required, decanting the fat, aspirating the liquid beneath the fat, even centrifuging the canisters are possible but probably unwarranted. The volumes of fat in the canisters should be measured with the liposuction machine running as once turned off the volumes of fat may be overestimated if the internal lining typical in disposable canisters retracts from the canister wall. The main point is that the conditions for measuring should always be as similar as possible so that like can be realistically compared with like.

Bruising and edema may occur soon after liposuction so as soon as symmetry seems to have been attained the patient is sat up to check. Persistent asymmetries can still usually be dealt with at this time.

Breast reduction

The patient is sat upright, straight and even. The patient should also be warm and relaxed so that the nipples do not constrict. An ‘inked’ 42 mm circular nipple marker is applied without tension to each nipple. Merely marking the first nipple may constrict the contralateral nipple. There should be minimal delay between marking both nipples to reduce iatrogenic nipple–areola size asymmetry.

The sternal notch is then marked with a vertically orientated cross as is the midpoint between the two breasts. The axis of each breast is then determined and marked with a tape measure placed around the back of the neck over the shoulders and extended down the breasts and over the nipples. The position of the tape measure over the breasts may then be adjusted to place the new nipples both along the axis of greatest convexity of the breast and as symmetric as possible. The level of the new nipple is determined by finger pressure from behind the breast, at the level of the inframammary crease, pushing anteriorly. A mark is placed where this pressure point is transmitted to the front of the breast along the previously marked axis. This mark is used to centre the nipple marker.

The breast having the larger reduction will have a greater decrease in skin tension and its nipple may elevate more than the side from which less weight was taken. This elevation discrepancy is not able to be accurately predicted; however, it is advisable to place this nipple a little lower (1–2 cm) to compensate. A nipple that is a little low is not unattractive and is relatively easy to elevate. An over elevated nipple is unattractive and is difficult to lower.

With the patient still sitting up a vertical line is dropped from the 6 o’clock positions of the areola marking. The symmetry of these lines is checked by measurement from the mid line and if necessary one or other may be adjusted.

The new nipple position is then marked with the patient sitting up at 45° with their hands on their head. A dedicated breast marker may be used. This comprises an incomplete metal circle that when closed has a diameter of 42 mm but can be opened outwards to approximate a hemisphere. Alternatively, an improvised breast marker to obtain a nipple of approximately 42 mm diameter (D) may be fashioned from a wire 130 mm long made into a circle with circumference (C) as C = πD, i.e. 130 = 3.14 × 42). The nipple is also fairly readily drawn freehand.

Where there is breast size asymmetry the hemi-circumferences of the breasts as measured from the anterior axillary line via the nipple to the sternal breast origin should be measured. For example the larger breast may measure 27 cm, the smaller 24 cm, the difference being 3 cm. To account for this, the nipple marker on the larger side can be opened out an extra 3 cm. Where the difference between the two distances is large (>6–8 cm) it may not be desirable or possible to open out the nipple marker this far. In this situation a compromise is required and the nipple marker should be opened out a proportion of the measured difference but without distorting the new nipple shape.

The breast is then pushed-rotated firmly in a superomedial direction and a vertical line dropped from the extent of the nipple marking to the midline then the breast pushed in a superolateral position and the medial line drawn to form a V a centimeter or so above the marked inframammary crease. The extent of the de-epithelialization beneath the nipple is then marked.

Intraoperatively both breasts are extensively infiltrated symmetrically with local anesthetic solution (20 cc 1% ropivacaine, 20 cc 0.5% bupivacaine and 1 cc 1 : 1000 epinephrine, diluted with 300 cc saline).

All surgical lines are then incised then the de-epithelialization performed. De-epithelialization precedes liposuction, as liposuction deflates the breast making de-epithelialization more difficult. Supero-medially, representing the cleavage, liposuction should be minimal or even avoided. Liposuction to correct unattractive lateral fullness can be extensive. Extra liposuction is also performed for quadrants or segments of the breasts where there is asymmetry. After liposuction, excess breast is then resected, more from the larger side to correct asymmetry and again generally significantly more laterally than medially and more from larger asymmetric areas.

To facilitate closure a horizontal mattress of 3-0 Vicryl is placed at the 12 o’clock position of the areola then a three-way corner stitch at the 6 o’clock position. The vertical incision is then closed in two layers with a deep dermal 2-0 Vicryl and a subcutaneous 3-0 Monocryl with no deep suspensory stitches and no pillar stitches. Once the vertical incision has been closed, it is then significantly easier to close the nipple, which is via a series of deep 3–0 Vicryl sutures then 4-0 catgut horizontal mattress suture.

Usually drain tubes are not used. Dressings comprise Steri-strips across all suture lines and gauze padding inside a bra.

Mastopexy

The technique is very similar to breast reduction but with minimal parenchymal resection

Mastopexy–augmentation

Preoperatively the patient is marked almost as if only the mastopexy were to be performed. The only variation is a slight, usually less than 1–2 cm lowering of the nipple to counter the additional elevation caused by the breast augmentation. The breast is then marked as if only the breast augmentation were to be performed.

Intraoperatively the breast augmentation is performed as if it were the only procedure. The patient is then sat up to check the augmentation and the mastopexy markings carefully checked that they too are still appropriate. The nipple position may need to be adjusted depending on how it has been elevated by the breast augmentation. It is worth reiterating that a nipple that is too low is fairly readily elevated but an over elevated nipple is unattractive and difficult to correct. The mastopexy lines are also checked that, now with the augmented breast, closure can still be performed with minimal tension and if necessary the markings can be adjusted accordingly.

The mastopexy is then performed almost as if augmentation had not occurred. If reduction is also required the excess breast tissue is excised. The pectoralis major muscle covers most of the breast implant. Below its inferior border it is preferable to leave at least a thin layer of breast tissue and not expose the underlying implant which therefore remains covered in its pocket.

Case Studies

Case 1

Surgical plan: bilateral breast augmentation with different sizes, diameters (dm) and projections (pr).

Figure 36.1 (age 28) requesting ‘fuller larger perkier.’ Clinical finding: right breast evidently larger.

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Fig. 36.1 Case 1. Bilateral breast augmentation with different sizes, diameters and projections. A Preoperative. B Postoperative. Although the right breast was reported to be 180 cc larger than the left breast by MRI, an intraoperative assessment of 60 g was correct as seen in the postoperative view.

Breast volumes as reported by MRI: right 870 cc, left 690 cc, difference 180 cc.

Operative detail: incisions were made in the inframammary creases, nipple to inframammary crease 7.5 cm. On the left 350 g (dm 12.5 cm, pr 3.8 cm) and on the right 290 g (dm 11.7 cm, pr 3.5 cm) implants were inserted and despite the MRI reporting 180 cc, apparent excellent correction asymmetry was attained.

Comment: intraoperative assessment is more important than an MRI report. A mild asymmetry where the inframammary crease is already in a good position with conservative implants should give an excellent result.

Case 2

Surgical plan: bilateral breast augmentation with different sizes, diameters and projections.

Figure 36.2 (age 35) requesting, ‘perky breasts and not look flat chested.’ Clinical finding: left breast smaller and nipple–areola a little higher.

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Fig. 36.2 Case 2, Bilateral breast augmentation with different sizes, diameters and projections. A, B Preoperative view with the left breast smaller. C Preoperative marking. D Postoperative views with different size implants chosen.

Breast volumes as reported by MRI: right 460 cc, left 400 cc, difference 60 cc.

Operative detail: inframammary creases were lowered bilaterally approximately 0.5 cm so that each nipple to inframammary crease was approximately 8 cm. The use of temporary sizers were used and consistent with the MRI findings, confirmed an approximate 60 cc difference with the right smaller than the left. The implants placed were on the left a 440 g (dm 13.8 cm, pr 3.9 cm), on the right 380 g (dm 13.1 cm, pr 3.8 cm).

Comment: MRI and intraoperative sizers assisted with appropriate implant size selection for good correction of a mild asymmetry.

Case 3

Surgical plan: bilateral breast augmentation with implants having same diameters but different sizes and projections.

Figure 36.3 (age 22) requesting ‘breast augmentation.’ Clinical finding: Left breast smaller and left nipple–areola smaller and higher.

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Fig. 36.3 Case 3. Bilateral breast augmentation with implants having same diameters but different sizes and projections. A Preoperative view with left breast smaller and left nipple and areola smaller and higher. B Preoperative marking (with laser level) showing that the right inframammary fold was higher. C Intraoperative inflatable temporary sizer. D Intraoperative sizer confirming size asymmetry. Dimensions of definitive implants. Right implant is chosen with a moderate projection and left implant with a higher projection. E Intraoperative definitive implants showing higher projection on the left. F Postoperative dressings. G Early postoperative result.

Breast volumes as reported by MRI: right 520 cc, left 460 cc, difference 60 cc.

Operative detail: inframammary crease was lowered approximately 1 cm on the right and then to symmetry on the left with a new nipple to inframammary crease distance of 6.5 cm. On the left a 335 g (dm 12 cm, pr 4.7 cm) ‘full projection’ implant and on the right a 270 g (dm 12 cm, pr 3.7 cm) ‘moderate projection’ implant with volume difference 65 cc, projection difference 1 cm but both a diameter of 12 cm.

Comment: good agreement between MRI and postoperative result. Maintaining breast base symmetry with symmetric diameter implants but correcting volume differences per clinical and MRI guidance challenging to plan but may give excellent asymmetry correction.

Case 4

Surgical plan: left mastopexy-augmentation and right breast augmentation.

Figure 36.4 (age 32) requesting ‘even, fuller breasts, size D.’ Clinical finding: left breast ptotic and slightly larger.

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Fig. 36.4 Case 4. Left mastopexy-augmentation and right breast augmentation. A Preoperative. B Preoperative marking for left mastopexy. C Postoperative.

Breast volumes as reported by MRI: right 680 cc, left 710 cc, difference 30 cc.

Operative detail: after left mastopexy with very conservative reduction (30 g), bilateral 320 g (dm 12.3 cm, pr 3.5 cm) implants were inserted.

Comment: the original MRI reported no significant volume difference but as clinically there was an apparent difference this was checked and re-reported as a small but significant 30 cc difference. Whenever MRI seems at variance to clinical findings, both should be checked.

Case 5

Surgical plan: right breast liposuction then bilateral breast augmentation with different sizes and different diameters but same projections.

Figure 36.5 (age 26) requesting ‘chest in proportion, breast enhancement, decrease the gap.’ Clinical finding: right breast evidently larger.

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Fig. 36.5 Case 5. Right breast liposuction, then bilateral breast augmentation with different sizes, different diameters (dm) but same projections (pr). A Preoperative. B Preoperative. C Preoperative marking. D Intraoperative weighing lipoaspirate.E Intraoperative temporary sizer, over correction on right. F Intraoperative temporary sizer, determining volume asymmetry (320 – 260 = 60 cc). G Intraoperative definitive implants. H Postoperative result.

Breast volumes as reported by MRI: right 712 cc, left 579 cc, difference 133 cc (133 cc of fat weighs approximately 95 g).

Operative detail: to correct the size asymmetry the goal was liposuction from the right breast of approximately 95 g of fat. The liposuction was ceased after becoming bloody. While weighing 90 g, less than two-thirds of the lipoaspirate by volume was fat corresponding to about 50–60 g or 70–85 cc of fat. Temporary inflatable sizers confirmed a residual approximate 60 cc difference. To correct this 60 cc deficit, on the left a 320 g (dm 12.3 cm, pr 3.5 cm) implant and on the right a 260 g (dm 11 cm, pr 3.5 cm) implant were inserted. Symmetry was subsequently confirmed.

Comment: partial correction of the asymmetry with liposuction i.e. 60–70 cc allowed the implants to have only a 60 cc difference as opposed to without liposuction a 120 cc difference may have been required.

Case 6

Surgical plan: right breast liposuction

Figure 36.6 (age 38) requesting ‘even sized breasts and not fussed with size.’ Clinical finding: right breast significantly larger.

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Fig. 36.6 Case 6. Right breast liposuction. A Preoperative. Right breast larger. B Postoperative. Symmetry achieved in both volume and nipple position after performing liposuction of 120 g on the right side.

Water displacement test fairly consistently demonstrated an approximate 100 cc difference.

Breast volumes as reported by MRI: right 720 cc, left 620 cc, difference 100 cc and a glandular component of less than 30% volume.

Operative detail: the liposuction comprised aspiration of 120 g, which appeared to be predominantly fat.

Comment: more than 100 cc of liposuction was taken with the assumption that 10–20% of the aspirate would not be fat. Not only was good apparent size and volume attained but the mild right nipple ptosis relative to the left also appeared to correct highly satisfactorily.

Case 7

Surgical plan: breast reduction and liposuction of an asymmetrically larger but still fairly small right breast.

Figure 36.7 (age 20) requesting ‘the asymmetry of my breasts.’ Clinical finding: right breast larger.

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Fig. 36.7 Case 7. Breast reduction and liposuction of small right breast. Patient preferred to achieve symmetry by reducing the right breast. A Preoperative. B Postoperative. Symmetry achieved after two liposuction procedures on the right.

Breast volumes as reported by MRI: right 1100 cc, left 670 cc, difference 440 cc.

Operative detail: the hemicircumference of the right breast was measured to be 3.5 cm wider than the left and the inframammary wedge resection similarly measured to be 3.5 cm.

Liposuction (150 cc) 135 g and excision of 20 g to give a 155 g resection. The right remained under corrected and 12 months later the procedure was repeated, liposuction 120 ml, surgical excision 25 g and satisfactory correction achieved.

Comment: the MRI report was excessive, the first surgery too conservative and secondary surgery required. While not desirable, insufficient reduction can be corrected but excessive reduction cannot.

Case 8

Surgical plan: breast reduction of large right breast with iatrogenic asymmetry.

Figure 36.8 (age 49) requesting ‘reduction of right breast.’ ‘At age 16 had left breast reduction, subsequently the right grew and for 32 years lived with uneven breast.’

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Fig. 36.8 Case 8. Breast reduction of large right breast with iatrogenic asymmetry from previous breast reduction 32 years previously. A Preoperative. B Preoperative markings with right breast reduction being performed with a Wise pattern inferior pedicle. C Postoperative result.

Clinical finding: right breast significantly larger.

Water displacement test fairly consistently demonstrated an approximate 300 cc difference.

Operative detail: right breast reduction of 325 g with Wise pattern, inferior pedicle.

Comment: right Wise pattern was used, as this was most likely the technique for the left breast reduction. Similar procedures performed bilaterally, even years apart are more likely to give better symmetry than two different procedures.

Case 9

Surgical plan: bilateral breast reduction including conservative extra right reduction and correction shape asymmetry.

Figure 36.9 (age 32) requesting ‘to not have the pain. To be a size D if possible.’

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Fig. 36.9 Case 9. Bilateral breast reduction including conservative extra right reduction and correction shape asymmetry. A Preoperative. B Preoperative marking. C Postoperative result achieved with both liposuction and direct excision.

Clinical finding: both breasts large with the right breast fuller laterally and a little larger.

Water displacement test was inconclusive.

Operative detail: left breast liposuction (600 cc) 540 g, excision 660 g, total 1200 g. Right breast liposuction (650 cc) 550 g, excision 730 g, total 1280 g.

Comment: from the postoperative photograph there is still some mild persistent lateral fullness that will be readily amenable to lipectomy if desired.

Case 10

Surgical plan: bilateral breast reduction (very substantial) with greater reduction of the right.

Figure 36.10 (age 25) requesting, ‘reduce breast size to prevent damage to back.’

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Fig. 36.10 Case 10. Bilateral breast reduction (very substantial) with greater reduction of the right. A Preoperative. B Postoperative. Later correction of bilateral inverted nipples was performed.

Clinical finding: right breast significantly larger.

Water displacement test had significantly variable results ranging from 250 to 1000 cc. Excluding extremes an approximately 350 cc volumetric difference was estimated.

Operative detail: left breast liposuction (700 cc) 640 g, excision 1920 g, total 2560 g. Right breast liposuction (1000 cc) 880 g, excision 2070 g, total 2950 g. Right reduction 390 g greater than left.

Due to the very substantial reduction rather than bringing the inferior incision points to the ‘usual V’ a cm or so above the inframammary crease, a small 2–3 cm lateral extension similar to a J was performed.

Comment: interestingly, despite the anticipation of performing lipectomies to correct lower pole irregularities, this was not necessary as the skin irregularities and puckering resolved spontaneously over a twelve month period. The only revision at this time was for bilateral inverted nipples which were simply corrected via a small stab incision at the base of the nipple to transect the ducts. This case also illustrates that even very substantial breast reductions can be performed highly satisfactorily with the Lejour pattern superior pedicle via a combination of liposuction and surgical excision.

Case 11

Surgical plan: staged surgeries commencing with bilateral breast augmentation, then left breast reduction 6 months later.

Figure 36.11 (age 20) requesting ‘have symmetrical breasts through implants.’

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Fig. 36.11 Case 11. Staged, bilateral breast augmentation then with smaller right breast. Slightly larger but ptotic left breast. 6 months later left breast reduction. A Preoperative. B Postoperative first stage, bilateral breast augmentation. C Postoperative second stage, left breast reduction.

Clinical finding: left breast small and ptotic, right breast significantly smaller but not ptotic.

Water displacement test fairly consistently demonstrated an approximate 70 cc difference.

Operative detail:

1st stage: 270 g textured implants (dm 12.3 cm, pr 3 cm).
2nd stage: left breast reduction with 60 g resection.

Comment: while the definitive result here was good, in the 6 months between these procedures the asymmetry was very prominent. In staged surgery it is generally preferable to perform the unilateral reduction prior to the bilateral augmentation. These surgeries would now usually be performed simultaneously.

Case 12

Surgical plan: bilateral breast augmentation with simultaneous left breast reduction

Figure 36.12 (age 37) requesting ‘even breasts, unsure of enlargement or reduction.’

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Fig. 36.12 Case 12. Bilateral breast augmentation with simultaneous left breast reduction. A Preoperative. B Postoperative.

Clinical finding: left breast larger and more ptotic with lower inframammary crease.

Water displacement test suggested the left breast 150–200 cc larger.

Breast volumes as reported by MRI: right 530 cc, left 730 cc, difference 200 cc.

Operative detail: the breast hemicircumferences were 23 cm on the left and 17 cm on the right. To correct this breast width asymmetry the nipple marker was ‘opened wider’ by 6 cm when marking the left breast. The right inframammary crease was lowered 1 cm to symmetry. 290 g (dm 11.7 cm, pr 3.5 cm) implants were inserted then left breast reduction with160 g resection and elevation of the nipple to approximate symmetry.

Comment: combined surgical procedures require careful analysis of each asymmetry and planning to address each component.

Case 13

Surgical plan: multistaged complex correction.

Figure 36.13 (age 22) requesting ‘very asymmetric, want them even, probably enlarge the smaller.’

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Fig. 36.13 Case 13. Multistaged complex correction. A Preoperative. B Postoperative first stage, right breast reduction, and left mastopexy. C Postoperative second stage, bilateral asymmetric mastopexy-augmentation with conservative lower pole breast tissue reduction. Insertion of 320 g implants bilaterally and right lower pole resection of 50 g. D Postoperative third stage, lower pole asymmetric elliptical breast lipectomies.

Clinical finding: significant complex asymmetries.

The water displacement test measured 250 cc difference.

Breast volumes as reported by MRI: right 550 cc larger than left.

Operative detail:

1st stage: bilateral asymmetric breast reduction from the right breast liposuction (100 cc) 80 g, resection 240 g, total 320 g resection, then the left breast having mastopexy to approximate nipple symmetry.
2nd stage (21 months later): bilateral asymmetric mastopexy–augmentation with conservative lower pole breast tissue reduction. The breast hemicircumferences were 25 cm on the right and 23 cm on the left. To correct this breast width asymmetry the nipple marker was ‘opened wider’ by 2 cm when marking the right breast. 320 g (dm 12.3 cm, pr 3.5 cm) implants were inserted and as part of mastopexy from the right breast lower pole resected approximately 50 g
3rd stage (8 months later): lower pole asymmetric elliptical breast lipectomies. The left nipple to inframammary crease was approximately 8 cm and a small lipectomy was performed to bring this up to 7 cm. The right nipple to inframammary crease was approximately 14 cm and therefore a 7 cm wedge lipectomy was performed to also bring this up to 7 cm.

Postoperatively (early) there is still some minor but apparent residual asymmetry. If this does not settle a further small lipectomy may be indicated.

Comment: staged surgeries may be preferable in the correction of complex asymmetries.

Pitfalls and How to Correct

A Space Shuttle exploded in 1984 because of a small faulty part. The part had been inserted, sealing the Shuttle’s fate, months or even years prior to the flight. Without stretching the metaphor too far, adverse outcomes in the surgical correction of breast asymmetry are probably due more to not fully appreciating all of the asymmetries, resulting in incorrect selection of surgical techniques, rather than failure to correctly execute the chosen surgical technique.

Many of the pitfalls of breast asymmetry surgical correction may be minimized during the clinical assessment with careful examination, consideration and documentation including photography. The next stage is careful comprehensive patient education including explanation of the deformities, the surgical options and realistic outcomes. It is worth emphasizing that sometimes patients with severe breast asymmetry, despite good clinical education, still have unrealistic goals. These unrealistic expectations need to be identified, as surgery must not proceed under these circumstances.

In all patients it is critical to emphasize that perfection is not likely and that further surgeries are quite likely. Having a well-informed, realistic, sensible patient makes management of a difficult problem much easier. What is potentially very difficult surgery should never be rushed at any stage and particularly during the planning. It is far better to minimize complications with planning than to correct the consequences of bad planning, as after surgery sometimes problems may not be correctable. As with most adverse events, where possible, it is far better to anticipate and avoid the problem rather than to try to fix it once it has occurred. Ultimately, the best way to minimize pitfalls is with experience and until this is developed, seeking advice from a more experienced colleague may be invaluable.

The strategies for minimizing complications in breast asymmetry correction are important, but even more important after an initial unsatisfactory result requiring secondary corrective surgery. Sometimes the problem may seem so difficult that it may be desirable to try and ‘start again.’ This may mean removal of implants or other surgical procedures, then once settled to plan a completely new reconstruction. It is critical to not reoperate precipitously, despite a possibly distressed patient and significant pressure for immediate correction. Some asymmetries will resolve spontaneously with postoperative recovery. Timing is important, as it is usually better to wait until everything has settled, but equally not to protract further surgery unnecessarily.

The best way to correct most post-surgical problems remains prompt, honest, full acknowledgement and comprehensive explanation as to how, and over what time period, the problem will be corrected, including any financial implications and how these too will be managed.

Postoperative Care

Postoperative care for surgical correction of asymmetry is similar to that of the individual ‘generic’ surgical techniques used.

The main differences are that asymmetry patients may require more frequent attendances and more reassurance. The patient’s presenting concern was of asymmetry and postoperatively there will likely still be asymmetry. In the short term this is likely because two different breasts may have had two different surgical procedures. There will be differences in swelling, bruising, scarring and these need time to settle. In the medium term, once settled there may still be asymmetries due to under correction. In the long term there may be asymmetries, as two different breasts, having had two different surgical procedures, change differently with time. While it is preferable that the postoperative course will have been carefully discussed prior to surgery, postoperatively further reassurance will likely be required at these different stages of recovery. It will be important during the early postoperative phases to reassure that as both breasts continue to settle, better symmetry should occur. Further reassurance may be needed that if optimal symmetry is not attained, additional surgery may be indicated.

Postoperatively it is also important for the surgeon to continue to reassess, including frequent digital photography. Comprehensive, critical reappraisal, learning, and striving to always improve are fundamental in perfecting the surgical correction of breast asymmetry.

Further Reading

Araco A, Gravante G, Araco F, et al. Breast asymmetries: a brief review and our experience. Aesth Plast Surg. 2006;30(3):309-319.

Bruschi S, Bogetti P, Bocchiotti MA, et al. Congenital mammary asymmetry. Classification and surgical treatment. Ann Ital Chir. 2007;78(3):177-182.

De Paredes ES. Atlas of mammography. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007.

Dixon JM, editor. ABC of breast diseases. BMJ Books/Blackwell Publishing, 2006.

Kuzbari R, Deutinger M, Todoroff BP, Schneider B, Freilinger G. Surgical treatment of development asymmetry of the breast. Long term results. Scand J Plast Reconstr Surg Hand Surg. 1993;27(3):203.

Rees TD. Mammary asymmetry. Clin Plast Surg. 1975;2(3):371-374.

Reilley AF. Breast asymmetry: classification and management. Aesth Surg J. 2006;26(5):596.

Rintala AE, Nordstrom REA. Treatment of severe developmental asymmetry of the female breast. Scand J Plast Reconstr Surg Hand Surg. 1989;23(3):231-235.

Sakai S. Treatment of congenital breast asymmetry. Jpn J Plast Reconstr Surg. 2001;44(7):675.

Sandsmark M, Amland PF, Samdal F, Skolleborg K, Abyholm F. Clinical-results in 87 patients treated for asymmetrical breasts: a follow-up-study. Scand J Plastic Reconstr Surg Hand Surg. 1992;26(3):321-326.

Seyfer AE, Icocheas R, Graeber GM. Poland’s anomaly. Natural history and long-term results of chest wall reconstruction in 33 patients. Ann Surg. 1988;208(6):776-782.

Smith DJJr, Palin WEJr, Katch V, Bennett JE. Surgical treatment of congenital breast asymmetry. Ann Plast Surg. 1986;17(2):92.

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