The Aesthetic Surgery Journal August 2019 had an article, “Iatrogenic Symmastia: Causes and Suggested Repair Technique.” First to translate the doctor speak. Iatrogenic = caused by surgery. Symmastia = your breasts touch in the center. You have lost the separation between them.
Why does it happen?
There are women born with symmatia naturally, where they lack the separation between the breasts in the cleavage area. But it can be caused by surgery as well. Possible causes:
- Overdissection when doing a subglandular implant
- Disruption of the midline sternal fascia
- Oversized implant base diameter (the implant is too wide for the patient’s chest wall)
- Overdissection of the medial pec major attatchments to the sternum.
STUDY:
Retrospective chart review. 91 plastic surgeons saw 2.2 consults for acquired symmatia over the preceding year. 85% of these were from subpectoral (under the muscle) placement. (*Note at the time of this study most implants were placed under the muscle)
FINDINGS:
Symmastia was most often caused by pec major sternal dehiscence during the breast augmentation. In the senior author’s experience, he thought all symmastia patients were submuscular. Repair should include suturing fascia to the sternum and reattaching the pec major muscle to the sternum, avoiding using another subpectoral implant, and using things postoperatively to protect the repair.
DISCUSSION:
The author talks about how cadaver dissections show the pec major attachments can be very thin, only 3-4 mm in thickness. They also talk about how the pec major and pec minor may interlace, making it hard to distinguish the plane between them. If you get under the pec minor, they feel the force of the muscle may push the implant medially, putting pressure on the remaining muscle attachments medially, thinning or rupturing them. This allows the implant to migrate too far medially, and you get symmastia. They theorize this process initially starts in surgery from the placement, but is furthered because of muscle force vectors.
To fix the issue, they originally reattached the muscle, with or without the use of ADM (acellular dermal matrix), and kept the implant in the subpectoral plane. The implant under the muscle placed stress on the new repair, and so they saw failure of the repair.
They now recommend reattaching the muscle and placing the implant above the muscle, subglandularly. If they could not reattach the muscle, they would use ADM to span the difference. They then limited patient movement, so limited shoulder abduction, to not add muscle stressors while the new attachments healed.
Their final recommendation:
- Anterior capsulectomy but leaving the capsule over the sternum. They then cauterize this to thicken it if it is too thin.
- They use a running permenant stitch to secure Scarpa’s fascia to the chest wall near the lateral sternal border following the natural curve of the breast. They carry this along the inframammary fold to fix the “bottoming out” which likely is also present.
- They redrape the entire pectoral major muscle along the inferior attachment. (when doing this you need to immobilize the repair for 4-6 weeks- no using your pec muscle!)
- Postoperatively they are placed in a “thong bra” (I have used a towel rolled up to preserve the separation between the breast mounds).
- You may stop here or use another implant. They feel strongly about placing the new implant in a subglandular position. “This article will not discuss the pros and cons of subglandular vs. subpectoral.”
My thoughts?
As much as women want cleavage in a bra, you don’t want your breasts to be touching when you are not in a bra. It isn’t natural. This is a hard issue to fix. Prevention is key. Plastic SurgeonsPlastic Surgeons vary in how much they release the pectoral muscle, with some doctors not releasing much muscle, and some who do wide releases. I am in the camp of less release, and I usually do not do much at all on the medial muscle insertions onto the sternum. For me I don’t like to release the medial insertion of the pec major muscle for multiple reasons: part of the reason is to keep muscle coverage (so you can’t see implant edges or rippling), part is to avoid windowshading of the muscle (where the cut muscle retracts and bunches up on itself), and part is to avoid symmastia.
In their discussion of fixes, I agree with their muscle repair. I am not sure about the subglandular implant placement. Clearly this is controversial, as they state they will not discuss the pros and cons of subglandular vs. subpectoral. There are clear pros and cons.
As far as post op limitation of activity, I totally agree with this. Anytime you are doing muscle work or capsule work, I have patients limit arm activity and make them wear support (usually a strong underwire sport bra) 24/7 for around 6 weeks. Your body needs time to scar the tissue together, otherwise you could rip through your repair and be back where you started.
As with all things, every patients is different. How thin is the tissue? Have you tried repair before? How bad is it? and so on and so on.
It is a different topic to see in the journal, and I love hearing other plastic surgeon’s opinions and their reasoning. It isn’t a common issue for me to see in patients, but for sure happens, and when symmastia occurs it is challenging to fix.