BREAST ASYMMETRY – SEVERE

The below case is a patient who is 20 years old, presenting with severe tubular breast deformity on the left with severe breast asymmetry and right breast ptosis.  To reconstruct this young lady’s breasts in order to create a normal appearance, requires both different volume implants as well as a formal mastopexy on the right as well as release of the tubular breast deformity on the left.  This patient underwent augmentation mammoplasty procedure with 160 cc high profile saline implant placement on the right and 280 cc high profile saline implant placed on the left.  An inframammary release of the pectoralis major fascia was performed on the left in order to reduce the tubular breast appearance.  She also underwent formal mastopexy using the inferior pedicle Wise-pattern technique on the right to recreate a symmetric nipple areolar position and reduce the grade 3 ptosis.

The patient is now at three weeks postop, sutures have been removed today, the nipple areolar complex positions are even and the size is quite good.  The inframammary folds are even and the swelling is reduced greatly.

Only Board Certified Plastic and Reconstructive Surgeons should be performing these very difficult operations of tubular breast deformity with conical shaped breasts as well as breast asymmetry and ptosis.

Reconstructing these require experience in judgment and many years of training.  Only Board Certified Plastic and Reconstructive Surgeons should be performing these operations.  This specific patient underwent a right breast reduction with bilateral augmentation mammoplasty of different size implants in order to regain symmetry.  The tradeoff for the reduction of course is scarring, as noticeable on the right breast.  This is a full anchor scar or Wise-pattern technique, which was required.  Note, the postoperative symmetry is even, the folds are even and the nipple areolar complexes are symmetric as well.  This allows the patient to now feel comfortable both in and out of clothing, to wear appropriate bikinis and bras with symmetry and increase her confidence greatly.

Operations for tubular breast deformity with breast asymmetry are tricky, requiring a skilled, experienced, Board Certified Plastic Surgeon.  Although these are challenging cases, they are exceptionally rewarding when the results can improve the self-esteem of a woman for the rest of her life.

The above 19-year-old female presents with severe breast deformity with a combination of both tubular breast deformity and severe breast asymmetry.  This is an excellent case example of how tubular breast and asymmetry can be reconstructed safely with a single stage operation.  The above patient has a 34A breast on the left and 34AA breast on the right with grade 2 ptosis and severe constricted tubular breast deformity of the right.  The three obvious components include pseudo-herniation of breast tissue into the nipple areolar complex, poorly defined inframammary fold and complete flattening along the lower pole of her breast.  She is now two months post-surgical having undergone augmentation mammoplasty procedure with a 310 cc saline implant placed on the right and a 290 cc saline implant placed on the left.  She also has had retroareolar breast tissue removed from the right inferior nipple areolar complex to smooth out and flattened the protruded shape of her right nipple areolar complex.  At eight weeks, frontal view shows excellent symmetry, great cleavage, reasonable positioning of the right nipple areolar complex in comparison with the left side, smoothing and flattening of the right periareolar incision and a nice rounding shape along the right inframammary fold.  She is extremely happy with the results which will continue to settle over the next three to four months.  She is now wearing underwire bras and supportive athletic bras at night during sleep. 

Again, this is an excellent reconstructive example of combined breast asymmetry and tubular breast deformity, which can be easily and safely reconstructed under one surgical procedure.

Because Dr. Linder performs so many surgeries where scarring is such a significant part of his procedures, including mastopexies, breast lifts, abdominoplasties and breast augmentations, reducing the scarring is absolutely a main necessity.  The best product that we have used, certainly in the last decade, has been Kelo-cote or Bio Corneum.  Kelo-cote is a silicone gel spray which is used twice a day after sutures are removed, usually on day 14 to day 21, for at least three months.  The silicone gel spray greatly reduces the redness as well as hypertrophic keloiding of the scars and has smoothed out scars beautifully over the last two years. 

Look out for the next one and two-minute infomercials from Kelo-cote where Dr. Linder has been used as a scar expert for Advanced Bio Technology.  Because we believe so wholeheartedly in the use of Kelo-cote, giving worldwide testimonial as to the benefits of Kelo-cote, goes without reservation.  We look forward to seeing the Kelo-cote used worldwide and on television sets throughout the country.

Example No. 1 below shows a patient with significant bilateral breast hypertrophy with Grade 3 ptosis bilaterally.  The right breast is a 36E size breast, the left is a “B.”  In order to properly repair her breast, reconstructing it, she underwent a straight breast reduction procedure using the inferior pedicle Wise-pattern technique on the right and a breast lift on the left with a small 200 cc saline implant.

Example No. 2 shows breast asymmetry requiring a larger saline implant on the left with a straight formal mastopexy on the right to regain symmetry. 

The third result shows breast asymmetry repaired with simply breast implants of different volumes.  The right implant was a 510 cc implant and the left 420 cc.  This allowed for excellent symmetry of her breasts. 

Breast asymmetry is an operation that requires skill and experience and the surgery leads to extraordinarily satisfied patients, especially when they are trying to recreate a normal appearance to their breasts.

The case example below indicates a young female who desired a very natural full B, small C, final result that had slight breast asymmetry.

Upon reviewing her preoperative photos, it is obvious that the right breast is slightly smaller than the left and that the right inframammary fold is higher than the left.

The patient desires to have natural result and, however, has a narrow base diameter of 12 cm and will do well using high profile cohesive silicone gel implants.  A 300 cc implant was placed on the right, 280 cc gel was placed on the left.  This was done using the dual plane technique and through the periareolar approach underneath the areolas.

These results are six weeks postoperative, approximately 90% of the swelling is reduced, the implants successfully fall into the proper position by the use of an athletic sports bra without underwire for one month and an upper pole compression band that has softened and relaxed the muscle on the upper pole to allow the implants to fall into its natural position.

Patients over the age of 22 who desire the most natural results possible and have minimal breast tissue may have successful results using cohesive silicone gel implants of slightly different size volume in order to correct the asymmetry.

Massive breast hypertrophy, also referred to as gigantomastic breasts, can also occur in teenagers, referred to as juvenile breast hypertrophy or gigantomastia.  These patients may not be able to wait until 18 years of age to undergo reduction mammoplasty to reduce the massive size of their breasts, just due to simply increased pain, neck strain, grooving along the shoulders, physiological and emotional embarrassment.  These patients also may undergo surgery at a younger age if considered clear both mentally and physically, as well as with parental supervision for consenting the patient.

In general, when patients decide on body contouring, including augmentation mammoplasty procedure and liposuctioning and are under the age of 18, we normally have the patients wait until the age of 18 so that the majority of physiological breast growth is completed.

When a patient has already undergone breast augmentation with saline or silicone and will undergo breast revision surgery to correct this problem that wasn’t corrected initially, several approaches can be taken.  Breast revision surgery for secondary breast asymmetry problems include:
1. With saline implants refilling or reducing volume of one implant.
2. Replacing the saline implant altogether presenting a larger saline implant.
3. With silicone implant replacing with a larger or smaller silicone implant to the asymmetric side.
Patients who present to Dr. Linder in both Beverly Hills as well as in his Las Vegas practice, present with breast asymmetry preoperatively.  These patients’ folds are marked.  The distance of the inframammary folds must be identified and the distance between the inferior areolar to the inframammary fold distance shall also be reviewed.  Patients should be asked and clinically examined for obvious asymmetry in a brassiere.  When it is identifiable significant and saline implants are to be used before original surgery has occurred, then a different size implant of different volume will usually be used.  If the asymmetry is only slight, then the same implant volume, however, titrated differently.  For example, a 400 cc filled to 400 cc and a 400 cc filled to 430 cc can be placed in order to regain symmetry.  With silicone patients this is more difficult in that silicone implants will require obviously a standard pre-filled implant which cannot be changed in the operating room in terms of titrated volume.  The smaller volume of silicone implants has shorter ranges.  For example, 25 cc differences which can allow for increased symmetry.  As you get into the 500’s and larger, the volumes up by 50 cc make it more difficult to titrate the symmetry volumes.
When a patient presents with asymmetry after original breast augmentation and has saline implants, we like to obtain the previous operative report and implant catalog lot number and serial number with implant volumes identifiable.  Frequently, patients do not have access to the records and therefore Dr. Linder in the operating room has to make his own judgement through his experience of thousands of breast surgeries and revisions to determine the proper size and most appropriate volume.  Most importantly, remember that breast asymmetry, both before the original breast augmentation as well as after the primary augmentation is the norma and regaining absolute perfect symmetry is difficult, if not completely impossible.

Breast asymmetry can be congenital which often presents with a larger saggy breast on one side and a smaller, more conical or tubular shape breast on the other side with poor or arrested development. To repair these, usually the smaller breast only requires an implant as long as the nipple is above the inframammary fold. The larger breast which is saggy, will require a smaller implant obviously, as well as a breast lift.

The breast lift normally will either be a vertical or a formal mastopexy using an inferior pedicle Wise-pattern or an anchor scar. Implants of different sizes can be used. In general, we prefer to use saline implants with significant breast asymmetries because we can titrate the volume of the implants which can lead us to more precision, accuracy and final breast volume.

Silicone gel implants, however, can be used if the asymmetry is slight and not too significant. Breast asymmetries are seen in most women, at least slight asymmetry, however, when they become significant, they can be physically and psychologically tormenting to the woman’s self-esteem. Repairing asymmetries, once again, usually requires placing the implant, either saline or silicone, in a dual plane (half under and half over the muscle or two-thirds under, one-third over depending upon the thickness of the muscle), as well as reconstruction and removal of skin on the saggy breast side, which can be performed by simply removing skin around the areola and along the vertical plane and along the inframammary fold. To completely correct breast asymmetry, the absolutely correct breast lift must be performed. When a patient has grade 3 ptosis and the nipple is well over 3 cm below the inframammary fold, a formal mastopexy is usually required and that is an anchor scar.

When patient have a conical or tubular breast on one side, this can be easily enhanced with a larger saline or silicone implant and release of the tubular inferior pole of the breast with radial striations of the lower pole above the pectoralis major fascia is performed in order to round out the lower pole of her breast.

Dr. Linder enjoys fixing breasts from patients throughout the world and right here in Beverly Hills. Breast asymmetry is a challenging operation. Only Board Certified Plastic Surgeons should be performing these operations. They have the experience and judgment to allow for a reasonable and favorable result.