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Symmastia – Uni-boob or Medial Mal-position

Symmastia can happen when the breast implants migrate too far toward the midline, or when the surgeon over-dissects the medial area (or medial displacement) in hope of creating cleavage. This complication takes on an appearance of one breast versus two. Also known as “kissing implants”, “bread-loafing”, and “uni-boob” – it also remains the toughest complication to fix for a surgeon and even after repair or a reoccurrence can happen.  Symmastia is also caused by inserting too large of an implant into a patient, especially one with thin skin.

Each patient will vary with the degree of medial displacement, so therefore the reconstructive techniques will also vary. Normally with symmastia, it causes severe medial displacement of the breast implants, which in turn will cause the nipple-areola complex to appear off center on the breast mound. It is not uncommon to see other complications occur with symmastia, including bottoming out, rippling / and breast asymmetry.

 

 

                                  

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                                                   Patient with Mild Symmastia

 


 

Symmastia is caused from a couple of factors, one being the result of the loss of tissue support along the sternal area, allowing breast implants to move excessively towards the woman’s midline. If the pectoralis muscle that is connected to the sternum and goes across the implant is dissected or cut during surgery, then the implant can move toward the middle of the chest.

This complication of symmastia can result from aggressive attempts to alter a patient’s chest wall anatomy by basically trying to increase the cleavage. It also happens when too large of implant is used in a patient that is thin and has a slight build. Because there might not be sufficient room for the size of the implant, it eventually weakens the medial area with the tissue starting to lift off of the sternum. Symmastia seems to be more common among thin women mainly due to the fact that they have less tissue or fat covering the sternum.

Symmastia can occur with either under the muscle placement or over the muscle placement. Having the implants place sub-muscular, does help with providing the patient some softening and transition to the cleavage area from the augmented breast mound. The complication of symmastia with implants that are placed sub-muscular always involves the muscle, however with over the muscle placement; symmastia only involves the area of breast tissue.

Patients with Pectus Excavatum or a depressed breastbone are usually more prone to symmastia. Pectus Excavatum is the most common congenital deformity of the anterior wall of the chest, in which several ribs and the sternum grow abnormally. This deformity tends to cause the breast implants to slope more inward towards the cleavage area, which ends up creating more pressure on the tissues in that area, and ends up resulting in symmastia.  Pectus Excavatum is usually seen at birth and tends to progress during the time of rapid bone growth in the early teenage years, and sometimes does not appear until the onset of puberty.

 

 

       

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                                                         Patient with Mild Symmastia


 

 

Symmastia can be a very difficult complication to correct, one that takes a lot of planning and also surgical reinforcement with permanent sutures of the medial fold of the breasts. Reconstruction includes removing the breast implants and placing internal sutures extensively in the surgical area. Because repairing symmastia is an internal repair, the surgeon will cut away the scar tissue inside the cleavage area and roll it back into the actual pocket that was made for the implant to sit in. It is then that the surgeon will secure these rolls with permanent sutures. Each side of the cleavage will have these permanent rolls secured in order to hold the implant back. By doing this, some believe that it lowers the rate or recurrence of symmastia from happening again.

The breast implant pocket might be laterally opened up (which is the outer breast fold) to allow for proper positioning of the implant so that it is centered on the breast mound. By doing this, the medial area has less stress from the implant pressure against the medial suture line and to get a space back in between the implants. Most plastic surgeons recommend a smaller implant to help serve this purpose. Surgical time to correct symmastia can take 2 to 3 hours depending on the severity of the problem.

 

How Symmastia is repaired:

  • An incision can be used either in the inframammary crease or under the areola for a clear surgical view of the area.

  • The tissue that surrounds the implant is removed in the area of the planned repair.
    Tissue is sutured with permanent sutures to hold implant in place.

  • The incision is then sutured closed.

  • During the surgery, the patient is held upright to assess the repair and degree of symmetry.

  • Multiple rows of suturing may be necessary to achieve satisfactory repair and symmetry.

  • The use of tape is used to apply pressure on the previously elevated skin overlying the sternum post op.

  • Compressive dressings and a pressure bra are also helpful and or a thongbra.



                                        

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                              Patient After Symmastia Repair and Downsizing of Implants

 

 

 

Recovery from symmastia is longer than traditional breast augmentation, and special considerations need to be adhered to during this time. There is slightly more pain associated with this surgery, however pain medications manage any pain episodes. It is important to take your medication as prescribed, and to keep all post operative appointments with your plastic surgeon, so he can chart your recovery.

Drinking plenty of fluids will help with keeping you hydrated, and also will help with the swelling. Bed rest and taking things very easy should be first and foremost. Some patients can bounce back from this procedure within a couple of week; however every patient is different with their pain tolerance.

More than likely you will be fitted into a special bra or a thongbra during your post operative period. The “thong bra” is used to stabilize the area after the symmastia repair. This will allow the sutured area between the breasts to heal properly without excessive pressure being applied to the area. Your will be instructed to wear your thongbra for at least two – six months depending on the severity of the symmastia.  Wearing the thongbra this way will help apply constant pressure on the repair so that it has the best odds in healing with keeping the area stable.

 

 

                                                

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                                    Patient wearing thong bra after Symmastia revision surgery

 

 

You will not be able to shower until your sutures are removed as most like to keep the sutures dry, and your plastic surgeon could have used drains to help with the swelling. To read more about drains, please go to this link.

After a symmastia repair, the implant placement on the chest wall could be a little bit higher. This is caused from swelling and also all the suturing that was done.  In time, the implants will drop into a much more natural position.

 

 

 

 

 

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