Aesth Plast Surg (2009) 33:605610 DOI 10.

1007/s00266-009-9345-9

ORIGINAL ARTICLE

Correction of Acquired Synmastia with Muscle-Splitting Biplane Implant Replacement

Umar Daraz Khan

Received: 23 January 2009 / Accepted: 16 March 2009 / Published online: 5 May 2009 Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009

Abstract Background Synmastia following mammoplasty is an uncommon complication. The true incidence is not known and the condition is underrecorded and undertreated. Medial capsulorrhaphy is the treatment of choice and can be accomplished in a single or staged procedure. Musclesplitting submuscular biplane is used to correct synmastia following subglandular mammoplasty. The procedure allows the use of undisturbed submuscular anatomy and obviates the need for capsulorrhaphy. Methods A retrospective single-surgeon record of over 1900 implant-related surgeries included ve patients treated for synmastia. Four had their primary surgery done by the author and one was a secondary referral. Only one patient was aware of the condition and revision was done exclusively for synmastia. The other patients requested bigger implants without being aware of the condition. All ve had their mammoplasty done in the subglandular plane and the pocket was changed to a muscle-splitting biplane without capsulorrhaphy. One patient had associated bottoming down and so her inframammary crease was relocated and repaired with multilayer capsulorrhaphy of the lower pole only. Results All ve patients had acceptable results after synmastia correction. Keywords Synmastia Implant malplacements Submuscular muscle Splitting biplane Capsulorrhaphy

U. D. Khan (&) Belvedere Private Hospital, Knee Hill Abbeywood, London SE2 0GD, UK e-mail: Mrumarkhan@aol.com

Synmastia is the name that was given to the medial conuence of the breast when two cases of its developmental form were published in 1985 [1]. The term is very descriptive and refers to what was generally known as central webbing of the breast. Up to that time, acquired synmastia following augmentation mammoplasty was relatively unknown [2]. The condition has been referred to by different terms, one of which was sugar loang deformity coined by the Houston community of plastic surgeons [3]. Synmastia after augmentation mammoplasty is a relatively uncommon complication and constitutes part of a group of different malplacements seen as a complication of augmentation mammoplasty. Telemastia or lateral displacement is the mirror image deformity of synmastia, where the breasts are malplaced laterally. Other malplacements are seen in superior (high-riding breast) and inferior (bottoming down) planes. These deformities may present unilaterally, bilaterally, and in combination with other malplacements and can also be seen when an implant pocket dissection is performed either for mastopexy or breast reconstruction [48]. The deformity can be a direct result of aggressive dissection in the medial quadrant or selection of an implant that is wider than the width of the breast. Preoperative breast width measurement, selection of an appropriately wide implant, and careful medial dissection are the keys to avoiding this potential surgical morbidity. There is a paucity of literature on the subject and the citation and treatment of synmastia are usually grouped with those of general malplacements associated with implant-related surgeries [4, 6] There are very few articles dedicated to this complication and its treatment alone [5, 7] and almost all were reported in the subpectoral plane. Regardless of the initial pocket of dissection, treatment of choice is capsulorrhaphy [58]. Allodermal grafts have been used to supplement capsulorrhaphy repair [4, 7]. Use

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606 Fig. 1 A horizontal section through the nipples showing the underlying anatomy of synmastia in the subglandular plane. Implants are in contact with each other through a communication anterior to the sternum. The subpectoral plane remains intact due to the undisturbed medial attachment of the pectoralis

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Fig. 2 A horizontal section after placement of implants in the subpectoral plane. Intact pectoral attachment to the lateral border of the sternum acts as a new medial boundary of the implant pocket. The implant gains a retropectoral position at the level of the junction of the middle and lower third of the sternum. Red arrow shows the reconstituted cleavage without the need for medial capsulorrhaphy

of inatable implants can allow the multilayer capsulorrhaphy repair to consolidate before the delayed expansion of the prostheses is started [5]. In the largest series so far of 20 cases, the implant was moved to the partial submuscular position in only one patient [7]. Routinely changing the pocket is not practiced otherwise. In the current series of synmastia, all patients had their initial mammoplasties done in the subglandular pocket. Inadvertent aggressive medial dissection may result in gradual detachment of the presternal skin from its underlying attachment. The process may lead to an abnormal communication between the two pockets lying anterior to sternum (Fig. 1). In this case, the presence of an intact, deeper, pectoral anatomy allows the creation of a new submuscular pocket, and an intact pectoral attachment to the lateral sternal border acts as a medial boundary to the relocated prosthesis (Fig. 2). The

deeper submuscular relocation of the implant in an undisturbed anatomy eliminates the need for tedious multilayer capsulorrhaphy. The procedure also allows the patient the choice of obtaining a bigger cup size as with multilayer capsulorrhaphy, with a suitably selected implant and as a single-stage operation.

Material and Methods Five patients were treated for synmastia. All had their primary augmentation in the subglandular plane and highprole microtextured cohesive gel silicone implants wer used. All but one patient came to us for a change to bigger implants without being aware of their synmastia. All were treated by using the undisturbed deeper submuscular plane

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without performing medial capsulorrhaphy (Figs. 3a, b, 4ad). One patient had associated bottoming down and needed an inferior capsulorrhaphy for inframammary crease (IMC) relocation (Fig. 5ad). One patient had left unilateral incomplete synmastia secondary to capsular contracture resulting in left implant displacement across the midline without any communication between the two pockets (Fig. 6a, b). Examination Synmastia is obvious in most patients when either standing (Figs. 3a, 4a) or in the supine position (Fig. 5b), but in less obvious cases, simultaneous medial compression of the breasts can reveal an underlying condition (Fig. 4b). Technique While standing, patients are marked with a neomedial boundary leaving a 3-cm intermammary distance (Figs. 3a, 5a) or 1.5 cm from the midline in cases of unilateral displacement (Fig. 6a). The procedure is performed with the patient in the supine position and under general anesthesia with complete muscle relaxation. Old scars are used for access and old implants are removed and their integrity checked. All patients had high-prole microtextured cohesive gel silicone implants. The pectoralis major, with its obliquely oriented muscle bers, is identied behind the posterior capsular layer. The muscle is often attenuated

Fig. 3 a Patient presenting with synmastia after implantation of 300cc high-prole cohesive gel silicone implants in the subglandular plane. b Six-month postoperative anterior view after correction in the muscle-splitting biplane using 410-cc high-prole cohesive gel silicone implants

Fig. 4 a Patient with synmastia after mammoplasty in the subglandular plane using 300-cc silicone cohesive gel silicone implants. b Bilateral medial compression of breasts in supine position conrms abnormal communication between the two pockets. c Bilateral medial compression of 460-cc breasts after implantation of 60-cc cohesive gel silicone implants in the muscle-splitting biplane showing stable and restored intermammary cleavage. d Postoperative view after 6 months showing acceptable results

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b Fig. 5 a Preoperative markings of a patient with synmastia and

bottoming down following mammoplasty with 300-cc implants in the subglandular plane. Patient also had asymmetrical inframammary crease with asymmetrically placed nipple on an uneven thoracic cage. b Patient in supine position showing obvious abnormal communication between the two pockets. c Postoperative on-table view after placing 440-cc cohesive gel silicone implants in the muscle-splitting biplane with restoration of intermammary cleavage. d Three-month postoperative results

because of the pressure exerted by the prosthesis. The submuscular dissection begins medially at a level corresponding to the middle and lower third of the sternum. The muscle is picked and bers are separated using a long forceps or split using an electrocautery on cutting mode. The index nger is inserted and submuscular dissection is completed along the marked pocket externally. A light retractor is passed through the gap and muscle splitting is performed along the direction of the muscle bers [9]. Capsulotomy is performed on the anterior capsular layer corresponding to the lower border of the upper split

Fig. 6 a Preoperative view of left unilateral medial displacement of implant after subglandular mammoplasty with 300-cc cohesive gel silicone implants. b Six-month postoperative view after placement of 400-cc implants in the muscle-splitting biplane with left lateral capsulotomy

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pectoralis and the two are stitched using continuous 2-0 Vicryl. This maneuver prevents the implant from relocating into its old pocket and restores the skin muscle interface in the upper pole. High-prole microtextured cohesive gel silicone implants were replaced in the retropectoral position. Results All patients had acceptable results with a follow-up of 3 months to 3 years (Figs. 3, 4, 5, 6).

Discussion Breast augmentation is a commonly performed procedure and the most common late complication is capsular contracture which has been studied extensively [10]. Implant malposition and malplacement is reported in up to 11.3% of patients when augmentation mammoplasty was performed via the axillary approach [11]. Today we see less capsular contracture because a bigger implant pocket is used, there is more common use of the subpectoral plane, and the quality and choice of implants has improved. However, given the increase in the number of augmentation mammoplasties, malposition is more common than ever. Bottoming down is the most common form of malplacement and synmastia or medial malplacement is the least common. Synmastia is usually a direct result of using an implant that is wider than the width of the breast or aggressive dissection of the breast pocket in its medial quadrant. In the current series one patient had 350-cc implant (base diameter = 11.7 cm) and four had 300-cc implants (base diameter = 11.2 cm). The band size varied between 32 and 34 with the breast base diameter ranged from 15 to 17 cm. The number of patients is small but the data suggest that synmastia is due primarily to aggressive medial dissection rather than the size of the implant. In an aggressively dissected pocket, a larger-volume implant with a wider base may play a role but synmastia can be a direct result of aggressive dissection even with an appropriately selected implant. Careful planning should include measuring the base of the breast using the nipple as a central point and leaving an intermammary distance of 2.5 3 cm. A carefully dissected pocket along with a carefully selected implant is unlikely to result in synmastia. The term synmastia was rst introduced in 1985 [1] and was used for its developmental form. Until then, acquired synmastia as a complication following augmentation mammoplasty was known as a sugar loafed deformity and was treated with excision of all the endothelial lining of the aberrant communication and the resetting and

reconstitution of the medial boundary of the breast. Compressive dressings were applied for 6 weeks to permit obliteration of the repaired tunnel by scar tissue [3]. The term synmastia for the medial conuence of the breast after augmentation mammoplasty was used for the rst time in 1988 when multilayer capsulorrhaphy was described for the treatment of implant malplacements [6]. The term was used for both developmental and acquired synmastia. It was not until 2005 that the rst article exclusively on synmastia was published [5], some 21 years after the rst report of breast augmentation using a silicone implant [12]. Although use of Alloderm [4, 6] and inatable [5] implants has been added to the treatment, capsulorrhaphy has remained the mainstay of the repair. Almost all of the articles on synmastia have originated from the U.S., and in most of the reported cases implants were initially placed in the submuscular plane. Although the change of pocket to the subglandular plane is a theoretical possibility in selected cases, it was not considered as an option, possibly because of an increased use of saline implants in the U.S. However, with the availability of silicone implants elsewhere and with more frequent use of placement in the subglandular plane, a new pocket can be created in a deeper plane and used as an option for the treatment of synmastia following subglandular augmentation. Although physical appearance or medial breast conuence may look the same in both developmental and acquired synmastia, the two forms have entirely different underlying anatomy. In developmental synmastia, presternal skin webbing is either idiopathic as seen in average size breasts or secondary due to traction of hypertrophic breasts. In both these forms, there is no aberrant communication anterior to the sternum. In acquired synmastia, gradual pressure of the implant in an aggressively dissected pocket may lead to gradual detachment of presternal skin and communication between the two pockets [7]. Medial displacement secondary to capsular contracture may also present as synmastia but without any communication between the two pockets. To clarify the various forms of synmastia, the following classication scheme is used: Type 1: Developmental synmastia. No aberrant communication between the two breasts anterior to the sternum. Type 1a: Idiopathic webbing of cleavage in a small or average-sized breast. Type 1b: Traction synmastia. Webbing seen with mammary hyperplasia. Type 2: Acquired synmastia. Aggressive medial dissection resulting in gradual detachment of presternal skin with underlying communication between the two mammary pockets.

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Type 2a: Synmastia following subglandular augmentation. Type 2b: Synmastia following submuscular augmentation. Type 3: Synmastia associated with capsular contracture. Medial boundary of the breast is displaced toward the midline without any communication between the two implant pockets. Type 3a: Complete or bilateral, where both medial boundaries are displaced medially and are joined in the middle. Type 3b: Incomplete or unilateral, where medial displacement of the breast has taken place unilaterally.

References
1. Spence RJ, Feldman JJ, Ryan JJ (1984) Symmastia: the problem of medial conuence of the breasts. Plast Reconstr Surg 73:261 269 2. Hoffman S (1984) Symmastia. Plast Reconstr Surg 74:450 3. Fredricks S (1985) Medial conuence of the breast. Plast Reconstr Surg 75:283284 4. Baxter RA (2003) Intracapsular allogenic dermal grafts for breast implant-related problems. Plast Reconstr Surg 112:16921696 5. Becker H, Shaw KE, Kara M (2005) Correction of symmastia using an adjustable implant. Plast Reconstr Surg 115:21242126 6. Spear SL, Little JW III (1988) Breast capsulorrhaphy. Plast Reconstr Surg 81:274279 7. Spear SL, Bogue DP, Thomassen JM (2006) Synmastia after breast augmentation. Plast Reconstr Surg 118(7 Suppl):168S171S 8. Chasan PE, Francis CS (2008) Capsulorrhaphy for revisionary breast surgery. Aesthet Surg J 28:6369 9. Khan UD (2007) Muscle-splitting breast augmentation: a new pocket in a different plane. Aesthetic Plast Surg 31:353358 10. Biggs TM, Yarish RS (1990) Augmentation mammoplasty: a comparative analysis. Plast Reconstr Surg 85:368372 11. Troilius C (1996) Correction of implant ptosis after a transaxillary subpectoral breast augmentation. Plast Reconstr Surg 98:889895 12. Cronin TD, Gerow RM (1964) Augmentation mammoplasty: new natural feel prosthesis. In: 3rd international congress of plastic surgery, Excerpta Medica international congress series, No. 66. Amsterdam: Excerpta Medica, pp 4149

Conclusion The choice of submuscular placement of the implant in the muscle-splitting biplane is an option for the treatment of synmastia following subglandular mammoplasty. The technique also allows a surgeon to choose a larger implant if a change for a bigger cup size at the same time was the wish of the patient.

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