Cosmetic Ideas

and Innovations

Correction of Symmastia Using an

Adjustable Implant

Hilton Becker, M.D., Kevin E. Shaw, M.D., and Mahmood Kara, M.D.

Boca Raton, Fla.; and Bowrnanville, Ontario, Canada

Symmastia occurs following breast implant placement when the midline sternal attach- ment becomes disrupted (Figs. 1, above, left, and 2, left). This usually occurs as a result of overaggressive dissection of the implant pocket medially, resulting in communication of the two breast implant pockets with obliteration of the cleavage.

Correction necessitates surgical intervention with reattachment of the capsule and subder- mal tissue to the sternal periosteum. Recur- rence is common because of disruption of the sutures as a result of tension created by the implant.

A new technique of correction using adjust- able implants is described. The suture repair is allowed to gain sufficient strength before grad- ually filling the adjustable implant.

postoperative filling is started. The injection domes are connected and secured in subcuta- neous pockets close to the incision.

Routine closure is performed and a support- ive garment applied. Filling is started 1 week postoperatively by injecting 50 cc once or twice weekly (Figs. 1, right, and 2, above, left).

RESULTS

A total of five cases have been successfully treated by three surgeons (Figs. 1, below, and 2, right) with no recurrences. One patient had had three prior unsuccessful operations (Fig. 1, above, left). Patients were followed postoper- atively for 8 months to 2 years.

DISCUSSION

Bostwick' states in his book that symmastia is difficult to treat. He recommends total capsu- lectomy, medial suture repair, lateral release, and placement of textured implants to encour- age adhesion.

Recurrence is a common problem. The com- mon denominator in the recurrent cases was immediate replacement of the implant at the time of the repair. The tension of the implant is thus working against the suture repair, re- sulting in disruption of the sutures and recur- rence of the symmastia. By replacing the im- plants with an adjustable implant, filling of the implant can be delayed until the suture repair has healed sufficiently to withstand the tension of the implant.

The adjustable implant was described in 1982.2 The ability to delay filling has been ad-

METHODS

The original incision is reopened bilaterally and the implants are removed. The anterior and posterior capsule is then incised medially on each side one to two fingerbreadths apart. The flaps are then sutured to each other with two rows of nonabsorbable sutures, usually 3-0 braided polyester. Intraoperative expanders are then placed in each pocket and filled to the desired volume, and the adequacy and symme- try of the repair are assessed.

The expanders are removed and the appro- priately sized adjustable implants are inserted. The implants are not completely filled at this stage. Twenty to 50 cc of saline is added to each implant to allow the saline to back-flow when

Received for publication March 21, 2002; revised August 26, 2004.

Dr. Becker owns part interest in a company that receives royalties from Mentor Corporation for the adjustable implant.

DO!: 10.1097/01.PRS.0000164682.07583.A8

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Vol. 115, No. 7 / CORRECTION OF SYMMASTIA   2125

FIG. 1. (Above, left) Preoperative photograph of a patient after bilateral breast reconstruction with syrnmastia, after three unsuc- cessful attempts at correction. (Above, right) Postoperative result after symmastia repair, with placement of adjustable Smooth Spectrum 375-cc implants (Mentor Corp., Goeleta, Calif.) filled to 150 cc. (Center, left) One week after surgery, with implants filled to 200 cc. (Center, right) One month after surgery, with implants filled to 250 cc. (Below) Final result at 3 months, with implant filled to 375 cc.

vantageous in preventing circulation problems and in preventing muscle suture disruption.m

CONCLUSIONS

The advantages of delayed filling of the ad- justable implant after the suture repair has healed sufficiently have been demonstrated in the correction of symmastia. The principle of delayed filling to allow for adequate suture repair can be applied to any capsulorrhaphy procedure, and particularly to correction of inframammary fold problems.

Hilton Becker, M.D.

5458 Town Center Road, Suite 101 Boca Raton, Fla. 33486 hbeckermd@msn.corn

REFERENCES

  1. Bostwick, J., III. Plastic and Reconstructive Surgery of the Breast, 2nd Ed. St. Louis: Quality Medical Publishing, 2000.

  2. Becker, H. Breast reconstruction using an inflatable breast implant with detachable reservoir. Plast. Recon- str. Surg. 73: 678, 1984.

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2126   PLASTIC AND RECONSTRUCTIVE SURGERY, June 2005

Flu. 2. (Above, left) Preoperative bilateral augmentation mastopexy with medial migration of the left implant. (Above, right) Three months after surgery at the time of removal of the port of the adjustable Spectrum implant. (Below, left) A 39-year-old woman with symmastia after bilateral breast augmentation. (Below, right) Postoperative result.

3. Becker, H. Breast reconstruction using a permanent   4. Becker, H. Breast reconstruction using a permanent

tissue expander. Plast. Surg. Forum 9: 20, 1986.   tissue expander. Clin. Plast.Surg. 14: 519, 1987.

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