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Michael Law MD Aesthetic Plastic Surgery

Special considerations: asymmetry, tuberous/constricted breasts, etc

Many patients considering breast augmentation are seeking to not only enhance the volume of their breasts, but to also enhance the shape and/or improve the approximation of symmetry of their breasts. I say ‘approximation of symmetry’ as almost all patients have some measurable breast asymmetry, and perfect symmetry rarely exists.

A multitude of breast shape and symmetry issues can be improved during breast augmentation, and in essentially all cases it is possible to produce an aesthetically desirable breast profile. While many issues can be corrected in a single surgical procedure, more significant size asymmetries and breast shape problems may require a staged approach (i.e. more than a single surgery) to achieve an aesthetically ideal outcome.

Accurate preoperative evaluation, careful surgical planning and attention to detail during the surgical procedure are all crucial elements in achieving this goal. It is of utmost importance for the surgeon to clearly outline to each patient the issues that need to be addressed (and in what sequence), whether or not it is practical to accomplish all of the goals in one surgery, and the outcome that is expected from any individual surgical procedure.

Minor breast size asymmetry
Breast asymmetry is extremely common, and in fact essentially all pairs of breasts have some identifiable and measurable asymmetry. So the goal of surgery is not to create perfect symmetry, as that usually does not exist in nature, but rather to produce the closest approximation of symmetry that is possible.

In some cases it is possible to improve breast size asymmetry by using implants of different volumes and/or profiles. For these cases it is extremely helpful to try out different implant sizes and profiles during the breast augmentation surgery using sterile sizers. The surgeon must patiently and carefully evaluate a variety of implant sizers intra-operatively with the patient in the upright sitting position, in order to determine the combination of implants that produce the closest approximation of symmetry.

Silicone implants are prefilled and therefore of a fixed volume. So with one particular implant line you might wish you had a 290cc implant volume for the right or left breast, but have to choose between 275cc and 300cc. That situation speaks to the advantage of working with all three US gel implant manufacturers, for at a given implant base diameter you have the widest selection of implant volume and implant projection measurements if you are able to choose from the implant portfolios of three different companies.

In some cases breasts appear asymmetrical because of asymmetries in the shape and projection of the chest wall, even though the actual breast tissue volume may be equal or quite similar. This scenario may mandate the use of different size implants in order to produce the closest approximation of overall breast symmetry. If one side of the chest wall is more projecting, that side may require a less projecting implant than what is selected as ideal for the opposite side. The side with the more projecting chest wall may require a moderate profile implant, for example, while the less projecting side requires a moderate plus or high profile implants.

Major breast size asymmetry
If there is a significant difference in breast volume, and one attempts to address that difference solely by using implants of different size (which is not a good idea), then the inherent differences in the breasts end up being exaggerated by the breast augmentation surgery. The smaller breast with the larger implant will tend to appear youthful and perky-appearing, while the larger breast with the smaller implant will in comparison appear somewhat droopy, and this difference with only get worse as the patient ages. Not a pretty picture.

So for some patients with major size asymmetry it is necessary to reduce the volume of the larger breast by performing some form of breast reduction on that side (hence the somewhat confusing term ‘reduction augmentation’). Other patients may require a breast lift on one side and a breast reduction on the other, in addition to placement of implants. Equalizing the natural breast volume allows the surgeon to utilize implants of the same or similar size.

With implants of the same or similar size in place, and one side reduced so that the breasts have approximately the same volume of natural breast tissue, the rejuvenated breasts will not only appear close to symmetrical immediately postop but will also tend to age in a similar fashion and remain close to symmetrical over time.

Tuberous breast / constricted breast
Tuberous breast and its milder form, constricted breast, are fairly common breast shape abnormalities. Tuberous breasts tend to be narrow at the base and are overly projecting for their size, and this phenomenon may occur on one or both sides or to varying degrees on each side. In its mildest form, the lower pole of the breast is underdeveloped or may even appear constricted – sometimes referred to as a ‘constricted lower pole’. In severe cases the breast is conical in shape and is sometimes described by the patient as looking like a ‘torpedo’ or a ‘Snoopy dog’. Tuberous breasts can be perky or droopy.

Regardless of the degree to which a breast appears tuberous, it is possible to dramatically improve the appearance of the tuberous breast during augmentation surgery using a number of specialized surgical techniques. While I do not use a periareolar approach for primary augmentation of non-tuberous breasts, that approach can be useful in tuberous breasts. In some cases a periareolar incision has advantages over the inframammary fold approach, as it allows direct modification of the sub-areolar area – including mobilization, transposition and even removal of sub-areolar breast tissue when required.

Circumareolar excision of central breast skin excess is required in some cases, which can also serve to reduce an excessively large areolar diameter if present. If circumareolar skin excision is required, then it makes sense to perform the augmentation procedure through the periareolar incision. Fat grafting is another important means for tuberous breast shape improvement, as it provides a mean for expansion of the breast volume peripheral to the tuberous central breast.

Many patients with severely tuberous breasts have said to me that they have never removed their bra in an intimate setting. Careful patient assessment, thoughtful planning and attention to detail during the surgical procedure can produce a dramatic and life-changing improvement for most patients with tuberous breasts.

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