Modern Approaches to Breast Asymmetry
THE PROBLEM: Plastic Surgeons are frequently asked by patients to enlarge, lift, and reduce breasts that are displeasing because they lack balance to the hips and thighs. It is normal for some variation to exist between the basic shape and position of the breasts on each side of the chest. In fact, upon closer scrutiny in most cases, it is possible to see one of several scenarios:
(1) the axis or angle of emergence off the chest may vary, causing the breasts to swing to the center, straight forward, or outward
(2) The vertical or horizontal take-off of the breasts as they emerge from the chest may differ
(3) The shape can be more round, tear, or pear shaped from one breast to the other, as well as having a different axis and take off point
(4) The size, projection, nipple size, and droop of each breast can vary with the above situations,
(5) The breast bone may be flat, indented, or prominent causing the breasts of the same or different shape, axis, nipple size, and take-off to swing abnormally together or far apart.
THE SOLUTION: When a marked difference in the breasts begins to affect the proper fitting of a bra, bathing suit, blouse, and dress, then it becomes a matter of choosing to wear apparel and padding where necessary to assist in the balancing act. While there are an array of procedures, including true surgical lifts and reductions, that are the gold standard for restoring balance and symmetry, it is often possible to apply selected use of breast implants of varying shapes, diameters, and fill volumes, combined with internal tailoring, to achieve balance and symmetry without leaving the additional scars often necessary for the patients with extremes of asymmetry.
BASIC AESTHETICS: When the surgeon first examines a patient, he or she should stand behind the patient as they both look directly into a mirror. This vantage point can be more helpful than standing in front of the patient, since the surgeon sees the breasts precisely as the patient does. The above features of displeasing size, shape, and asymmetry can be quickly identified. Since the patient views cleavage, or lack thereof, as one of the main issues, one can then ask the patient to push the breasts together, or at least press the existing mounds, to a more pleasing point.
The first design points are to create the central take off, curve, or cleavage line, that is viewed by the patient when looking down and forward. In fact, the patients who are critical after surgery will insist that the surgeon stand in back and above them to look down at the breasts, to demonstrate the difference they perceive as bothering them. The eyes focus from the center outward. This is the cleavage swing factor as I term it, and it is critical in evaluating minor variations in breast size that are not always readily apparent when looking at the breasts while standing in front of the patient. The patients are very astute about the aesthetics of their view of the breasts from where they are wearing them!
The next design point is where the patient perceives the breasts should be on her chest, usually higher up and more full near the middle. A horizontal line should be placed at the upper pole or highest point of desired fullness, to establish the level where the breasts are to be restored or rejuvenated to satisfy wearing a fashionable bra, blouse, dress, or bathing suit.
Next, the surgeon marks the ideal outer curve of the newly fashioned breast, where it veers to the side and creates the upper silhouette that is harmonious to the hips. Some patients may want more or less curve, and may object to excessive lateral fullness that encroaches on the arms and armpit region. The busty patient often complains of bunching of large breasts that occur under the arms or that bulge over the lateral limits of the bra. When they seek lifting and reduction, they want that extra tissue to be reduced and shifted more forward. If the native breasts are widely spaced, or the axis is well lateral, then you must advise the patient that their postoperative position may incline to be lateral, as it is hard to shift the entire gland to the middle, except under extraordinary reduction and lifting procedures where external tailoring and the necessary scars will help shift the breasts more centrally.
MINIMAL SCAR METHODS TO RESTORE SYMMETRY WITH IMPLANTS:
While it is generally agreed that round implants in most patients can accomplish augmentation, lift, and restoration of symmetry, there are cases in which the natural and tear shaped prostheses may be of added benefit. When the breasts are small and not well defined, and the patient wishes a moderate size augmentation, then round implants of perhaps different base diameters and volumes can create the desired balance of shape, cleavage, and symmetry. When a t-scar, vertical scar, or peri-areolar lift approach is applied at the time a round prosthesis is inserted, this generally satisfies the most extreme of diminutive asymmetric breast cases. The latter approach satisfies the minimal external scar methodology most commonly applied.
As the degree of basic asymmetry increases, and the goal for breast size is moderately large, then the use of teardrop implants or round implants with and without internal surgical tailoring called scoring, is instituted. The pear or tear shape of the abnormally shaped breast is splayed out or expanded with tiny cuts made on the inside of the breast, so it will expand to the desired new shape and size. When the tear or pear shape breast has a discreet take-off point from the chest and one desires to enlarge it, lower it, or direct it to the inside or to the outside, then the perimeter of the breast in those zones is loosened and scored with tiny cuts made on the inside. This will permit the breast to expand to the perimeter of the implant (best suited for a tear shaped prosthesis) that is inserted. A temporary double fold may appear underneath, medially, or to the outside, that usually smooth's out in several weeks to several months. The use of a larger implant with internal manipulation of the breast can create gentle pressure and hasten the effect to expand the breast. A round implant will suffice when the chest wall has a 36 size or larger diameter, and when the basic starting shape and desired ending shape is generally more round. When changing the basic shape remarkably or shifting to a moderately large cup, then a tear shaped prosthesis with or without internal modification is advised. When the native posture of the breast is droopy or ptotic, then the implant is placed low and perhaps more behind the breast at the bottom. When performing submuscular augmentations in droopy breasts, it is customary to make the pocket more in front of the muscle at the bottom. A tear shaped implant may help expand this lower glandular pocket more than a round implant.
For the patient adamant about external scars inherent to a standard lift, one option is to suggest the use of the peri-areolar, or vertical lift, which eliminates the wide horizontal scar of the standard lift/reduction. While the best method to restore symmetry in breasts of unequal skin volume is to perform a surgical lift, some patients may be asked to undergo a larger augmentation to fill and stretch the loose skin to offset the skin tailoring by a standard lift. In fact, these patients are carefully counseled about accepting a larger cup augmentation as a tradeoff for declining a lift with its attendant scar. They are also advised that if the droopier breast is still not perfected from the use of larger, more tear shaped prostheses at different fill volumes, and some internal surgical adjustments, then they can undergo a lift at a future time. The future lift can most likely be one of the circular peri-areolar methods, not the vertical or t-scar techniques. This strategy is a win-win situation for patients desiring a fuller bust line, since the added size and volume can help expand, lift, and balance even the most asymmetric of breasts. Where the general configuration of asymmetric breasts is best treated by external scars, yet the patient declines this approach because of the fear of scars, or due to finances, at worst, the breasts will be of similar shapes in a suitable bra, but vary somewhat when not wearing a bra. If the patient is properly informed of this fact, and the general axis of the breasts has been improved by the surgery, then they will usually be quite satisfied. Larger breasts with some bilateral variance that fill the upper torso have better harmony with the hips and are better tolerated than smaller, slightly asymmetric breasts that do not balance the hips.
RECOVERY: The convalescence from augmentation surgery is usually five to seven days with added caution to avoid strenuous activities for four weeks. When the internal modification procedures are applied at the time different shape/volume implants are inserted to correct asymmetry, these patients are told that their final resting shape may not occur for a number of weeks to a few months. Thus, the aesthetic recovery is delayed a bit longer than for a standard breast augmentation. Some adjustments may be necessary in some patients, and few individuals may wish to pursue a secondary minor lift and change of implant or implant fill volume in time. Since tear implants settle the most in time, delivering their main volume to the center and lower portions of the breast where most asymmetry and drooping problems occur, the results may appear more pleasing than for patients selecting round implants applied to the same asymmetry problem. The patients selecting round implants for their asymmetric reconstruction may be more likely to request an adjustment in time. If the internal scoring and releasing techniques are applied to these individuals assuming this fact, then they will enjoy a higher measure of satisfaction.
SUMMARY: In selected patients with minimal to marked breast asymmetry who decline the application of external tailoring techniques and their attendant scars, they may be candidates for use of appropriate tear shaped breast augmentation with different shell dimensions and volumes, combined with internal surgical tailoring. In patients whose finances preclude either the combination of augmentation and external lift, or the use of tear shaped implants, then round implants combined with internal tailoring techniques may suffice. Subsequent revisions of minor asymmetry are more likely in the patients with significant asymmetry who opt for sole use of round implants or tear implants alone without internal tailoring.