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Goal
To describe the most common manifestations of breast asymmetry and treatment options, or choices. Minor asymmetries are very common and relatively easy to correct. Creating breast asymmetry in a severe case is difficult at best. It’s one of the most challenging yet rewarding of all breast surgery procedures.
Findings/Manifestations
Most woman have some degree of breast asymmetry only the degree varies. This can be caused by the following:
- Asymmetric breast inframammary fold (IMF)
- Asymmetric volume
- Asymmetric chest wallprojection
- Congenital absence of the pectoralis muscle and breast tissue (Poland’s Syndrome)
- Asymmetric breast ptosis (sagging of the breasts)
- Asymmetric size and location of the nipple areolar complex (NAC)
- A combination of above
Determining Breast Volume Asymmetry
Using the sizing technique below, start with a nylon filled with rice to make your smaller breast equal in size to your larger breast using your current bras. This way you will know the difference in size between your breasts.
As far as size, you know all bras are not equal in “cup size” measurements. Varying by bra manufacturer, cup size is a very crude and non-standardized measurement. Thus, the actual cup size you are eventually measured at is not as important as your body proportions as it relates to your desired breast size.
- Realizing there is no standard bra (cup and strap) sizing, purchase several bras — full bodied and no padding — of the cup and strap size you think you want to be.
- Take a measuring cup (1 oz = 30 cc’s) and place rice in a nylon. (Therefore, 10 oz = 300 cc’s etc.)
- Try on various volumes of rice with some form-fitting clothes.
- If the implant is placed under the pectoralis muscle, I usually add 10 percent volume to what the patient chooses. This is done to compensate for the muscle pressing down on muscle and for the natural settling of the implant, which often makes the breast appear smaller two to three months after surgery.
Chest Wall Evaluation
Once volume asymmetry is determined, the plastic surgeon usually evaluates the chest wall anatomy including the following:
- Pectus carnatum: sunken central chest
- Pectus excavutum: overly projected central chest
- Poland’s Syndrome: lack of pectoralis muscle and breast tissue
Treatment Options/Choices
Implants
Breast appearance, size, filler material, shape and implant location is a personal choice guided by the experience of your plastic surgeon. Your specific breast anatomy will dictate some of your choices.
A. Implant profile
- For the same volume, the higher the profile the narrower the base width.
- There is very little difference in projection between a moderate- to high-profile implant, thus little effect on how the actual nipple will look.
- The base width of the breast should equal the base width of the implant — thus, I personally chose the profile based on the patient’s chest measurements. A high profile on a wide chest may not result in the cleavage desired, and,conversely, a low profile on a narrow chest may result in some of the implant appearing in the outside arm
B. Cleavage is largely determined by your anatomy. This can be optimized by choosing the best profile implant and postoperative implant displacement exercises toward the midline of your chest.
C. Implant Shape
- For the vast majority of cosmetic patients, I recommend round implants.
- For reconstructive patients, shaped/form-stable implants are often used.
D. The implant placement decision (subpectoral, dual plane or suprapectoral) will be determined based on your anatomy and long-term goals and benefits.
- Filler material
- Silicone gel feels more like breast tissue, has less potential rippling, comes prefilled so the size cannot be adjusted intraoperatively, and involves larger incisions to place compared to equal-sized (non-prefilled) “normal” saline implants.
- Normal saline implants can be adjusted in size intraoperatively, if there are ruptures normal saline absorbs, has a potential increase in rippling compared to silicone gel, and involves a smaller incision to place.
E. Tissue expanders (TE) are used in extreme cases where there are major breast volume differences and a lack of skin to create symmetry. The device is placed, and there are weekly injections into the TE port until the skin is stretched to the volume that accommodatesthe selected permanent breast implant. This method is usually used after a mastectomy related to breast cancer.
Breast Lift (Mastopexy)
After breast volume asymmetry is corrected, a difference in shape, sag/ptosis and NAC can still exist. This can be corrected by surgical techniques known as mastopexy, which allow not only “sculpting” of the breast skin to correct shape but also correction of NAC size and position.
Conclusion
Creating breast asymmetry is not unusual. Most women have minor differences in breast size, shape or sag that is correctable. In the more severe cases of isolated breast asymmetry or associated chest wall deformity, the correction can be difficult at best. Breast asymmetry correction is one of the most challenging yet rewarding of all breast surgeries. In closing, I often tell my patients, “I can make sisters not twins.”
