Iatrogenic Symmastia: Causes and Suggested Repair Technique

Novel technique for repair of symmastia using external negative pressure therapy for continuous pre-sternal compression

Symmastia, a term used to describe the medial intermammary confluence that may appear as a complication following breast augmentation or reconstruction, is a cosmetic issue breast surgeons occasionally encounter and must be prepared to correct. Over-dissection of medial structures, oversized implants, and forces applied to implants in the sub-pectoral space have all been proposed as potential causes of the development of symmastia. Numerous techniques to correct symmastia have been described in previous literature, including capsulorrhaphy, dermo-sternal adhesion, neo-pocket creation, and techniques based on muscle repair. However, these methods are susceptible to recurrence. In this case report series, we present three cases in which symmastia was successfully corrected following surgical repair with post-operative external negative pressure therapy over the intermammary sulcus.

Congenital and Acquired Symmastia: Experience from 100 Cases Treated

BACKGROUND

Symmastia, first defined by Spence et al. in 1984, is a medical condition characterized by the convergence of breast tissues in the midline, resulting in the absence of adhesion between the skin and subcutaneous tissue over the presternal area. It can be either congenital or acquired. Currently, there is no universally accepted treatment for symmastia. This study presents a surgical approach and preoperative and postoperative care for the correction of symmastia.

METHODS

Between January of 2014 and December of 2020, a surgical technique was performed on 100 patients, including 59 with congenital symmastia and 41 with acquired symmastia. The technique involved creating a thin skin flap and attaching it to the sternum to reconstruct the intermammary V-shaped region.

RESULTS

All patients in both groups underwent subglandular implant placement, with textured/polyurethane prostheses used in 97% of cases. Three cases did not use any implants. In the corrective surgery, patients received smaller, round implants, following the steps of the surgical approach devised by the author. The median satisfaction scores were high in both groups.

CONCLUSIONS

The surgical approach described in this study is a safe, one-time procedure with a low risk of complications and high patient satisfaction. The technique is reproducible and provides consistent outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Acquired Symmastia: Classification, Causes, and Repair Strategy

BACKGROUND

Acquired symmastia is a rare complication after breast augmentation that is difficult to fix.

METHODS

The medical records of 18 female patients with symmastia treated by our team were reviewed. Data collected included preoperative medical history, implant size, and breast base width. Surgical techniques were systematically reviewed and analyzed based on postoperative follow-up results.

RESULTS

Of the 18 patients, 15 patients had undergone implanted breast augmentation and 3 had injected breast augmentation. All 18 patients underwent comprehensive repair with various surgical techniques. Three patients showed recurrence after operation. Four patients were dissatisfied with postoperative breast size and underwent 2-stage replacement surgery.

CONCLUSIONS

Symmastia is an intractable surgical complication. Surgical classification can help assess the difficulty of surgery in advance, and the surgical strategy plan can help the surgeon to control the quality of the repair surgery.

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications

BACKGROUND

The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care.

OBJECTIVE

This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications.

RESULTS

In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases.

CONCLUSION

Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Does Implant Surface Texture Affect the Risk of Capsular Contracture in Subglandular Breast Augmentation and Breast Augmentation-Mastopexy?

BACKGROUND

Previous studies have reported decreased rates of capsular contracture associated with the use of textured surface breast implants placed in the subglandular plane during breast augmentation. However, since the publication of these studies, our understanding of the pathophysiology of capsular contracture, as well as the surgical techniques utilized to minimize bacterial contamination of the implant, have advanced considerably.

OBJECTIVES

The purpose of this study was to re-evaluate the relation between implant surface texturization and capsular contracture rates for breast implants placed in the subglandular plane during primary breast augmentation.

METHODS

Retrospective chart review was performed of all primary subglandular breast augmentation procedures involving the use of either smooth or textured round silicone gel implants, with or without simultaneous mastopexy. The primary outcome measures included clinically significant capsular contracture (Baker grade III/IV) and revision surgery for capsular contracture.

RESULTS

Between 2010 and 2017, 526 patients underwent primary subglandular breast augmentation with either smooth (n = 212) or textured (n = 314) round silicone gel implants; 248 patients underwent breast augmentation, whereas 278 underwent breast augmentation-mastopexy. Average follow-up was 756 days in the textured group and 461 days in the smooth group. Five cases of capsular contracture were observed in the textured group, and 7 cases of capsular contracture were observed in the smooth group (P = 0.20).

CONCLUSIONS

Smooth surface implants placed in the subglandular plane were not at a significantly increased risk of capsular contracture compared with textured surface implants. We suggest that adherence to a surgical technique focused on minimizing bacterial contamination of the implant is of greater clinical significance than implant surface characteristics when discussing capsular contracture.

LEVEL OF EVIDENCE: 4