1; J. Mestak
2; O. Mestak
Esthé – Private Clinic for Plastic Surgery and Laser Medicine, Prague
1; Plastic Surgery Clinic, 1st Medical Faculty, Charles University, University Hospital Na Bulovce, Prague, and
2; Surgical Clinic, 1st Medical Faculty, Charles University, University Hospital Na Bulovce, Prague
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 50, 3, 2008, pp. 85-88
confluence of the breasts, or synmastia, was first described by
Robert Spence in 1984 (1). The term synmastia has its origin in the
Greek syn (together)
and mastos (breast).
Synmastia can be either congenital (2) or acquired from augmentation
mammaplasty (reffered also as breadloafing, uniboob, kissing
implants). Synmastia after mammaplasty is defined as unnatural
communication between the breasts, created by infringement of the
midline of the chest with medial movement of one or both implants and
subsequent contact between both implants above the breast bone.It is
probably the least common complication, which is why most plastic
surgeons are not aware of the right diagnosis and treatment for this
condition. Either they tell patients they do not have synmastia or
they treat patients by removing implants and replacing them some time
a surgical point of view synmastia happens most frequently when the
surgeon excessively dissects the tissues and muscles over the sternum
to further bring the breasts closer, together resulting in more
cleavage. Once the implants touch each other, the natural cleavage is
lost. In case of subpectoral placement the muscle can be damaged at
the point where it attaches to the breast bone. Less frequently, with
subglandular placement, synmastia can arise from excessive dissection
of sub cutis in medial direction (3). Incomplete separation of small
and large pectoral muscles can contribute to synmastia on the lateral
side of the breast, while activity of both muscles pushes the implant
medially. In addition, one factor can be the use of implants which
are too large, or are of unsuitable shape. Synmastia is more common
in patients after repeated breast operations.
to adhere to proper post-operative behavior could be a cause on the
part of the patient. In an effort to present full cleavage, patients
wear underwear which presses breasts medially and cranially too soon.
Synmastia probably occurs more often in thin women who have less fat
which overlaps the sternum, and also in women with pectus excavatum.
Consequently it is better to choose smaller implants in these cases.
consists of removing the capsule in the area above the sternum and
connecting soft tissues to the breast bone again (preferably with
non-absorbing stitches) (4). In case of subglandular placement of
implants we prefer to create a new cavity submuscularly. If the
implants are primarily placed submuscularly it is necessary to
connect the interrupted insertion of the muscle to the sternum again.
It is important to expand the cavity laterally or use new implants of
smaller diameter. Recurrences after correction are common, mainly due
to rupture of stitches which are under pressure of the implant.
addition, in the literature another possible method of correction is
mentioned in cases of recurrent synmastia: using implants with
adjustable volume retaining capsule and suture of the anterior and
posterior flap of the capsule medially. Filling of the implants is
performed after healing of suture repair – at a time when it has
sufficient strength (5). In addition, we can find information about
the possibility of correction with alloderm grafts in the
patient from USA, 179 cm high, weight 55 kg, with slim habitus and
rather thin subcutaneous tissue, underwent an operation at our
clinic. She asked for enlargement of her breast to size B/C. The
breasts were asymmetric, with hypoplasia of the middle level. The
left breast was smaller, and the areola was located higher and more
laterally in comparison with the right – the reason was asymmetry
of the chest with typical prominence of the left sternocostal joint.
The patient agreed to implants size 275cc, which was recommended
during the preoperative examination.
an operation from periareolar access a cavity under the large
pectoral muscle was created, and the muscle was
disconnected from the 3rd
to the 9th rib.
Inside the cavity round implants were later inserted (Mentor co.,
moderate profile), size 275 cc. After insertion of drains, we
performed suture of tissues in layers. The drains were removed after
24 hours. The patient was discharged to outpatient care after
application of her own bra with breasts in good anatomical position.
At a post-operative examination (7th
post-operative day), before leaving for the USA, the position of
breast was still satisfactory. How-ever, at this time a slight
suspicion of movement of the left implant medially was found. Patient
was instructed about on-going care.
consequent post-operative care in the USA there was a change in
position of both breasts – they moved to- gether medially. That
was documented by photographs sent by email. After 5 months she came
for a check-up, at a time when synmastia was fully evolved and its
operative correction was indicated. At this time both breasts were
located medially, while the movement of the implant was more evident
on the left side.
started reoperation after preoperative drawing of the future location
of new implants was performed. After we carried out extraction of the
implants and cut through rather thin fibrous tissue, we enlarged the
cavity for the implants laterally and cranially. Then we partially
reinserted loose breast muscles into the site of their original
insertion with nonabsorbent stitches. At the end of the operation we
replaced the implants with verification of their new placement. (Fig.
of synmastia in this patient can be due to several reasons including
unfavorable anatomical conditions, and also to excessive effort being
made to achieve symmetric placement of both implants. Distinctively
prominating sternocostal joint, which affects most probably the left
side of the chest and is noticeable mainly in thin women, always
pushes an inserted implant more laterally in comparison with the
other side. In these cases, while we try to place both implants
symmetrically, the implant can move medially by excessive
mobilization of sub cutis above the prominating joint and by
disconnecting the breast muscle. This phenomenon can also be
facilitated by insufficient room for implant made by preparation
laterally and cranially.
is an uncommon complication of breast augmentation. Prevention of its
origination consists of careful preparation of the cavity for
implants in a medial direction, especially in slim women where we
find asymmetry of the chest with prominence of sternocostal joint.
Furthermore, for these women the plastic surgeon should not be
induced to use disproportionate sized implants. During the operation
the muscle should not be released with sub-muscular placing above the
areola or 7th rib.
With subglandular placement of the implant the edge of the sternum
should not be exceeded. It is necessary not to leave fascicles of
small and large pectoral muscles connected, which sometimes happens
during blunt dissection, but to detach them sharply until the
subcutaneous fat is visible. As with any deformation of the chest
accompanied by asymmetry, it is always important to instruct the
patient about this fact and to indicate the extreme unlikelihood of
faultless symmetry with the augmented breast. The fact that patients
should always wear correct post-operative underwear for at least 3
months after operation should of course be obvious.
00 Prague 1
1. Spence RJ., Feldman JJ., Ryan JJ. Symmastia: the problem of medial confluence of the breasts. Plast. Reconstr. Surg., 73, 1984, p. 261–269.
2. Salgado CJ., Christopher J., Mardini S. Periareolar approach for the correction of congenital synmastia. Plast. Reconstr. Surg., 113, 2004, p. 992–994.
3. Spear SL., Bogue DP., Thomassen JM. Synmastia after breast augmentation. Plast. Reconstr. Surg., 118(7S), 2006, p. 168S–171S.
4. Bostwick J. III. Plastic and reconstructive breast surgery. 2nd Ed. St. Louis: Quality Medical Publishing, 2000.
5. Becker H., Shaw KE., Kara M. Correction of synmastia using an adjustable implant. Plast. Reconstr. Surg., 115, 2005, p. 2124–2126.
6. Baxter RA. Intracapsular allogenic dermal grafts for breast implant-related problems. Plast. Reconstr. Surg., 112, 2003, p. 1692–1696; discussion p. 1697–1698.