What/when is the best way to repair medial malposition (symmastia)? I need feedback before I see the surgeon next week. (Photo)

Breast lift/silicone implants/under the muscle/mod profile /420cc. Surgeon picks the diameter and only allows patients to pick projection. Currently 3 months post op. On day 3, I noticed a lot of lifting from the sternum, but he said no need for thong bra(swelling). Week 3, he recommended a thong bra. No change to tenting since. I will ask for a revision. This is surgeon error? Implant diameter too large? How should he do the repair? How long should I wait? Does thong bra help anything now?

Doctor Answers 4

What/when is the best way to repair medial malposition (symmastia)?

 I am sorry to hear about your concerns after breast augmentation/lifting surgery. Although, based on your photographs, you do have medially positioned breast implants and skin tenting (based on your description), I do not think that you have true symmastia present. If the breast implants are too close to one another for your liking, then revisionary surgery will likely involve internal suture reinforcement of the medial capsule areas (capsulorraphy) and/or the use of additional supportive material such as acellular dermal matrix or biosynthetic mesh. Discuss your concerns in a calm/constructive fashion with your plastic surgeon. You may find the attached link, demonstrating true cases of symmastia reconstruction, helpful to you as you learn more. Best wishes.

What/when is the best way to repair medial malposition (symmastia)?

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 I am sorry to hear about your concerns after breast augmentation/lifting surgery. Although, based on your photographs, you do have medially positioned breast implants and skin tenting (based on your description), I do not think that you have true symmastia present. If the breast implants are too close to one another for your liking, then revisionary surgery will likely involve internal suture reinforcement of the medial capsule areas (capsulorraphy) and/or the use of additional supportive material such as acellular dermal matrix or biosynthetic mesh. Discuss your concerns in a calm/constructive fashion with your plastic surgeon. You may find the attached link, demonstrating true cases of symmastia reconstruction, helpful to you as you learn more. Best wishes.

Symmastia Repair Requires Significant Experience.

Ingenious,


Your photos may show symmastia, and likely do, given your surgeon's recommendation. Correct diagnosis required direct physical exam, though a set of special photo views can also tell a lot.   However, a thong bra with neither stabilize, nor reverse unrepaired symmastia, and your surgeon should also know that.  Many surgeons have never repaired symmastia, and it is key to have the repair done properly to prevent further damage and loss of tissues needed for the repair.  Generally those who are adept at repairing symmastia have the experience of many previous repairs, and they also are adept at avoiding it in the first place, as it is always an issue of either poorly-conceived cutting the medial pectoral muscle origins to move the implants closer together, or over-dissecting the medial pockets in the instance of symmastia with implants over the muscle.  If your surgeon is going to attempt to repair the problem, they should be able to show you photos of previous successful repairs, generally in patients who have traveled to them for repair.  A surgeon should not find that they have to repair multiple cases of symmastia that they have caused, as it would indicate failure to understand the cause in the first place, and would cast doubt on whether they understand what must be done to effect proper and stable repair.  Further detailed information concerning symmastia is found at the link below. I hope that this helps you.

Best wishes,

Tom DeWire, MD, FACS    

Richmond, VA

Thomas M. DeWire Sr., MD (retired)
Richmond Plastic Surgeon
4.3 out of 5 stars 35 reviews

Symmastia Repair Requires Significant Experience.

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
Ingenious,


Your photos may show symmastia, and likely do, given your surgeon's recommendation. Correct diagnosis required direct physical exam, though a set of special photo views can also tell a lot.   However, a thong bra with neither stabilize, nor reverse unrepaired symmastia, and your surgeon should also know that.  Many surgeons have never repaired symmastia, and it is key to have the repair done properly to prevent further damage and loss of tissues needed for the repair.  Generally those who are adept at repairing symmastia have the experience of many previous repairs, and they also are adept at avoiding it in the first place, as it is always an issue of either poorly-conceived cutting the medial pectoral muscle origins to move the implants closer together, or over-dissecting the medial pockets in the instance of symmastia with implants over the muscle.  If your surgeon is going to attempt to repair the problem, they should be able to show you photos of previous successful repairs, generally in patients who have traveled to them for repair.  A surgeon should not find that they have to repair multiple cases of symmastia that they have caused, as it would indicate failure to understand the cause in the first place, and would cast doubt on whether they understand what must be done to effect proper and stable repair.  Further detailed information concerning symmastia is found at the link below. I hope that this helps you.

Best wishes,

Tom DeWire, MD, FACS    

Richmond, VA

Thomas M. DeWire Sr., MD (retired)
Richmond Plastic Surgeon

Symmastia at 3 months post-op is unlikely to improve without revision

Although things may still be settling, at this point the symmastia is unlikely to change much.  It appears that you do in fact have some medial encroachment from your implants on your sternum, and the tissues have possibly lifted from their attachments.  This can sometimes happen when too much stress is placed on the tissues or when the muscle is released too much.  Two things that would likely be included in any plan to correct this in your case would be the use of some type of reinforcing material like Seri or Acelllular Dermal Matrix (ADM), such as Strattice, Alloderm, or Flex HD, and the use of a narrower profile implant with a  base width that won't stress your midline tissues so much.  The reinforcing materials noted above will provide strength to the stretched or over-released natural tissues, and this will keep the implants from moving toward, or across, the midline.  They are sutured in place by the surgeon, and when done properly it is highly, not 100% but highly, effective at correcting and controlling symmastia.  You may be advised to wear a thong bra after such a procedure.  With regard to the implants, you report that you have 420 cc moderate profile silicone implants.  The only manufacturer that makes 420 cc moderate profile implants in the US is Allergan, and the base dimension of those implants is 14 cm.  Without knowing your actual size or chest wall measurements, I can tell you that, relatively speaking, that is a fairly wide diameter for an implant.  With the many types and sizes of implants available, you have some room to decrease the diameter of your implants without sacrificing on volume or projection.  Your questions about "surgeon error," or whether or not you should have worn a thong bra are all speculative, and at this point not productive in helping you to move forward to reach your goals.  I think you should do as you have suggested that you will, and discuss the possibility of a revision with your surgeon.  You need to hear his input as to what is going on and what can or should be done to correct things.  Most surgeons would want to wait about 4 to 6 months minimum before undertaking such a revision, so you still have some time to figure out what you wish to do and to get some answers to your questions.  But I think that it is likely that if you want your symmastia improved, you will need another procedure at some point.  Good luck.

Symmastia at 3 months post-op is unlikely to improve without revision

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Although things may still be settling, at this point the symmastia is unlikely to change much.  It appears that you do in fact have some medial encroachment from your implants on your sternum, and the tissues have possibly lifted from their attachments.  This can sometimes happen when too much stress is placed on the tissues or when the muscle is released too much.  Two things that would likely be included in any plan to correct this in your case would be the use of some type of reinforcing material like Seri or Acelllular Dermal Matrix (ADM), such as Strattice, Alloderm, or Flex HD, and the use of a narrower profile implant with a  base width that won't stress your midline tissues so much.  The reinforcing materials noted above will provide strength to the stretched or over-released natural tissues, and this will keep the implants from moving toward, or across, the midline.  They are sutured in place by the surgeon, and when done properly it is highly, not 100% but highly, effective at correcting and controlling symmastia.  You may be advised to wear a thong bra after such a procedure.  With regard to the implants, you report that you have 420 cc moderate profile silicone implants.  The only manufacturer that makes 420 cc moderate profile implants in the US is Allergan, and the base dimension of those implants is 14 cm.  Without knowing your actual size or chest wall measurements, I can tell you that, relatively speaking, that is a fairly wide diameter for an implant.  With the many types and sizes of implants available, you have some room to decrease the diameter of your implants without sacrificing on volume or projection.  Your questions about "surgeon error," or whether or not you should have worn a thong bra are all speculative, and at this point not productive in helping you to move forward to reach your goals.  I think you should do as you have suggested that you will, and discuss the possibility of a revision with your surgeon.  You need to hear his input as to what is going on and what can or should be done to correct things.  Most surgeons would want to wait about 4 to 6 months minimum before undertaking such a revision, so you still have some time to figure out what you wish to do and to get some answers to your questions.  But I think that it is likely that if you want your symmastia improved, you will need another procedure at some point.  Good luck.

Synmastia

It is difficult to assess your result from photos. Certainly there is at least a tight cleavage. Your preop photos do show a reasonable volume of tissue centrally between the breasts which doesn't appear as obvious because the rest of the breast is hanging.
Cleavage following this type of surgery reflects what you have beforehand so even with properly placed implants, from your photos I would expect a tight cleavage.
Although not impossible, it is less common to develop synmastia with implants under the muscle and if so it is usually in the lower part rather than upper.
Unfortunately though, augmentation mastopexy is a difficult procedure that needs a revision in 10% at least. There are also a lot of changes that develop following the surgery and your surgeon has worked hard to control the excess skin and potential for droop to develop again. I think so far you have a  good result for a difficult case.
I am not sure you will need a revision when the final result is at hand and suggest you talk with your surgeon and see what he has to say.
Good luck.

Mark Magnusson, FRACS (Plast)
Brisbane Plastic Surgeon
5.0 out of 5 stars 4 reviews

Synmastia

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It is difficult to assess your result from photos. Certainly there is at least a tight cleavage. Your preop photos do show a reasonable volume of tissue centrally between the breasts which doesn't appear as obvious because the rest of the breast is hanging.
Cleavage following this type of surgery reflects what you have beforehand so even with properly placed implants, from your photos I would expect a tight cleavage.
Although not impossible, it is less common to develop synmastia with implants under the muscle and if so it is usually in the lower part rather than upper.
Unfortunately though, augmentation mastopexy is a difficult procedure that needs a revision in 10% at least. There are also a lot of changes that develop following the surgery and your surgeon has worked hard to control the excess skin and potential for droop to develop again. I think so far you have a  good result for a difficult case.
I am not sure you will need a revision when the final result is at hand and suggest you talk with your surgeon and see what he has to say.
Good luck.

Mark Magnusson, FRACS (Plast)
Brisbane Plastic Surgeon

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