Breast implant revision to fix symmastia?

Question

First saline implants caused slight symmastia and pocket placement issues. 2 surgeons have 2 different plans. 1: under the muscle, switch to silicone implants, & create a neopocket. I would get implants removed, heal for 6 months, & get new implants. 2: deflate current implants, wait 3-5 weeks to heal, get new silicone implants put in over the muscle, use galaflex to create an internal bra. I am 5’5, small-frame, 140 pounds, and heavy weight train. Are both plans viable or is one better?

Matthew S. Kilgo, MD · Answer

Hello I’m assuming the implants are currently sub muscular in position? If so, either plan would be a reasonable option. What is important in the correction of symmastia is a pocket change. In my experience, creation of a neo subpectoral pocket can be challenging if you have a very thin capsule. I rarely stage these procedures. The decision comes down to whether you prefer sub glandular or sub muscular implants. Often, for my patients who exercise heavily, I recommend sub glandular placement to reduce unwanted animation with weight lifting. However, if you are very thin, the trade-off would be increased risk of visibility with subglandular implants. You should choose a surgeon who is certified by the American Board of Plastic Surgery and has extensive experience in revision breast surgery. Good luck.

Maryam Zamani (Saheb-Al-Zamani), MD · Answer

Hi Phenomenol,
Symmastia can be a challenging problem and as such there can be different solutions to it. Both proposed plans seem reasonable. As a surgeon experienced with implants both above and below the muscle and use of Galaflex as an internal bra, I prefer the second option considering some additional factors: You previously had saline implants which suggests your implants are under the muscle; therefore, going above the muscle can be a pristine pocket and less likely to cause symmastia recurrence. Galaflex can further reinforce this pocket and correct the symmastia. Lastly, since you weight train heavily, having your implants above the muscle will minimize the risk of movement and animation deformity with lifting and you would not have to adjust your activity level or workout regimen. 
Best,
Dr. Zamani

Gary M. Horndeski, MD · Answer

I would recommend removing the implants, waiting 6 months and then place submuscular silicone implants.  I also recommend smaller size implants as well.

Best Wishes,

Gary Horndeski, M.D.

Gerald Minniti, MD, FACS · Answer

Always under, always silicone. Make a neosubpectoral pocket if they are currently under. If current implants are over, make a new pocket under the muscle. No mesh necessary if making either a primary subpectoral pocket or a neosubpectoral pocket.

Connie Hiers, MD, FACS · Answer

Photos would have been helpful, but an examination is needed to be certain. Both plans do work for many women. You can keep saline unless placed in front of the muscle. I recommend going down in size for a smaller base.

Jason Pozner, MD · Answer

I dont like either plan. I would open the pocket laterally as they are too tight laterally and close the pocket medially and support with galaflex mesh - and place silicone implants This is not that complicated.

Mats Hagstrom, MD (license on probation) · Answer

It all kind of depends on a number of variables. Any of those methods can work and can fail if not done correctly. The degree of synmastia will have a big impact as will the size and types of implants used as well as the patients willingness to reduce implant size esp immediately after the correction.
Provider selection is by far the most important variable and this is also the most difficult determination. 
Has your provider done this before? If so how many times? What do the before and after pictures look like? 
I prefer to never remove implants and would much rather reduce implant size at least temporarily after the correction if I think it’s going to be difficult. On easy cases using permanent sutures to close the medial pocket while opening the pocket in other directions to take the tension of the repair should be sufficient. Closing the implant pocket sufficiently using permanent sutures requires involving enough tissue with the permanent sutures that some puckering should be seen immediately after in order to get a sufficient repair. Those suture marks will go away over time if done correctly. If the rapair is insufficiently then it will not last and if too aggressive then the skin dimples may not go away. 
It’s just one of those things. A good surgeon will be able to balance all the variables and get this repaired in a single procedure. With the wrong surgeon the repair will not hold and things can get more complicated or worse. 
In the end, provider selection is by far the most important variable, and probably more important than what technique is used.
Best,
Mats Hagstrom MD

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