Symmastia repair: do you sew the skin down to the bone in cleavage? Or do you just hope it reattaches after surgery.

Question

I have lose skin in cleavage after downsizing. I have been told I have symmstia and told I do not have symmstia by different surgeons. All board certified. I am confused. I need to know if when you fix symmstia do you use internal sutures in the cleavage area? If you have lateral displacement and symmstia can that be fixed at the same time? Are silicone implants much lighter than saline and better in a revision surgery?

Richard Baxter, MD · Answer

When downsizing there are two things to consider: The dimensions of the new implant, and the match of the skin envelope to the size of the implant. If the new implant is not as wide, then the pocket would have to be reduced with internal stitches (called a capsulorrhaphy.) Symmastia is when the pocket goes to the midline or across, and I cannot think of a reason why  this would occur after downsizing. This suggests to me that the issue is more related to excess skin, which is the second concern. Smaller implants will not fill up the skin envelope, which would mean doing a lift. Pictures and more specific information about your implants would be helpful.

Jed H. Horowitz, MD, FACS · Answer

Symmastia is a condition which can occur when the implants are too close together. Patients often refer to this as a “uniboob.” Occasionally, the space or pocket for the breast implant is created towards the center, or the tissue stretches, forcing  the implants to fall too much towards the center of the breasts.  
Correction of this problem may involve using different implants such as textured, a smaller size, or a smaller base and placing the implants in a new pocket. On occasion, this may require surgery in more than one stage to allow the tissues to heal and then place the implants. If the implants have been placed above the muscle, converting them under the muscle frequently will help and, again, the use of a dermal substitute may be required for additional support if the tissues are thin. The techniques of capsulorrhaphy and neopectoral pockets may apply here as well. 
 Additional elective cosmetic #surgery is a personal choice. Your procedures should always be performed by a #PlasticSurgeon who is board-certified and has a great deal of experience specializing in cosmetic #surgery. You will then greatly improve your chances of getting the result you desire, and, without the need for a revision surgery. It is suggested that you look at before and after photos of the surgeons actual patients, and read patient reviews. Gathering all of this information will help you make a well-informed decision.

Alejandro Nogueira, MD · Answer

I'll try to shed some light about this interesting topic, in order to help your understanding and find the right surgeon:-if you have loose skin at the cleavage after downsizing means... your surgeon committed a very basic error: not considering dimensions of the implants and instead use the cc/gr scale (something absurd and irrelevant) to choose the new implants; this means... you can freely decide to downsize the grade of breast increase you had... but the WIDTH of the implants base is holy, taboo, has to match with precision the maximum available breast base for them; not doing so... leads to empty cleavage and loose sking there; it is well likely to guess your surgeon downsized the base of the implants without any anatomical reason for that; note: with the same implant width of base you may find in the market dozens of different implants with varied effects of augmentation, sizes of breasts, shapes, etc-if the cause of the cleavage loose skin is the one mentioned in the previous item, then the solution is inserting better width-optimized implants; if the cause is a real symmastia (unlikely after a downsizing) then the solution is a multipoing capsulorrhaphy to reattach skin to the cleavage-if additionally you have excessive lateral pocket then also a multipoint capsulorrhaphy is also bound as treatment, in this case made between the lateral breast skin and the costal arcs at the side, both can be done at the same time if needed (medial cleavage and lateral breast capsulorrhaphies; furthermore sometimes also a submammary fold / lower pole capsulorrhaphy is associated)-weight of implants is absolutely irrelevant-strongly recommended to use the latest generation of implants, the safest and best looking anatomical shaped, cohesive gel filled and macrotextured implants (aka 5th generation).

Kenneth R. Francis, MD, FACS · Answer

Dear sadgirl4,The diagnosis of synmastia is sometimes as elusive as its correction.  It is reasonable to say that there are grades of synmastia, even though no grading system exists.  Also, the extent of synmastia present may even be affected by real time conditions in your body, such as the tone of your pectoral muscles at any given moment in time.  This could explain your confusing diagnoses.  Correction of synmastia usually involves internal suturing of your implant capsules, with or without use of biological support materials, such as acellular dermal matrices.  In general, although it can be done, it is difficult to address lateral displacement and synmastia simultaneously, as repair of one will create tension on the other.  Silicone implants are only slightly lighter than saline implants and the full advantages and disadvantages of each implant type should be discussed with your board certified plastic surgeon.  Good luck!

Tom J. Pousti, MD · Answer

Generally speaking, I utilize permanent sutures along the "cleavage area" when it comes to correction of symmastia. I have found the use of acellular dermal matrix helpful for most patients undergoing this type of surgery.   Although some skin "tenting" may persist after this type of revisionary breast surgery, I have been impressed with the degree of skin redraping that occurs.  Actually suturing skin down to the sternal bone, in my opinion, can lead to a very unsatisfactory aesthetic outcome. Silicone gel breast implants have some advantages when it comes to potential rippling/palpability; they are slightly lighter in weight than saline implants. Again, it will be important that you select your plastic surgeon carefully. Best wishes.

Steven Wallach, MD · Answer

Often sewing the central breast pocket is performed as well as performing a capsulorrhaphy.  Best of luck.

Francis (Frank) William Rieger, MD (retired) · Answer

this repair is always goi No to be a difficult repair. The repair may require a central separation of the breast edges, and this may require either the use of internal separation of the breast pockets with alloderm( tissue introduced after purchase and suture insert into the pocket), possible natural internal capsulorraphy( scar suturing to narrow the pocket internally), as well as a necessary downsizing of the breast implants to place less strain or force on the repair.  Discuss this fully with your Plastic Surgeon.Good luck to you.Frank Rieger M.D.  Tampa Plastic Surgeon

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