Article courtesy of Steven Teitelbaum, M.D.
March 15, 2010
Synmastia (also known as symmastia) is a condition that occurs when breast implants sit too close to the middle of the patient’s chest. Some women refer to it as ‘breadloafing” and extreme cases can even lead to the “uniboob” look. The problem can be corrected through breast augmentation revision surgery. This presentation by Dr. Steven Teitelbaum, M.D., F.A.C.S. explains in detail how to detect and repair synmastia. The pictures give you visual guidance while the text explains what you are looking at and how the repair is performed.
Dr. Teitelbaum is a plastic surgeon practicing near Los Angeles, California. He has extensive experience with both primary breast augmentation and with breast augmentation revision. He has compiled this presentation from actual cases of synmastia that he has revised recently.
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This variety of patients with synmastia (symmastia) demonstrates the underlying problem: the implant is sitting too far towards the center rather than behind the breast itself. The markings indicate where the implant should sit; correction involves closing off the overly large space so that the implant remains where it looks best |
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There are cases in which the breast only crosses the center of the body when it is forcibly pushed over; this is still synmastia (symmastia,) albeit a more mild case. |
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Notice how her implants are so close that they are even touching! The implants should not have been allowed to migrate into the area of the hatched red line. The problem can be due to inadvertent overdissection by the surgeon, the shape of the patient’s rib cage, the size of the implants, or weakness of the patient’s tissues. |
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In addition to the implant pocket being open too far towards the center, it is often too low in many cases of severe symmastia (synmastia.) |
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Laying on her back prior to surgery, it is apparent how the implants come too close to the center and the skin over the breastbone is tented up into the air. The red hatch marks represent the area of her old implant pocket that needs to be closed off. |
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Many symmastia (synmastia) patients have somewhat of a depressed breast bone area; gravity can then pull an implant down the slope towards the center. |
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This patient has the opposite type of a breast bone: it is protuberant (the medical term for it is “pectus carinatum.”) Note that gravity has pulled this patient’s implants down towards her sides. |
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Correction requires closing off the hatched areas so that the implant just remains within the inner solid line. This can be done with sutures (capsulorraphy), placing a patch of material, or with the newest technique, creation of a new space called a neosubpectoral pocket. |
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With correction using the neosubpectoral pocket, the symmastia is totally corrected and looks smooth on the table at the end of the case. Note the wide gap between the new pocket and the line indicating where the old implant used to sit. |
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Immediately before and immediately after correction, still in the operating room. The implants now have a normal distance between them and the skin over the breast bone no longer “tents” from the pressure of the implants. It is often important to switch to a smaller implant in order for the symmastia repair to heal and for the problem not to recur. Imagine if the implant in the after photo below were a lot larger; it is easy to visualize how that would stress the repair and if large enough, may cause the skin to tent again over the breast bone. |
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Everyone wants cleavage but it must be smooth and even. As in this case, sometimes it is important to leave the breasts just a little wider than ideal in order to be sure that there is ample tissue to prevent recurrence of the problem. |
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Symmastia (synmastia) should be judged in a variety of positions. With the arms raised preop in the upper left, the joining of the breasts creates a “uniboob” type of a look which is shown corrected in the upper right photograph. While cleavage is good, note in the lower left how odd it looks when the skin pulls off of the breast bone. This is corrected as shown in the postop in the lower right photo. |
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Note how much deeper and more attractive the cleave is on the left. In the middle photos, note the severe extent of the tenting of the skin off of the breast bone. In the upper right, look how far the implant can be moved across the center, but how the implant is restricted to its side in the photo beneath it following repair. |
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In this severe case of synmastia (symmastia), the patient literally had a single pocket in which the implants were touching. Not all synmastia repairs turn out this excellent. Sometimes the tissue gets stretched from longstanding synmastia and other times it may have been damaged at the time of the first operation. |
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Her underlying problem is that her implants were way too wide for her body and crossed the centerline of her chest. The right was also too low. By raising them, moving them out, and making them a bit smaller, she enjoyed a significant improvement not just to the appearance of her breasts, but to their feel as well. |
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When implants are too close to the center, the nipples point out; when they are too low, the nipples point up. It is fascinating to note in symmastia (synmastia) patients how implants in the wrong place can so dramatically change the appearance of the nipples. |
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Note in the frontal view how much more even the implants are, and how they are no longer touching in the center. Cleavage is good, but the skin over this patients breastbone pulled away from her body when she would lean forward. Note that in the sideways view, her upper bulge is reduced but not eliminated. This was by the patient’s own choice; had she selected a smaller implant, there would be less of an upper bulge and the nipple would not tip down. |
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In severe cases of symmastia with large implants that have been neglected for years, there is often stretch of the skin in the lower inner part of the breast towards the breast bone, leaving the folds that are seen. These could be improved with a lift, but the patient preferred leaving it as it is to having scars of a lift. It is also fascinating to look at the sideways photos and note how the nipple no longer points out to the side when the implant is properly positioned in three dimensions. |
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This is another example of a patient with severe, long term stretching of the skin over her lower breast bone. Such folds are usually only seen in thin patients with very large implants who have lived with their symmastia for years. She would need to have a lift if she would like to improve these. Note how an implant sitting too far towards the center doesn’t just distort the center; the breasts in the preop photos are too narrow, they do not fill the width of her chest, and the result makes her whole torso look unbalanced. |
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This patient has successful correction of her symmastia, but no doubt some asymmetries still remain. The thinner the patient and the larger the implant, the more likely there is to be some residual deformities. But other than looking straight into a mirror or camera, her shortcomings are not noticeable. Large implants definitely contribute to causing symmastia, and placing large implants back in after correcting symmastia – as in this case, can still lead to implants that look more round than natural. |
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It is obvious not just that her implants did not sit symmetrically, but they are simply too big for her body. One of the most frequent causes for problematic outcomes after breast augmentation is selecting implants for which a patient simply does not have the room on her chest for them to be! Any patient considering an augmentation for the first time - as well as getting a revision – would be wise to choose an implant no larger than fits their body. |
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This is the same patient as shown in slide 11. Although her symmastia seems subtle when standing, it was actually quite severe and deforming in clothing. By creating symmetrical pockets within which the implants can sit, the breasts become noticeably more attractive for her torso. |