Principles of Surgical Treatment of Congenital, Developmental and Acquired Female Breast Asymmetries

Background/Aim. There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. Methods. We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 – January 2009). Results. During the above mentioned period, 82 female patients, 18 – 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental , " pubertal " (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients , while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Po-land), accessory and tuberous breasts. All patients under


Introduction
Female breasts go through three stages of development.During the intrauterine fetal growth, the nipple is formed between the 8th and 10th week, while the primitive milk dusts are formed by the 5th month of fetal life.Breast development is definitely completed at puberty under the influence of female gonadal hormones when lobules are formed 1 .There is a smaller or larger natural asymmetry in normal female breasts which may be in the shape, position and size of the breasts or in the projection of the nipples; however, these differences are almost invisible and do not require any esthetic-surgical correction.Nahai 2 has given a detailed description of the causes leading to the breast asymmetry and divided them into 3 groups.
Breast asymmetry is not a rare phenomenon and it presents one of the greatest challenges for a plastic surgeon, particularly in terms of surgical technique selection.Correction surgery for breast asymmetry falls into the sphere of cosmetic surgery.
Once an examination has been completed and diagnosis established, female patient is thourougly informed about the possibilities, advantages and disadvantages of some surgical procedures.Upon reaching an agreement, the patient and the doctor decide on the surgical technique that would allow for achieving optimal results.Sometimes, it would be needed to combine one or more surgical techniques.
However, all surgical procedures, the number of which is large, for correction of breast asymmetry using either patient's own tissue or artificial material, require complete preoperative preparation of the patient.
Depending on the type of asymmetry, additional diagnostic procedures may be indicated such as chest radiography, breast ultrasound examination, hormone status, color Doppler, mammography and basic laboratory analyses, as well as anesthesiology consultation prior to the surgery.
Surgical correction of breast asymmetry is a demanding surgery and it is often performed in several stages.Congenital asymmetries are usually corrected after the puberty, developmental in the adolescence period and acquired even in the advanced ages 3 .
The aim of the study was to present the importance of knowing various surgical techniques for correction of female breast asymmetries.Possessing a good knowledge of these surgical procedures ensures the most adequate treatment of some types of asymmetry.

Methods
This paper presented a retrospective study of female patients with asymmetric breasts admitted to the Clinic for Plastic Surgery and Burns, Military Medical Academy in Belgrade, for correction surgery over the period from January 2002 to January 2009.Based on the data obtained from patients medical records, all surgical techniques chosen for each type of breast asymmetry were analyzed and their effectiveness in achieving functional and esthetic results evaluated.

Results
Based on the data obtained from medical records of surgically treated female patients for breast asymmetry, it was possible to divide them into three groups depending on the type of asymmetry classified by Nahai (Table 1).The group I included the patients with congential breast asymmetry, those with developmental asymmetry were in the group II, while the patients with acquired asymmetries felt into the group III.
Surgical methods used for correction of breast asymmetries included reduction mammaplasty, breast augmentation and mammaplasty, reconstruction of the missing breast using local flaps and silicone gel implants, as well as the combination of the above mentioned techniques.
The patients from the group I with the primary (congenital) asymmetries were treated for Poland's syndrome characterized by the defficiency of a large pectoral muscle by combination of the muscle flap and implant.Those with tuberous breasts were treated using the Muti-type technique 4 .Accessory breasts were excised without the need for additional correction of the exisitng breasts 5 .
The group II of patients with secondary (developmental) asymmetries was the largest.Ultrasound examination of both breasts were conducted and hormone status determined in all the patietns.Prior to a specific surgical procedure, they all underwent endocrinological examination.Asymmetries were mostly corrected by augmentation mammaplasty, silicone gel implants "Mentor" of various sizes 6 , and various techniques of reduction or suspension mammaplasty such as Motturi-, Pitanguy-, McKissock-, Lassus-, or Lejour-type mammaplasty techniques [7][8][9][10][11][12][13] .
Acquired breast asymmetries in the patients from the group III were mostly a consequence of a previous surgical treatment for benign or malignant breast tumor.Upon clinical examination, the patients were presented to the conciliar commission, which then indicated breast reconstruction and/or subcutaneous mastectomy.In patients with such condition arising out of unilateral mastectomy, color Doppler of the blood vessels in the scapular and axillary region was performed prior to the surgical procedure to exclude the injury of a. thoracodorsalis that could happen during the primary surgery.These types of asymmetries were corrected using myocutaneous m. latissimus dorsi flaps and silicone gel implants of the approapriate size.Asymmetries acquired after pregnancy and breastfeeding were treated by the breast augmentation or suspension mammaplasty [13][14][15] .
All the procedures were performed under general endotracheal anesthesia.Functional status of the surgically treated breasts and satisfaction of the patients with the visual outcome were scored to evalute the overall achieved results.From the functional and esthetic aspects, the results achieved with congenital breast asymmetry corrections were satisfactory.Among the patients from the group I, there were two patients with Poland's syndrome.The absence of pectoral muscle, hypoplastic milk glands and the nipples in a lateral position inclined to the ipsilateral were found in both of them.Asymmetry in the first patient was corrected by unilateral augmentation mammaplasty using silicone gel implant "Mentor" of an adequate size and shape, because the size and shape of the contralateral breast was satisfactory.The defficiency of pectoral muscle in the second patient was rebuilt using the ipsilateral latissimus dorsi muscular flap on the vascular pedicle and implants of various size because the contralateral breast was also hypoplastic (Figures 1 a-e).
Corrections were performed as one-stage procedures using implants which were placed subglandularly in both cases.Tuberous asymmetry in 3 patients was treated by the Muti-type technique.Due to the particularly pronounced breast deformity in the areola complex region in those patients, breast asymmetry reduction and suspension was required.Augmentation mammaplasty was performed in the second stage.There were also two other patients with bilat-eral accessory breasts which were asymmetric and extended lateraly towards the axilla.The accessory breasts were excised, the wounds were sutured directly with intradermal suture leaving a minimal post-operative scar.Hystopathological examination revealed that the milk gland tissue was affected.
The group II included the largest number of patients with breast asymmetry, so various surgical techniques had to be used.The difference in the shape of the developmental asymmetric breasts was corrected in 19 patients using silicone gel implants "Mentor" of various size and shape (Fig- ures 2 a, b).
The most adequate of too many breast reduction surgeries was chosen in the case of 14 patients with one breast more ptotic due to a large volume of fatty tissue in relation to the contralateral breast of satisfactory size and shape (Fig- ures 3 a, b, and 4 a, b).
The other patients from the group, seven of them, with developmental breast asymmetries required the combination of two surgical procedures, augmentation and reduction mammaplasty (Figures 5 a, b).To place silicone gel implants, we used a submammary approach in all these cases.A skin incision was made in the submammary fold and the implant was inserted subglandurally in 70% of cases and submuscularly in 30% of cases.The functional results achieved with correction surgery of inverted nipples in the patient who underwent augmentation mammaplasty were absolutly satisfactory.In the case of other patient with lactation definitely complete, unilateral correction surgery was performed using the method by which milk ducts in the nipple were cut off.In 21 patients from the group III with acquired breast asymmetry who previously underwent unilateral mastoctomy, secondary breast reconstruction surgery was performed.Latissimus dorsi myocutaneous flap in combination with the silicone gel implant of adequate size was used in these cases (Figures 6 a, b).
In 50% of the patients from this group, the areolamammary complex reconstruction was simultaneously performed.Subcutaneous mastectomy of the fibrocystic contralateral breast primarily reconstructed by the silicone gel implant was required in 10% of the cases.
There were also 10 patients in this group with breast asymmetry occuring after the pregnancy and breastfeeding.The post-operative recovery lasted 14-21 days in 95% of the cases.
Complications of the above mentioned surgical procedures were negligible as compared with the achieved successful results.They were presented in Table 2.

Table 2
The most often complications in patients subjected to breast asymmetry surgical corrections this type accompanied by radiodermitis and atrophic scar as a consequence occured in two patients who underwent radiation therapy after the primary surgery.

Discussion
The results of this analysis showed that giving importance to a detailed preoperative evaluation of asymmetry and the possibilities of esthetic surgical methods can ensure complete symmetry of surgically treated breasts with the certainty of female patients satisfaction.
Discussions on this issue is inevitable in terms of continuous advancements in the field of esthetic surgery.It is also neccessary to score the differences in the volume of the breasts, position of the submammary fold, the position, the size of the nipple and the shape of the bazal area of the breast.
The patients were informed about the advantages and disadvantages of axillary, periareolar and submammary pattern augmentation mammoplasty, as well as the shape and size of the scar arising out of the reduction or suspension mammoplasty.A special consideration was given to the choice of technique for patients who had not breastfed.The submammary approach was always used to insert the implant in those patients, and it was placed subglandularly to avoid additional traumatizing of the the breast gland tissue.In patients with lactation period definitely completed, the choice of surgical procedure was much more facilitated.However, highcohesive silicone gel implants were used in all the cases because they provided the best optimal results in our clinical practice in terms of a decreased percentage of infections and refusal of the implant as a foreign body.Our experinces gained in female patients undergoing augmentation mammoplasty by silicone gel implants correspond to those of Araco 16 .
A correction of congenital chest-wall deformities accompanied by a marked breast asymmetry was feasible by a perforator or microvascular free flaps.Gautam et al. 17 favor perforator flaps, but our patient with Poland's syndrome chosen a muscular island flap primarily because of a scar that occurs as a consequence of the secundary defect 18,19 .
Persichetti et al. 20 studied both tuberous and tubular brests in their paper and proposed modifications of already described techniques.Their observations were of a great significance to us in selecting surgical techniques, and our knowledge of more similar techniques ensured greater intraoperative certainty.
Our choice of treatment with accessory breasts was excision even though liposuction allows for achieving equally successful esthetic results 5 .
In choosing reconstruction method, we followed reconstruction ladder which means that desired outcome was to be achieved with a simplier method.Reconstruction by some of perforator flaps, DIEP (epigastric flaps) or TRAM (transverse rectus abdominis myocutaneous flaps) or distant m. gracillis or m. glutealis flap, was considered as a possible treatment option in the case of eventual ischemic post-operative complications that require complete necrosis after the primary reconstruction [21][22][23] .
We think that breast reconstruction surgery with the m.latissimus dorsi myocutaneous island flap on the vascular pedicle along with the primary reconstruction of the mammila-areola complex [24][25][26] is the method of choice.According to our experience, complex, m. latissimus dorsi myocutaneous flap has many advantages such as the length of vascular pedicle, the possibility of taking a large dermal island, as well as esthetically acceptable secondary deffect-associated scar that may be hidden by a bathing suit 27 .
In addition, general endotracheal anesthesia provided the best possible comfort for both a surgeon and a patient, although reduction mammaplasty may be performed under local infiltration anesthesia 2 .
Over the last years, a great significance has been given to the preventive and early detection of the brest tumor, and in that sence, the relationship between breast asymmetry and more often occurence of breast malignant diseases was found 28,29 .
All breast asymmetry correction surgeries performed in our patients were preoperatively planned in details depending on the type of asymmetry (Table 1) 30 .
There are other classifications available but like other authors, we followed a classification of asymmetric brests by Nahai as a very precise, clear and most comprehensive 31,32 .

Conclusion
Following the principles of plastic, reconstructive and aesthetic surgery and wishes of female patients with breast asymmetry as well, provide more successful dealing with the dilemma on selecting the most appropriate surgical technique.
Knowledge and the availability of a large number of surgical techniques for breast asymmetry corrections provide the possibility of selecting one or more surgical procedures that would allow for achieving optimal functional and aesthetic results for each patient.