INTRODUCTION
Breast asymmetry present an aesthetic challenge
to plastic surgeons as it is a symbol of female
beauty; thus congenital and pathological breast
conditions affect women lives to a great extent.
Physiological asymmetry exist in normal female
breasts. However, different cultures, the modern
beauty parameters led women to look for perfection.
Nahai classified breast asymmetries into three
groups: (1) Primary (congenital) breast asymmetry
as Poland's Syndrome (PS) (2) Secondary (developmental)
breast asymmetry (3) Patients with
tertiary (acquired) breast asymmetry [1].
Improving the body image and breast symmetry
is associated with better quality of life. To get good
patient satisfaction, pre-operative examination and
planning are considered main predictors of the
aesthetic outcome. However clearly discussing
with patient to achieve perfect symmetry is almost
impossible and that it may take several procedures
to achieve the goal [2-6].
Contra lateral symmetry following oncoplastic
breast conservation is limited regarding patient
decision-making and a systematic analysis of patients'
views regarding this topic is lacking [7-12].
Smeele et al., 2019 ran an interview study to explore
the factors involved in patient decision making
about contralateral reduction mammoplasty [13].
All the surgical techniques described in the
literature is based on the presurgical marking [14-
23]. However it is of little value if immediate symmetry
carried on the contralateral breast and the
amount of breast tissue to be excised is judged or
altered according to the intraoperative findings as
in; oncoplastic procedures, recurrent multiple fibro
adenoma, juvenile hypertrophy of the breast, application
of breast implant which chosen according
to the intraoperative assessment as in Poland syndrome,
nipple areola sparing mastectomy (NASM),
Skin Sparing Mastectomy (SSM), and reconstruction
with autologous tissue.
The aim of the study is to present our technique
solving the dilemma of breast marking for managing
congenital and pathological breast asymmetry.
PATIENTS AND METHODS
It is a cohort retrospective study included 41
patients with congenital and pathological breast
conditions offered immediate contralateral mastopexy
or reduction mammoplasty as well. It was
done between June 2015 and June 2019 in Ain
Shams University Hospitals, Cairo, Egypt “The
Breast multidisciplinary teams MDT”. Patients age
ranged from 14 to 63 years (mean 39.36 years).
Informed consent was obtained for all patients to
be include in any study and for medical photography
documentation as well.
Demographic, oncologic, operative, and photographic
data were obtained for each patient. Patients
were followed at 3, 6 and 12 months postoperatively
(range 3-30 months). Criteria for inclusion
were a complete demographic and oncologic
history and photographic follow-up of at least
twelve months (minimum 12 months, max 29
months). The variables include: Age, BMI, smoking,
hypertension, diabetes, post-mastectomy radiation,
adjuvant chemotherapy, and history of
unilateral reconstruction or other breast procedures.
See (Table 1).
Pre-operative assessment, medical and surgical
plane was done by the breast MDT. In the present
study, the modified SOS procedure was done to
treat the pathology and achieve symmetry in the
contralateral side. If there is a plan for radiotherapy,
the symmetry procedure was delayed for at least
9 months. Patients were subdivided into three
groups [24,25]. (1) Primary (congenital) breast
asymmetry caused by Poland's Syndrome (PS) (2)
Secondary (developmental) breast asymmetry
caused by unilateral breast hypertrophy, and (3)
Tertiary (acquired) breast asymmetry caused by
burns, granulomatous mastitis, and we added in
our study the benign: Recurrent fibro adenoma
and malignant breast tumors and post mastectomy
reconstruction as well. See (Table 2).
120 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
Tumor excision procedures was done by the
two breast surgeons and reconstruction were performed
by the two plastic surgeons. Post-operative
photographs were assessed by 5 plastic surgeons
(3 men and 2 woman). We used the same method
previously described by Visser et al., [26]. Pre and
post-operative standardized photographs of the
breast area was done using a wide-angled digital
camera. The breast region included the shoulder
region level and the level of the umbilicus. Patients
are were instructed to place their hands beside their
body touching their buttocks and with a uniform
background. 4 different views were taken to each
patient: Frontal view, lateral and with an angle of
45 degrees between frontal and lateral views.
Assessment was done as regard the breast volume,
shape, symmetry, scars, and nipple areola complex.
For each of these items a 5-point Likert scale is
used for scoring. This scale ranges from “very
dissatisfied,” “dissatisfied,” “neutral,” “satisfied,”
to “very satisfied”.
Patients were asked to complete a satisfaction
questionnaire based on the Harvard scale, introduced
by Jay Harris in 1979. It classifies the overall
aesthetic results in four categories from excellent,
good, and fair to poor [27-29]. See (Table 3).
Post-operative complications such as prolonged
pain, hematoma, seroma, infection, flap necrosis,
compromised nipple and areola complex vascularity,
altered nipple and areola sensation, hypertrophic
scar formation and secondary symmetry procedure
were recorded. Informed consent was obtained
from all patients included in the study.
Technique used:
In the modified SOS technique, the patient is
marked pre-operatively as originally described by
Fahmy et al., 2006 [30] and the epsilateral breast
is treated as shown in (Table 2) and the marking
is repeated while the patient is under general anesthesia.
While the patient is under general anesthesia,
surgical stables were applied in the epsilateral
breast e.g.: After tumor excision and before changing
patient's position. The sitting position is adopted
to mark the midline, the midclavicular point, and
the breast meridian. It is marked as a straight line
joining the midclavicular point to the current nippleareola
complex extending down to the inframammary
fold.
The supine position is used to mark the inframammary
fold incision and the medial limit of
the vertical markings. The inframammary fold is
Egypt, J. Plast. Reconstr. Surg., January 2020 121
marked, with a very gentle pressure on the breast
mound, the breast will naturally fall laterally. A
straight line is drawn joining the superior limit of
the vertical limbs to the meridian. This will indicate
the medial limb of the vertical limbs.
The oblique position is taken to mark the lateral
limb of the vertical markings. The patient is
marked in the left and right oblique positions. In
the left oblique position, the right breast will
naturally adopt a medial position. A straight line
is marked joining the superior limit of the vertical
limb to the meridian. This marks the lateral limb
of the right breast. The same is done for the other
side.
Finally, the patient is returned to the sitting
position. The medial and lateral vertical limbs are
measured at a length of 7cm from the superior
limit of the vertical limbs. The two vertical limbs
are then joined to the medial and lateral ends of
the inframammary fold marking. See Fig. (1).
Table (1): Patient's data summary.
Etiology of asymmetry
Poland S
Infection
NASM
RMFA
Oncoplastic
SSM
Burn
TRAM
RMFA
Oncoplastic
Poland S
PMR LD, TE and prosthesis
SSM
TRAM
Oncoplastic
NAS M
TRAM
Poland S
NAS M
RMFA
Oncoplastic
JH
PMR: LD,TE and prosthesis
TRAM
JH
NASM
PMR: LD, TE and prosthesis
Burn
TRAM
Oncoplastic
SSM
PMR: LD, TE and prosthesis
JH
Oncoplastic
Oncoplastic
TRAM
Burn
Oncoplastic
TRAM
RMFA
PMR: LD, TE and prosthesis
Age
20
42
43
29
29
37
32
35
27
37
18
63
45
42
45
56
33
16
39
40
46
14
35
57
18
47
48
37
53
34
46
51
16
49
61
29
29
50
41
35
45
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
#
2
3
1
1
1
1
1
3
1
1
2
3
1
2
1
1
2
3
1
1
1
2
2
3
1
1
3
2
2
1
1
3
1
1
1
2
1
1
2
1
2
No. of
operations
Follow-up
(months)
19
12
22
3
20
17
6
30
7
25
6
17
10
12
21
25
18
7
11
9
23
6
13
15
8
16
10
5
8
25
18
14
8
16
19
4
7
10
6
4
11
DM
No
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Smoking
No
No
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Hypertension
No
No
No
Yes
No
No
No
No
No
yes
No
No
No
No
Yes
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
No
Yes
No
No
No
RT
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Chemo
therapy
No
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
: Diabetes Mellitus.
: Radiotherapy.
: Recurrent Multiple Fibro Adenoma.
: Juvenile Hypertrophy.
: Post Mastectomy Reconstruction.
DM
RT
RMFA
JH
PMR
: Skin Sparing Mastectomy.
: Nipple Areola Sparing Mastectomy.
: Transverse Rectus Abdominis Myocutaneous flap.
: Tissue Expander.
SSM
NASM
TRAM
TE
122 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
Table (2): Patient's categories and type of surgical intervention.
Primary breast asymmetry (congenital) (n=3):
- Poland syndrome
Secondary breast asymmetry (developmental) (n=3):
- Juvenile breast hypertrophy
Tertiary breast asymmetries (acquired) (n=35):
- Infection “following granulomatous mastitis”
- Burn
- Recurrent multiple Benign tumor excision n=4
- Malignant tumor excision:
1- Oncoplastic procedure (n=8)
2- Nipple areola sparing mastectomy N=4
3- Skin sparing mastectomy N=3
4- Post modified radical mastectomy reconstruction:
- TRAM N=7
- LD, tissue expander and prosthesis N=5
Classification of breast asymmetry (Nahai system) No. of
patients
2
1
1
2
1
3
3
1
1
4
3
3
1
3
12
1
6
4
1
• LD flap, tissue expander, prosthesis, fat grafting, contralateral
SOS technique mastopexy.
• Tissue expander, prosthesis, NAC transposition, contralateral
SOS technique mastopexy.
• Reduction mammoplasty using superior pedicle and SOS
marking technique.
• Reduction mammoplasty using inferior pedicle and SOS
marking technique.
• Tissue expander, prosthesis, NAC reconstruction, contralateral
SOS technique mastopexy.
• Scar revision, Z-Pasty, SOS technique mastopexy.
• Tumor excision, superomedial pedicle and SOS marking
technique mastopexy.
• Tumor excision, inferior pedicle and SOS marking technique
mastopexy.
• Superior pedicle, SOS marking technique in both sides.
• Superior medial pedicle, SOS marking technique in both
sides.
• Inferior pedicle, SOS marking technique in both sides.
• Mastectomy, LD, prosthesis, contralateral SOS mastopexy.
• Mastectomy, prosthesis, contralateral SOS mastopexy.
• Mastectomy, LD, prosthesis contralateral SOS mastopexy.
• TRAM flap, immediate contralateral SOS mastopexy, NAC
reconstruction.
• TRAM flap, immediate contralateral SOS mastopexy.
• LD flap, tissue expander, prosthesis, immediate contralateral
SOS mastopexy.
• LD flap, tissue expander, prosthesis, immediate contralateral
SOS mastopexy, NAC reconstruction.
Treatment
Table (3): Patient satisfaction score “Harvard scale”.
Patient
satisfaction
Excellent
Good
Fair
Poor
Description
• Treated breast nearly identical to untreated
breast.
• Treated breast slightly different than untreated.
• Treated breast clearly different from untreated
but not seriously distorted.
• Treated breast seriously distorted.
Table (4): Percentage of complications in the three groups of
patients.
Hematoma
Seroma
Prolonged pain
Infection
Delayed healing and flap necrosis
Compromised NAC vascularity
Altered NA sensation
Hypertrophic scarring
Secondary procedure
5.3%
21%
5.3%
5.3%
5.3%
5.3%
21%
0%
5.3%
Group
3
Group
2
0%
0%
21%
0
10.5%
5.3%
21%
0%
5.3%
Group
1
0%
66.7%
0%
0%
0%
0%
0%
33.3%
33.3%
RESULTS
This cohort retrospective study included 41
patients suffering from breast asymmetry and underwent
breast reconstruction surgeries and immediate
symmetry procedure in the contralateral
breast, with age range (14-63 years) and mean age
(38.3±12.5 years). Among these 41 patients; 3
patients (7.4%) were due to congenital cause (Poland
syndrome) with mean age (18±2 years), 19
patients (46.3%) were due to developmental causes
with mean age (35.3±12.2 years), while 19 patients
(46.3%) were due to iatrogenic causes with mean
age (44.5±8.9 years).
Operative time varied among each group;
(3±0.6) in congenital group (group 1), (3.3±0.5)
in developmental group (group 2) and (4±0.8) in
iatrogenic group, see Diagram (1).
Follow-up time varied among groups; (10.6±7.2
months) in group 1, (12.3±7.6 months) in group
2, and (14.6±6.4 months) in group 3.
Post-operative patient's assessment was done
objectively by using the 5 point subscale. Data
analysis showed highest score in group 1 (8±0.9),
then group 2 (7.6±1), while the lowest one was in
group (7.1±1). See Diagram (2).
Patient satisfaction score “Harvard scale” was
used for subjective evaluation. Data conducted
from this scale showed the same sequence as 5
point subscale; highest Score was in group 1 (7±1),
followed by group 2 (6.8±1) and the lowest score
was in group 3 (6.7±0.9), see Diagram (3).
In this current study, the mean of overall 5
point scale assessment for all 41 patients (objective
method) was (7.4±1) while the mean of overall
Harvard satisfaction scale for all patients (subjective
method) was (6.6±0.9). The overall correlation
between the objective assessment “5 point subscale”
and the subjective assessment “Harvard scale” was
done showing significant correlation with a p-value
<0.01, see Diagram (4).
Post-operative complication rate for all groups
of patients were recorded and analyzed. All recorded
complications were analyzed and tabulated
including hematoma, seroma, prolonged pain,
infection, delayed healing and flap necrosis, compromised
NAC vascularity, altered NA sensation,
hypertrophic scarring, and the need for secondary
procedure, see (Table 4) and Diagram (5). Some
of our patient's pre and post-operative photos are
shown in Figs. (2-11).
Egypt, J. Plast. Reconstr. Surg., January 2020 123
Group 1 Group 2 Group 3
Diagram (1): Operative time spent in each group of patients.
5 point scale assessment
Diagram (2): Relation between the three groups using the 5
point objective analysis.
8.0
7.8
7.6
7.4
7.2
7.0
6.8
6.6
Group 1 Group 2 Group 3
Diagram (3): Relation between the three groups using the
Harvard scale.
7.0
6.9
6.8
6.7
6.6
6.5
Group 1
Harvard scale
Group 2 Group 3
9
8
7
6
5
4
3
2
1
0
8 points scale
Harvard satisfaction
Diagram (4): Overall correlation
between 5 points subscale
assessment and harvard
satisfaction scale.
100
90
80
70
60
50
40
30
20
10
0
%
Hematoma
Altered NA
sensation
Seroma
Pain
Infection
Delayed
healing
Compromised
NAC vascularity
2ry procedure
Hypertrophic
scarring
Group 1
Group 2
Group 3
Diagram (5): Complication
rate and correlation among the
three groups of patients.
124 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
Fig. (1): Pictures showing the SOS marking technique, the (upper left) patient lying in supine position under general
anesthesia and the yellow arrows point on the infra mammary fold while the red ones point on the medial limb which continues
with the breast median. (The upper right) patient lying in oblique position Unger general anesthesia and the blue arrows point
on the lateral limb which continues with the breast meridian. (Lower left) showing the pre-operative marking, (lower right)
showing the meeting of both meridians while using a stapler to imagine an tailor the amount of skin and tissue to be excised.
Fig. (2): Patient with Poland syndrome. The 1st raw of photos showing the deformity, marking the anterior chest wall and
the trans axillary approach for harvesting the LD flap and application of tissue expander. The 2nd raw shows the post-operative
result after inflation of the tissue expander. The 3rd and 4th rows shows the pre and post-operative clinical picture after definitive
reconstruction with silicone implant and contralateral reduction mastopexy.
Egypt, J. Plast. Reconstr. Surg., January 2020 125
Fig. (3): Patient with Poland syndrome, sever deformity of the chest wall and spine, frozen shoulder, sand history of trauma over the back
treated with split thickness skin graft and mid line lower abdominal incision. (1st raw) showing the pre-operative clinical picture. (2nd raw)
after application of tissue expander, and the CT scan showing the deformity of the chest wall and spine. (3rd and 4th rows) showing the pre
and post-operative result after definitive reconstruction with silicone implant and reduction mastopexy off the contra lateral side.
Fig. (4): Patient with bilateral post burn contractures and scaring. (Upper raw) showing the pre-operative clinical picture. (Lower raw) after
release of the contractures by multiple z pasties and reduction mastopexy off both breast using the modified SOS marking technique.
126 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
Fig. (5): Patient with unilateral juvenile hypertrophy of the breast. (Upper raw) showing the pre-operative clinical picture. (Lower raw)
post-operative result after definitive reconstruction with the inferior pedicle and wise pattern skin closure by using modified SOS marking
technique.
Fig. (6): Patient with bilateral
recurrent multiple fibro
adenomas of the breast. (Upper
raw) showing the pre-operative
clinical picture. (2nd raw) postoperative
result after reconstruction
with inferior pedicle
and wise pattern skin closure
by using modified SOS marking
technique. (3rd raw) showing
the pre-operative marking.
(4th and 5th rows) showing the
left side pre and post mammography
result and unfortunately
missing the preoperative
mammography on
the right side.
Egypt, J. Plast. Reconstr. Surg., January 2020 127
Fig. (7): Patient with malignant breast cancer (duct carcinoma in situ) underwent oncoplastic breast conservation. (Upper photo) showing
the pre-operative marking and the lesion is at 12 o'clock on the left breast (2nd and 3rd rows) post-operative result after reconstruction with
inferior pedicle and wise pattern skin closure by using modified SOS marking technique.
Fig. (8): Patient with malignant breast cancer (duct carcinoma) underwent oncoplastic breast conservation. (Upper photo) showing the preoperative
marking and the lesion is at 11 o'clock on the right breast (2nd and 3rd rows) post-operative result after reconstruction with superior
medial pedicle and wise pattern skin closure by using modified SOS marking technique.
128 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
Fig. (9): Patient with post
mastectomy breast deformity.
(Upper row) showing the preoperative
clinical picture (lower
row) post-operative result after
reconstruction with TRAM flap
and mastopexy of the contralateral
side using modified SOS
marking technique.
Fig. (10): Patient with post
mastectomy breast deformity.
(Upper row) showing the preoperative
clinical picture. (Lower
row) post-operative result
after reconstruction with
TRAM flap, Lipofilling the upper
pole of the right breast, nipple
and areola reconstruction
with skate flap, full thickness
skin graft from the contralaral
breast and mastopexy of the
contralateral side using modified
SOS marking technique.
Fig. (11): Patient with post mastectomy breast deformity. (1st row) showing the pre-operative clinical picture and scaring of the right side
of the lower abdomen “previous appendectomy”. (2nd row) post-operative result after reconstruction with TRAM flap, the contralaral breast
was operated previously operated upon in another hospital. (3rd row) showing failed previous two attempts to reconstruct the breast using the
LD flap and anterolateral thigh flap in another hospital.
DISCUSSION
Aesthetic parameters of the breast affect greatly
the entire female beauty; therefore, congenital,
developmental and iatrogenic breast asymmetry
affect significantly patient's self-esteem [31,32].
Physiological breast asymmetry is a common and
achieving symmetrical breasts require different
strategies [33,34].
Reliable assessment for the aesthetic outcomes
are scarce. It could be done through questioners
answered by the patient, photograph to be assessed
by other plastic surgeons, or by other professional
e.g. nursing staff [35,46]. However, methods varies
widely between studies and often they are ill
defined. It is important to have standardized scoring
system, to objectify the subjective aesthetic
outcome.
The subjective assessment is the most commonly
used method for breast aesthetic evaluation
undertaken by one [47-58] or several observers [59-
73]. The most commonly, simple and cost effective
is evaluating the static photograph and using the
digital video has been proposed [74]. Potter 2011
stated the introduction of the 3-dimensional and
4-dimensional breast scanning. In our study we
used both the subjective method in the form of
questioner and the objective method as a standardized
scoring system [75]. Patients were asked to
complete a satisfaction questionnaire based on the
Harvard scale, introduced by Jay Harris in 1979
and we used the scoring method described by Visser
et al., [26]. To assess the breast volume, shape,
symmetry, scars, and nipple areola complex. For
each of these items a 5-point Likert scale is used
for scoring.
Patients were classified in our study into three
groups: Congenital breast deformities comprised
the first group. Sir Alfred Poland in 1841 enumerated
the anomalies and Patrick Wensley Clarkson
in 1962 who named the associated anomalies as
Poland Syndrome. The incidence is 1:20,000-
1:32,000, three time more common in males than
females and it is more commonly affecting the left
than the right side. Intrauterine fetal insult occurs
between the fifth and eighth weeks of gestation,
and genetic predisposition is not proven yet [76,77].
The clinical picture mandate the absence of the
pectoralis major muscle “sternal head “, but a wide
variety is mentioned in the literature [79].
We included three patients in our study. Two
patients treated with trans axillary harvesting the
latismus dorsi muscle flap and application of rounded
tissue expander with an internal valve (450,
500cc) as a first stage, inflation was done exceeding
the volume of the expanders and waiting for three
months. The second stage was delivery of the
expanders and application of breast implants and
simultaneous mastopexy and or mastopexy was
done in the contralateral side. A third stage was
in the form of Lipofilling in the takeoff area of
the breast. The third patient was treated in the
same sequence without doing a latismus dorsi
muscle transfer because of its atrophy, nor Lipofilling,
however nipple and areola transposition
was carried.
Data analysis showed the highest 5 point subscale
in this group of patients (8±0.9), and highest
patient satisfaction score “Harvard scale” (7±1).
The operative time was the high in this group due
to changing from lateral to supine the position
during surgery and matching the best breast volume
when choosing the breast implant. Seroma rate
was high on the donor site, managed by adhesive
compression taping and multiple cessions of drainage
by syringe. One patient had trans axillary
hypertrophic scar in the trans axillary approach
which entailed scar revision under local anesthesia.
The second group of patients included three
patients with juvenile hypertrophy of the breast.
It is a benign condition where rapid, and continued
breast hypertrophy occurs [80]. It is also described
as virginal hypertrophy, juvenile gigantomastia,
and juvenile macromastia [81,82]. Neinstein 1999
stated its rarity (2% of all breast lesions) after
reviewing 15 publications over 40 years period
[83]. Hoppe et al., 2011 reported 65 cases between
1910 and 2009 [82]. Additional nine cases from
2010 till 2017 [86-90]. The most challenging aspect
in the management of JHB is the difficulty in
effecting a definitive treatment. Using reduction
mammoplasty techniques is ideal, reported recurrence
rate is high which might necessitate secondary
intervention [80-82].
Three patients with unilateral juvenile hypertrophy
of the breast were included in our study.
Wise pattern reduction mammoplasty utilizing the
superior pedicle in one patient and inferior pedicle
in two patients and SOS marking technique in the
contra lateral side. No recurrence were reported
with an average follow-up time (12.3±7.6 months).
The operative time was high due to the time needed
for excision of the huge size breast, adequate
hemostasis and symmetry reduction and mastopexy
on the contralateral side. Patient's satisfaction and
the objective 5 point subscale analysis was (6.8±1),
(7.6±1) respectively denoting above average aesthetic
outcome. Post-operative complication rate
Egypt, J. Plast. Reconstr. Surg., January 2020 129
130 Vol. 44, No. 1 / Solving the Dilemma of Congenital & Pathological Breast Asymmetry
was high as regard prolonged breast pain due to
the skeletal neck and shoulder pain which takes
few months to recover. Altered nipple and areola
sensation and vascularity due to the extensive
dissection and excision of the pathological breast
tissue. Secondary sutures was done in one patient
had delayed wound healing over the meeting point
between the horizontal and vertical incision.
In our study the third group of patients included:
Infection, post burn scarring, benign and malignant
tumor excision and post mastectomy asymmetry.
Granulomatous mastitis and post burn scaring
significantly affects both the size and contour of
the breast with variable degrees of nipple areola
complex affection. If the insult occurs before
puberty breast development will be affected. If it
is after puberty breast shape will be altered due to
the presence of scar contractures which alter the
parenchyma of the breast [91-94]. One patient with
post granulomatous mastitis asymmetry included
in the study managed by: Tissue expansion (rounded
expander 450cc, over inflated 600cc and left
for three months) followed by prosthesis reconstruction
and symmetry SOS mastopexy on the
contralateral side. Three months later skate flap
and full thickness skin graft were used to reconstruct
the nipple areola complex. Post burn scaring
of the breast included three patients managed by
scar revision, Z-Pasty and bilateral SOS mastopexy.
Breast-Conserving Therapy (BCT) is one of
the most effective and commonly used surgical
oncological therapy for breast cancer, however it
but it significantly affect breast symmetry. This
depend on the balance between the volume of tissue
to be excised “lumpectomy” and the total breast
volume [95-103]. Patients with ptotic and hypertrophic
breasts with a relatively large lumpectomy
volume, immediate oncoplastic reconstruction
could be done by means of reduction or mastopexy
pattern techniques, at the time of the lumpectomy.
The aim is to obliterate the lumpectomy dead space
and reduce the potential breast asymmetry and
distortion that will follow after radiation therapy
[104].
Oncoplastic reduction mastopexy procedures
are safe, showing high patient satisfaction and
favorable aesthetic outcome. This procedure can
be done immediately, at the time of the lumpectomy
or delayed, after the radiation therapy [104-119].
Each protocol has its advantage and disadvantage
regard the tumor margins, complications (radiated
tissue), secondary intervention, and aesthetic results
[119].
Weichman et al., retrospectively studied patients
undergone BCT without immediate oncoplastic
reconstruction looking for improving the aesthetic
outcome after completion of the oncologic therapy.
He concluded that irradiation and previous surgical
intervention is a surgical challenge to correct the
breast deformity asymmetry with four to ten time's
higher risk of delayed wound healing, infection,
and scarring in breast reduction after BCT [114].
Others demonstrated lower complication rates
in post irradiated breast asymmetry management
when surgical patient education and surgical refinement
in the form of: Avoiding excessive skin
undermining [114-120], wide nipple areola complex
pedicle [115-117], and thick skin flaps dissection
[115-117,120]. A major drawback is the limited
number of patients included in these studies [114-
120]. Barnea 2019 studied 25 patients with post
irradiated breast deformity looking for breast symmetry
procedure. The main outcome of the study
was the complication rate and reoperations but no
aesthetic evaluation were provided [121].
In our study the third group of patients included
patients with recurrent multiple benign tumor,
oncoplastic procedures, nipple areola sparing mastectomy,
skin sparing mastectomy and post modified
radical mastectomy reconstruction, see (Table
2). The operative time was maximum in this group
of patients (4±0.8) which explains the complexity
and the surgical challenge in such patients. Oncoplastic
procedures entails intraoperative frozen
section biopsy, changing the operative position
when latismus dorsi is used for post mastectomy
reconstruction, and matching symmetry in patients
with TRAM flap reconstruction. The longest period
of follow-up was noted (14.6±6.4 months) with no
recurrence of malignancy. Objectively by using
the 5 point subscale was the lowest as compared
to the other groups (7.1±1). Patient satisfaction
score “Harvard scale” was lowest score as well
(6.7±0.9).
Out of 35 patients in the third group of patients,
one patient with post mastectomy deformity and
history of radiotherapy, reconstructed with LD flap
and application of tissue expander developed postoperative
hematoma (after 24 hours), at the anterior
chest wall (recipient site) required evacuation and
hemostasis under general anesthesia. One patient
with history of smoking treated with nipple areola
sparing mastectomy, application of breast implant
and contralateral SOS mastopexy, developed subcutaneous
seroma over the anterior chest wall and
ultrasound guided aspiration was used for drainage.
Compromised NAC vascularity which managed
with dailey dressing. Patient complaint of altered
nipple and areola sensation which is a normal
squeal in this type of mastectomies. And lastly 53
years old patient with history of radiotherapy and
hypertension having post modified radical mastectomy
deformity, reconstructed with TRAM flap
and immediate contralateral SOS mastopexy, and
developed fat necrosis followed by wound infection
and disruption of the recipient site, which required
debridement of the necrotic fat and 2ry sutures
under general anesthesia.
The study has a number of week points. It is a
cohort retrospective study with potential bias in
patient selection and outcome, objective analysis
using soft wear programs for accurate breast measurements
could be used in further studies.
Conclusion:
It is a novel marking technique solved the
dilemma of changing the pre-operative plane according
to the intraoperative judgment and altering
the amount of tissue to be excised or reconstructed
in patients suffering from congenital and pathological
breast asymmetry. It is technical easy to learn,
reliable with satisfactory aesthetic outcome especial
in congenital asymmetries, with acceptable complication
rate.
Acknowledgments:
We would like to thank the breast multidisciplinary
team and nursing staff for their preoperative,
operative assistance and post-operative
care of the patients included in the study.
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