Surgical Reconstruction of Iatrogenic Symmastia

Sir: Symmastia, medial confluence of the breasts producing a web across the midline, is occasionally encountered clinically, but it is uncommon.1 It may be congenital or iatrogenic. Iatrogenic symmastia occurs following overaugmentation, when the midline sternal attachment becomes disrupted. This usually occurs as a result of overaggressive dissection of the implant pocket medially, which results in communication of the two breast implant pockets and obliteration of the cleavage. We present one case to highlight the problem and to present the surgical approach used to correct the deformity. A 27-year-old woman presented to our department with the complaint of a soft-tissue web over the sternum connecting the breasts. She had undergone breast augmentation elsewhere several months earlier (Fig. 1). She was dissatisfied with the existence of a central breast web. With access through the inframammary folds, her 295-cc silicone gel implants were removed. We observed a communication of the two breast implant pockets with obliteration of the cleavage. The anterior and posterior capsule was then incised medially on each side one to two fingerbreadths apart. The flaps were sutured to each other with two rows of absorbable suture (Vicryl 3-0 W9890). We also performed transcutaneous suturing of the presternal soft tissue to the sternum periosteum utilizing Vicryl 2-0 W9718 suture. Then 265-cc silicone gel–filled prostheses (round with textured surface) were implanted subpectorally. Routine closure was performed and a supportive garment was applied. At 2-year follow-up, the result is still favorable. Our patient was successfully treated with no recurrence, parasternal scarring, or infection (Fig. 2). Neither puckering nor dimpling was visible in the patient's central chest.Fig. 1.: A 27-year-old woman with a soft-tissue web over the sternum connecting the breasts.Fig. 2.: Two-year postoperative result.Iatrogenic symmastia is difficult to treat and recurrence is common. Correction requires combined restoration of the presternal subcutaneous integrity and medial closure of the pocket. In our case, we removed the implants and performed a combination of medial closure of the pocket on each side and transcutaneous suturing of the presternal soft tissue to the sternum periosteum. The prostheses were implanted during the same stage. It is essential that oversized implants not be used. The tension of the implant must not be allowed to work against the suture repair. Several other methods have been described for surgical reconstruction of iatrogenic symmastia, such as allogenic dermal grafting,2 fibrin-based tissue glue,3 and delayed filling of the adjustable implant.4 Even though it has been reported that transcutaneous fixation may lead to scarring and infection,5 in our hands, the combination of medial closure of the pockets and transutaneous suturing of the presternal soft tissue to the sternum periosteum was successful. It led to reconstruction of the presternal median cleavage without parasternal scarring or infection. The result was judged satisfactory by both the patient and the surgeons. The combination of medial closure of the pockets and transcutaneous suturing of the presternal soft tissue to the sternum periosteum provides one satisfactory option to the surgical reconstruction of iatrogenic symmastia. Andreas Foustanos, M.D. Harris Zavrides, M.D., Ph.D. Department of Plastic Surgery IASSO Hospital Athens, Greece DISCLOSURE Neither author has any financial interests in this communication.