5 Breast Deformities
As mentioned earlier, the breast—viewed as a fundamental symbol of femininity—is extremely important in a woman’s life, forming an integral part of her physical and psychological sense of wholeness. Any deviation from normal size or shape is considered unattractive. This is by no means merely an aesthetic problem. The long-term negative effects on body image and emotional well-being can significantly reduce a woman’s self-esteem and quality of life.
In the past two decades, plastic surgery has addressed this issue by developing well-balanced surgical measures that allow fundamental breast corrections. Along with advances in surgical technique, the development of silicone breast implants has contributed greatly to improvements in this area. All surgical measures have the common goal of improving the appearance of the breast to conform to what the patient finds aesthetically pleasing. Changes may involve reducing size; altering the shape without reducing substance; enlargement; or establishing symmetry. The indications for surgical treatment are thus based on different assessment criteria. For the patient, breast deformity is a significant cosmetic problem and may result in psychological distress. Treatment may be indicated for either aesthetic or psychological reasons, and sometimes these overlap. A somatic indication is present in patients in whom physical complaints are the main presenting symptom. Abnormally large breasts can cause actual structural symptoms—particularly pain in the breast and back. A social indication for treatment may be based on issues such as personal or job-related problems resulting from breast deformity.
Breast augmentation and reduction procedures are no longer regarded as being purely cosmetic measures. They are now accepted forms of medical treatment for physical and psychological disorders.
Classification of Congenital Breast Deformities
The most common congenital deformities are breast asymmetry, tuberous (or tubular) breast deformity, and Poland syndrome. Severe hypoplasia or hypertrophy of breast tissue in excess of what is considered “normal” can also be regarded as a type of deformity.
Tuberous breast deformity in particular is often present in varying degrees in hypoplastic or hypertrophic breasts. This can makes precise differentiation difficult.
It is important for the appearance of the breast to be classified as a deformity or disorder in order to ensure coverage by the patient’s health insurance. While hypoplastic breasts are seldom recognized as requiring medical treatment, refusal to cover treatment of other deformities should not be tolerated.
Surgical treatment of breast hypertrophy is indicated for medical reasons when—as shown in studies by Zwiorek and colleagues—the resection weight per breast is at least the minimum of the square of the patient’s body mass index (BMI2 g).
Even in patients with “natural” breast asymmetry, obvious asymmetry should be classified as a deformity. There are always a few patients in whom repeated corrections requiring follow-up surgery are needed. It is therefore advantageous to have the asymmetry recognized as a medical indication.
This chapter focuses on deformities. Surgical techniques for treating hypoplastic and hypertrophic breasts are described elsewhere in the book.
When assessing breast asymmetry, it is necessary to evaluate the anatomic structures contributing to the asymmetrical appearance. These include the thoracic wall, muscle, and mammary gland. Often an asymmetrical chest wall can cause the breasts to appear asymmetrical. If other parts of the body are also affected by developmental anomalies, it is likely that the patient has Poland syndrome (p. 72).
In simple breast asymmetry, there is abnormal growth of one breast. The beginnings of a tuberous breast deformity are also often recognizable.
When establishing a recommendation for treatment, it is important for the “normal” breast to be identified. The appropriate treatment is determined by the normal breast. The patient’s personal preferences with regard to size and shape also play a significant role.
In principle, surgical treatment should be oriented toward adjusting the larger breast to match the smaller one, thereby avoiding an increase in volume. However, the reality is that most patients prefer augmentation to reduction. Depending on the initial clinical picture and the patient’s wishes, symmetry is achieved by a combination of the reduction and augmentation methods described in the other chapters of this book.
Often, one breast is larger and usually ptotic, while the other is firm and mildly hypoplastic. Surgical management thus frequently consists of a combined intervention involving augmentation on one side and a breast lift on the other ( Figs.5.1, 5.2 ).
It can be difficult to determine the difference in size between the two breasts. Nevertheless, it is important to determine the size of the breasts as accurately as possible, even for planned reductions, before surgery (e. g., with the aid of sample implants). Intraoperative assessment of the patient in a sitting position (preferably with supported arms) is equally important. The augmented breast usually appears larger, since the implant cannot be compressed.
Despite the various options available in plastic surgery that make it possible to come close to establishing symmetry, the patient should be informed that absolute symmetry is impossible to achieve and that over time, the larger, ptotic breast will increasingly droop again.