Symmetry Procedures in Breast Reconstruction

Introduction

Achieving optimal symmetry is the primary goal of unilateral and bilateral breast reconstruction. In cases of unilateral breast reconstruction, which is the focus of this chapter, this often requires a secondary procedure on the ipsilateral breast and/or contralateral breast. It is estimated that up to 70% of women will undergo one or two procedures in an attempt to obtain symmetry. The primary operations utilized include augmentation mammaplasty, mastopexy, and reduction mammaplasty. Additionally, autologous fat grafting can further refine and correct contour deformities on both breasts, yielding a more natural and symmetric appearance.

The discussion of the likely need for such a symmetry procedure should occur at time of initial consultation with the patient, when breast reconstruction is discussed. The patient should be informed that both the need and desire for a contralateral symmetry procedure will be high. Furthermore, the timing of this procedure should also be discussed. In addition to discussing the likely procedures necessary, based on the patient's goal size for the reconstructed breast, the different external scars that may result on both breasts should also be described.

The timing of secondary and symmetrizing operations remains an issue of debate. Proponents of simultaneous contralateral operations argue better aesthetics without an increased complication rate, and a reduction in the number of overall operations. However, opponents contend that immediate postoperative changes in the reconstructed breast, primarily swelling, are often unpredictable, and a more symmetric final result may be achieved by waiting until the reconstructed breast has reached its ultimate size and location on the chest wall prior to matching. Ultimately, either approach is acceptable, as long as the patient understands the benefits of each, and makes an informed decision.

In planning the approach, the plastic surgeon must also account for timing around any adjuvant oncologic treatment being delivered to the patient. If a contralateral operation is not done at the time of the patient's initial reconstruction, it is preferable to delay until the patient has completed any adjuvant chemotherapy or radiation therapy. Because the reconstructed breast will often be operated on simultaneously, for aesthetic enhancement, such an approach will reduce complication rates, and improve symmetry.

Indications and Contraindications

It is the authors’ opinion that almost every patient undergoing unilateral breast reconstruction will be a candidate for some form of contralateral breast symmetry procedure. This is offered with the goal of achieving optimal aesthetic outcome. The key is selecting the appropriate procedure in each patient's situation.

For those patients undergoing a large size increase from native to reconstructed breast, then a contralateral augmentation mammaplasty will usually be offered ( Fig. 18.1 ). This is the consistent method used for achieving volume symmetry in these patients. When offering this procedure, the surgeon must ensure the patient has appropriate soft tissue quality to support either a subglandular or submuscular implant placement. Furthermore, if greater than grade 1 ptosis exists on the breast, the need for a simultaneous mastopexy should be discussed.

For those patients in whom a smaller reconstruction volume is achieved, relative to native breast size, a contralateral reduction mammaplasty is offered. The primary techniques considered for reduction include the classic inverted “T” inferior pedicle (Wise pattern), and the vertical pattern with medial or superior-medial pedicle. The Wise pattern reduction is reserved for patients with grade 3 breast ptosis, in need of significant skin resection, and greater than 800 g parenchymal resection. The vertical pattern is used for breasts with grade 2 ptosis, and anticipated parenchymal resection of less than 800 g. The authors’ preference is the vertical pattern, as it results in a breast with greater projection, and longer lasting result, due to the parenchyma reshaping involved; thus, this better matches a reconstructed breast.

In patients requiring correction of nipple–areola complex (NAC) position on the breast, without alteration of breast size, mastopexy is preferred. In the authors’ experience, when used for contralateral symmetry in breast reconstruction, mastopexy is often performed in conjunction with another procedure for symmetry on that breast. Most commonly, it accompanies an augmentation mammaplasty, for further correction of NAC height. Alternatively, it can be performed as a component of a reduction mammaplasty, which also elevates the NAC position, in conjunction with size reduction. All patients must undergo careful evaluation of changes in NAC position in the reconstructed breast, when nipple-sparing mastectomy (NSM) is performed, and allow this to guide the need for contralateral mastopexy. Oftentimes with NSM and prosthetic reconstruction, there is NAC elevation, due to skin and/or muscle contraction.

Autologous fat grafting is promoted by the author for almost all reconstructive patients, given that fat injection carries a multitude of benefits, both aesthetic and restorative. Most commonly, autologous fat grafting is performed on the reconstructed breast, for enhancing upper pole aesthetic symmetry with the native breast. In the reconstructed breast, upper pole parenchyma resection during the mastectomy results in tissue deficit and hollowing, and autologous fat grafting is an ideal correction. On the contralateral breast, fat grafting can similarly restore volume and enhance contour in specific, isolated areas of the breast. Furthermore, autologous fat offers restoration of tissue quality in the breast, due to its high stem cell concentration, and this benefits both breasts.

In all cases, the only absolutely contraindication to contralateral symmetry procedures is active smoking. In such cases, the elective procedures should be delayed until the patient has quit smoking for a minimum of 6 months. Relative contraindications to these procedures include a contralateral breast with a history of prior radiation therapy, obesity, or a preoperative breast shape/size that makes achieving reasonable symmetry unlikely.

Preoperative Evaluation and Special Considerations

During a patient's initial preoperative evaluation, the surgeon must discuss patient-specific reconstructive options, while also addressing patient goals and expectations for both breasts. At this visit, a complete breast and oncologic history should be obtained, with particular emphasis on need for adjuvant treatment therapies including chemotherapy and radiation. While the ultimate goal of complete oncologic resolution should take precedence, the timing and coordination of reconstructive procedures can often impact reconstruction success and final cosmesis.

A careful examination and measurement of key landmarks on both breasts is critical, particularly breast base width, distance from nipple to inframammary fold, and distance from sternal notch to nipple ( Figs. 18.2–18.4 ). Any asymmetries must be noted, in both position and size of the NAC on both breasts. Furthermore, these measurements must be repeated on the reconstructed breast through the treatment, as the NAC position can change through mastectomy and reconstruction, and this must be accounted for when planning contralateral symmetry procedures.

Finally, the projection of both breasts must be assessed carefully. The majority of prosthetic reconstruction is performed with high or enhanced high projection implants. This will often result in the need to either increase or decrease projection of the contralateral breast, which can be accomplished by accurately planning the augmentation mammaplasty or reduction mammaplasty, respectively.

Surgical Techniques