INTRODUCTION
In addition to their role in the physiology of lactation, breasts are related to femininity,
sensuality, and self-esteem. Variations in normality, shape, volume, or position affect
women psychologically and are an essential cause of demand in plastic surgery offices1.
The recognition of the importance of breast asymmetry dates from 1968 when the author
describes the surgical treatment modalities2. The interest in creating a classification was growing and, in 1976, Elsahy2, proposed a morphological classification of breast asymmetries, in order to facilitate
preoperative planning. Later, in 19843, Vandenbussche subdivided them as to their etiology into four types (1 - congenital,
2 - primary, 3 - secondary, and 4 - tertiary), concluding that type 2 asymmetry was
the most frequent2. In 2006, another group analyzed 177 patients with breast asymmetries to propose
a classification and its treatment4.
These works contributed to the understanding of breast asymmetries and their treatment,
but a more simplified and reproducible update to clinical practice, added to the new
therapeutic modalities available, is a medical need that has not yet been met. Gross
anomalies, such as Poland’s syndrome, are widely discussed, but there is an evident
need to detail Vandenbussche’s type 23, not only for its incidence but also because it is the subtype that most refer to
the aesthetic character of these abnormalities. Another critical milestone to be considered
was the consecration of fat grafting within the therapeutic arsenal of breast surgeries,
which had its condemnation phase, but is now widely accepted, both in reconstructive
and aesthetic surgeries5.
OBJECTIVE
The present work proposes a practical and simplified classification of breast asymmetries
with the highest incidence in plastic surgery offices, and with a more accurate diagnosis,
it proposes to guide surgical treatment.
METHODS
The textual search was carried out on PubMed with the terms “breast” and “asymmetry”
and articles that had the proposal to classify breast asymmetries were considered
eligible. Also included were articles dealing with the subject of asymmetry even though
it did not propose a classification. After confronting the information collected about
classification and treatment, an attempt was made to make the classification more
simplified and reproducible at the clinical practice, taking into account, in this
new classification, the patient’s possible interest in the final volume of the breasts
and the incorporation of fat grafting, as a therapeutic arsenal. Chest asymmetries,
as described in the Vandenbussche classification, in 19843, despite its high relevance and limitations for better results in correcting breast
asymmetries, were not included in the new classification proposal, since plastics
surgeons do not address most of them.
RESULTS
In Chart 1, we see the principal authors with their respective classification proposals.
Chart 1 - Classifications available for mammary asymmetry.
Hueston (1968)1 (review)
|
1 - Unilateral aplasia; |
2- Unilateral hypoplasia; |
3- Hypertrophy; |
4- Destruction of the nipple-areolar complex (NAC); |
5- Mastectomy. |
Elsahy (1976)2 |
1- Unilateral hypertrophy; |
2- Unilateral hypotrophy; |
3- Hypo and hypertrophy. |
4- Bilateral hypertrophy; |
5- Bilateral hypotrophy. |
Vandenbussche (1984)3 (150 patients)
|
1- Congenital; |
2- Primary; |
3- Secondary; |
4- Tertiary. |
Araco et al. (2006)4 (177 patients)
|
1- Bilateral hypertrophy (n = 30); |
2- Hypertrophy, normotrophy (n = 15); |
3- Hypertrophy with amastia or hypoplasia (n = 10); |
4- Amastia or hypoplasia, normal contralateral (n = 5); |
1- Bilateral hypoplasia (n = 81); |
2- Unilateral ptosis (n = 36). |
Chart 1 - Classifications available for mammary asymmetry.
In the classification proposed in this work (Figure 1), the first group presents hypotrophic breasts with volume asymmetry (type 1), the
second group presents volume and shape asymmetry in hypotrophic breasts (type 2).
Normotrophic breasts are included in types 3 and 4, they have breast ptosis and have
been subdivided into those who wish to maintain volume (type 3) and those with a desire
for volumetric increase (type 4). And finally, asymmetric hypertrophic breasts in
type 5.
Figure 1 - Proposed simplified classification for breast asymmetries.
Type 1 |
Hypotrophic breasts with volume asymmetry |
|
Type 2 |
Hypotrophic breasts with volume and contour asymmetry |
|
Type 3 |
Normotrophic breasts, with ptosis, with no desire for volumetric increase |
|
Type 4 |
Normotrophic breasts, with ptosis, and desire for volumetric increase |
|
Type 5 |
Hypertrophic asymmetric breasts |
|
Figure 1 - Proposed simplified classification for breast asymmetries.
After the classification described in Figure 1 and based on the treatments recommended
by the medical literature, the surgical planning protocol was created and used for
the therapeutic decision, as shown in Figure 2.
Figure 2 - Surgical planning protocol to correct breast asymmetries.
Figure 2 - Surgical planning protocol to correct breast asymmetries.
In type 1, the breasts are hypotrophic and have a similar contour. The simple prostheses
placement of different volumes is enough. Particular attention should be given when
measuring breast volume and estimating which difference in volume and/or profile to
use. Most of the time, the experience of the surgeon associated or not with the use
of molds is sufficient. Techniques that use Archimedes’ law to measure volume turn
out to be of difficult clinical applicability6 and three-dimensional scanning software is still poorly accessible to most surgeons.
In type 2, simply placing different implants is not enough. Some areas of the breast,
after the placement of the prostheses, deserve a thorough analysis with the stretcher
in an elevated headboard position and the areas for fat grafting demarcated. In this
situation, we may have a volumetric deficit in any of the breast poles or in the entire
breast. The fat preparation technique ranges from simple decanting7 to the Coleman technique (1995)8 and the fat infiltration performed with 1.8mm cannulas in the subcutaneous and intramammary
plane4,8
In type 3, the patient has ptosis and is satisfied with the volume of the breasts
and/or does not want the use of implants. In this case, simple mastopexy is performed,
using the surgeon’s experience technique, drying the mammary parenchyma of the largest
breast sufficiently for volumetric symmetrization9,10.
Type 4 also presents ptosis and differs from type 3 only by the patient’s desire to
increase the final volume, and, for this reason, breast implants are used during a
mastopexy. Priority is given to identical implants, and symmetrization is done by
manipulating the breast parenchyma. In this group, refinements with fat grafting can
also be of great value.
In type 5, there is asymmetry with evident breast hypertrophy, and, in this case,
there is an indication of symmetrization through reduction mammoplasty with recognized
techniques(10,11 )such as Pitanguy, in 196712 and Silveira Neto, in 197613.
RESULTS
In Figure 3A, there is a type 1 breast asymmetry, whose treatment was performed with a Mentor
300ml breast prosthesis (subfascial plane) on the right and 275ml on the left, both
with a high profile.
Figure 3 - Clinical cases of breast asymmetry with their classification and surgical treatment.
Figure 3 - Clinical cases of breast asymmetry with their classification and surgical treatment.
In Figure 3B, we have an asymmetry of volume and contour, configuring type 2. On the left, the
surgical mark and the liposuction area in the underarm region are shown. In this case,
the prostheses (subfascial plane) used were quite different: textured Silimed 230ml
high model on the right and 305ml extra high on the left, in addition to global fat
grafting on the left and medial pole on the right. In detail, the surgical marking
and liposuction area.
Figure 3C shows another example of type 2 asymmetry, but asymmetry predominated in contour
and mammary fold. In this case, it was decided to keep the same prosthesis textured,
330ml extra high Silimed (subfascial plane), mammary fold lowering, and fat grafting
of the lower poles of both breasts.
In Figure 3D, there is a case of type 3 asymmetry, where there is breast ptosis and the patient’s
desire to keep the breast volume smaller. Mastopexy performed using the Pigossi technique,
resulting scar in inverted T.
In another case of type 4 asymmetry (Figure 3E), the patient has ptosis but wishes to increase the breast volume. It was indicated
mastopexy with prosthesis and marking proposed by Pitanguy 196712, using a 200ml prosthesis in the subglandular plane.
Finally, a case of type 5 breast asymmetry (Figure 3F), in which there is evident breast hypertrophy with dense and ptotic breasts. We
opted for the reduction mammaplasty technique with superomedial pedicle, a technique
by Silveira Neto (1976)13.
DISCUSSION
As it is a frequent pathology and of unique importance in women’s self-esteem and
well-being, breast asymmetry is a reason for the high demand in plastic surgery offices.
The analysis of this pathology begins with adequate clinical evaluation of the patient,
in all its aspects such as volume, contour, consistency, and presence of ptosis. The
creation of classification systems facilitates the language between specialists, and
the protocols guide the forms of treatment.
Obviously, each patient is unique and must be assessed individually, since breast
asymmetry is considered the rule and not the exception. Several morphometric studies
have attempted to establish fixed points for better breast evaluation. However, they
presented limitations both in vivo and through photographs, as they were linear measures14. Despite these limitations, several of these parameters have been used since its
publication in 1986, as the distance between the sternal furcula and the nipple, and
the distance between the nipple and the mammary fold15. Perfect breast symmetry, even according to morphometry studies, is practically nonexistent
in the pre- or postoperative period, but it is a reality and not a distortion of the
patient’s self-image, therefore deserving its due respect. Brown et al., In 199916, demonstrated that the finding of asymmetry is more frequently reported in patients
looking for reduction mammoplasty compared to patients looking for breast augmentation.
Classifications favor more accurate diagnoses and, when associated with treatment
protocols, minimize the chances of errors due to inappropriate conduct. An example
of this is the high incidence of postoperative breast asymmetry demonstrated in a
retrospective study after breast augmentation surgery, concluding that preoperative
systematizations are essential to minimize conduct errors17.
Stark’s work in 199118 demonstrates how classifications translate a universal language among surgeons. Its
preoperative analysis was based on the classifications of Elsahy (1976)2 and Vandenbussche (1984)3, and the study aimed to propose an objective assessment of asymmetric breasts in
the postoperative period using standardized measures18. The classification of Vandenbussche (1984)3 takes into account only the etiology of asymmetry (congenital, primary, secondary
or tertiary), which is of great value for reconstructive surgery, but somewhat limited
for aesthetic cases since the vast majority would fit in the congenital and primary
etiologies. The classification of Elsahy (1976)2, on the contrary, assesses in detail the breast asymmetries from a clinical and morphological
point of view, subdividing them into five main groups. Its limitation is the analysis
complexity, with multiple possible associations involving breast trophism and not
evaluating the patient’s desire regarding the change in her breast volume.
In 2006, Araco et al. noted the evident need for a new classification and, based on
their sample of 177 patients, subdivided the asymmetries into six categories and proposed
the respective treatment for each one. At work, however, there is no mention of fat
grafting in its treatment algorithm as a valuable adjuvant therapy and does not mention
the current and relevant desire of the patient regarding the final breast volume considered
normotrophic4. Emphasizing the need for such classifications for better understanding, clinical
analysis, and communication among professionals, Roxo et al., in 200919, proposed a classification and treatment of mammoplasty; however, this classification
is limited to patients after massive weight loss.
A standardized language undoubtedly facilitates the discussion of cases and the exchange
of experiences, guiding the conduct of the less experienced and making the dialogue
with the patient in the preoperative medical consultation clearer.
CONCLUSION
The extensive review of the literature allowed the creation of a simpler and reproducible
classification of breast asymmetries. It was added to the treatment protocols already
established in this work, fat grafting as an adjunct in the treatment of asymmetries.
The patient’s desire regarding the final volume of her breasts was also included.
REFERENCES
1. Hueston JT. Surgical correction of breast asymmetry. Aust NZJ Surg. 1968 Nov;38(2):112116.
2. Elsahy NI. Correction of asymmetries of the breast. Plast Reconstr Surg. 1976 Jun;57(6):700-3.
3. Vandenbussche F. Asymmetries of the breast: a classification system. Aesthetic Plast
Surg. 1984;8(1):27-36.
4. Araco A, Gravante G, Araco F, Gentile P, Castrí F, Delogu D, et al. Breast asymmetries:
a brief review and our experience. Aesthetic Plast Surg. 2006 Mai/Jun;30(3):309-19.
5. Illouz YG, Sterodimas A. Autologous fat transplantation to the breast: a personal
technique with 25 years of experience. Aesthetic Plast Surg. 2009 Set;33(5):706-15.
6. Stark B, Olivari N. Breast asymmetry: an objective analysis of postoperative results.
Eur J Plast Surg. 1991;14:173-6.
7. Tezel E, Numanoglu A. Practical do-it-yourself device for accurate volume measurement
of breast. Plast Reconstr Surg. 2000 Mar;105(3):1019-23.
8. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic
Plast Surg. 1995 Set/Oct;19(5):421-5.
9. Sakai RL, Tavares LC, Soares RA, Oliveira IN, Komatsu CA, Faiwichow L. Mastoplastia
de aumento em mamas assimétricas: implantes de silicone + lipoenxertia. Rev Bras Cir
Plást. 2013;28(3 Supl 1):1-103.
10. Pigossi N, Andrade A, Calange H. Mamaplastia estética e funcional - experiência de
25 anos. Arq Catar Med. 1994;23:19-22.
11. Ariè G. Nova técnica em mamoplastia. Rev Lat Amer Cir Plást. 1975;3:28.
12. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg.1967;20(1):78-85.
13. Silveira Neto E. Mastoplastia redutora setorial com pedículo areolar interno. In:
Anais do XIII Congresso Brasileiro de Cirurgia Plástica e I Congresso Brasileiro de
Cirurgia Estética; Abr 1976, Porto Alegre, RS, Brasil. Porto Alegre (RS): SBCP; 1976.
14. Quieregatto PR, Hochman B, Furtado F, Ferrara SF, Machado SF, Sabino Neto M. Photographs
for anthropometric measurements of the breast region. Are there limitations?. Acta
Cir Bras. 2015;30(7):509-16.
15. Smith Junior DJ, Palin Junior WE, Katch VL, Bennet JE. Breast volume and anthropomorphic
measurements: normal values. Plast Reconstr Surg. 1986 Set;78(3):331-5.
16. Brown TP, Ringrose C, Hyland RE, Cole AA, Brotherston TM. A method of assessing female
breast morphometry and its clinical application. Br J Plast Surg. 1999 Jul;52(5):355-9.
17. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast
augmentation: a retrospective analysis of 100 patientes. Plast Reconstr Surg. 2003
Apr;111(4):1513-9;discussion:1520-3.
18. Stark B, Olivari N. Breast asymmetry: an objective analysis of postoperative results.
Eur J Plast Surg. 1991;14(4):173-6.
19. Roxo CDP, Rodrigues EW, Roxo ACW, Aguiar EBP. Classificação e abordagem de mamas pós-grandes
perdas ponderais. Rev Bras Cir Plást. 2009 Jul/Set;24(3):310-4.
1. Private Clinic, São Paulo, SP, Brazil.
2. Hospital das Clínicas, Faculty of Medicine, University of São Paulo, SP Brazil.
3. Instituto Boggio, São Paulo, SP, Brazil.
Corresponding author: Gladstone Eustáquio de Lima Faria, Rua Alves Guimarães, 462, Sala 31, São Paulo, SP, Brazil. Zip Code: 05410-000. E-mail:
gladstonefaria@hotmail.com
Article received: July 24, 2019.
Article accepted: February 29, 2020.
Conflicts of interest: none.