Symmastia after Breast Augmentation with Fat Grafting: Report of a Rare Case.

Abstract

Sir: Fat grafting enjoys increasing popularity as an autologous filler for breast augmentation. A comprehensive description of its complication optimizes patient selection and improves aesthetic results. Inspired by the systematic review of Mathias Ørholt et al.,1 we would like to report a rare complication following breast augmentation with fat grafting. A 23-year-old woman presented with an obvious confluence of the bilateral breasts for 1 year after gaining over 10 kg of weight. Breast augmentations with fat grafting were performed twice at another institute 4 years ago and 3 years ago with unclear injection volumes. Outside our institute, liposuction of the medial confluence region achieved no correction of this breast deformity. Because of the manifestation of a soft-tissue bridge across the sternum (Fig. 1), the patient was diagnosed with symmastia. On preoperative magnetic resonance imaging examination, small adipose nodules were observed in the medial confluence region measuring 2 × 1.5 cm. In addition, no family history of breast abnormalities or breast augmentation with implants was reported. The cause of symmastia, therefore, was established as overaggressive tissue dissection and fat grafting with a sharp cannula during prior surgery that disrupted the medial breast border and presternal attachments.Fig. 1.: This 23-year-old woman presented normal volume and contour of the bilateral breast with a palpable bridge of soft tissue across the sternum.First, we attempted liposuction of the confluence region. The subcutaneous tissue, however, had already undergone fibrosis and no fat content was aspirated. Subsequently, through a 4-cm periareolar incision in the bilateral breast, a tissue bridge measuring 16 × 3.5 cm was removed from the cleavage region; the lateral border was 1.5 cm away from the sternum bilaterally, the upper border was 1 cm below the clavicle, and the lower border was along the inframammary fold. Then, three palpable cysts were removed and identified as adiponecrosis on histopathologic examination. The largest of these cysts was approximately 4 × 4 cm. Subcutaneous tissue was fixed to the sternal periosteum with subcutaneous interrupted suture at the lateral border of marked cleavage bilaterally. An elastic vest had been used postoperatively for 4 weeks to aid in the adherence between the subcutaneous tissue and sternum. Correction of the symmastia had been achieved immediately and maintained without complications such as infection, wound dehiscence, or seroma at the 8-month follow-up (Fig. 2).Fig. 2.: Eight months after surgery, the correction of symmastia had been maintained, with no recurrence.Symmastia, the medial confluence of the breasts, is a rare but complex problem that is typically associated with iatrogenic injury during breast augmentation with implants. To the best of our knowledge, we report the first case symmastia following breast augmentation with fat grafting. When this complication occurs, if fat accounts for a major part of the confluence tissue, liposuction is effective in correcting the deformity and minimizing injury to the intermammary vessels. When the intermammary tissue is composed mainly of fibrous septa and glandular tissue, treatment involving tissue excision and subdermal suturing by means of different incision approaches2–5 should be performed. Fat grafting is often regarded as a symmastia-safe operation in the parasternal areas, but our report has upset this belief. The application of sharp cannulas and the area injected should be limited and kept 1.5 cm away from the sternum with this approach. The important anatomy and boundaries of fat grafting should be highlighted in the first place to prevent symmastia. DISCLOSURE The authors declare that they have no conflicts of interest to disclose. Yiye Ouyang, M.D.Chunjun Liu, M.D.Plastic Surgery Hospital (Institute)Peking Union Medical CollegeChinese Academy of Medical SciencesBeijing, People’s Republic of China