**1. Introduction**

Symmastia after breast implants is a rare and highly recurrent complication [1]. The incidence is unknown [2]. In 1983, Symmastia (from Greek syn - together, masto - breast) was defined for the first time as a confluence of the mammary borders through the midline and loss of the intermammary fold [3]. Symmastia can be congenital or acquired, when it is due to the poor positioning of the implants that cross the midline. The first reference for correction of acquired symmastia was in 1988 [4]. The acquired symmastia can be monocapsular (**Figure 1(a)**) (when the implant pocket communicate becoming only one), or bicapsular (**Figure 1(b)**) (when there are two capsules, one or both implants can be medialized and there is a loss of insertion of the midline adhesions) [5]. It is considered severe when both sides of the capsule need to be corrected. When the implants are medialized, but with the medial

#### **Figure 1.**

*(a) Representation of retromuscular monocapsular symmastia. (b) Representation of retromuscular bicapsular symmastia. (c) Representation of simasty correction with central membership points and making new retro pectoral pocket.*

sternal fascia intact, the term "medial malposition" is preferred [5]. Khan [6] suggests an etiological classification for the types of symmastia (**Table 1**). In this work, we describe three cases of patients with symmastia after breast reconstruction who were treated surgically with an integration of techniques.


#### **Table 1.**

*Khan's etiological classification of symmastia.*

#### **2. Objective**

To report an integration of techniques for the surgical treatment of symmastia after breast implant reconstruction, also indicated for the treatment of symmastia after breast augmentation.

#### **3. Methods**

For the discussion of this report, a bibliographic survey was carried out in the Medline and Cochrane Database, using the descriptors "symmastia", "breast reconstruction" and "surgical treatment". All articles were reviewed, with inclusion only of those that referred to acquired symmastia.

#### **4. Procedure**

The patients underwent a surgical procedure under general anesthesia, and all were discharged the next day. Initially, the desired breast furrow was marked with methylene blue, as well as the midline and the inner edge of the breasts to be reconfected.

The prostheses and/or expanders were removed through a scar in the breast crease (previous or not) or by the scar from the mastectomy.

The midline region was scarified with a small curette or electrocautery, followed by adhesion points with non-absorbable threads: at least three points on the midline with 2–0 mononylon, following previous demarcation and a sequence of at least three points for delimitation of the new medial margin of the breasts (on each side of the store).

Then, the anterior capsule flap was made. Decreasing the power of the electrocautery, the anterior capsule of the pectoralis major muscle was detached, which was folded, in order to make a neo pectoral pocket. In two cases, partial capsulectomy was performed and material was sent for anatomopathological examination. The anterior capsule was fixed to the posterior by some points of mononylon 2–0 to close the previous pocket and inferiorly it was fixed with several points on the lower edge of the previous space. This prevented the accumulation of liquids (seroma/hematoma) in the old pocket, as well as sliding movements of the new prosthesis over the previous space. Thus, the previous area was completely closed and the manufactured pocket can be expanded laterally, inferiorly or superiorly, according to the need of each case.

Finally, new breast implants were placed, suction drains were inserted and the usual synthesis of the tissue planes was carried out (**Figure 1(c)**). The drains were removed on an outpatient basis, after 2 to 5 days.

There were no major complications. Patients 1 and 3 required drainage for a longer time due to high blood flow rate, and patient 2 used antibiotics for 2 weeks in the postoperative period, due to a slightly hyperemic irradiated breast.

#### **5. Results**

Case 1: Patient operated on 03/15/2017 presenting mono capsular symmastia (previously submitted to bilateral mastectomy in another service, with resection of the areola on the right and resection of inverted T skin on the left; placement of an anatomical expander on the right 450 cc and prosthesis anatomical left of 490 cc textured and evolving at the time with partial necrosis of flaps on the left). Right breast

previously irradiated. Symmastia correction was performed (there was complete communication of 6 cm vertically in the pre-sternal region) as described and placement of 455 cc microtextured super high profile prostheses and correction of left breast scars. **Figures 2**–**5**. There was no recurrence of symmastia, but she evolved with distant and locoregional tumor recurrence on 03/03/2019, and death on 07/2020 **Table 2**.

Case 2: Surgery performed on 23/05/2018. Patient underwent bilateral mastectomy in another service with resection of the nipple areola complex on the right and implant placement - expander prosthesis on the right 460 (Becker 35) and 390 anatomic prosthesis on the left. She presented bicapsular symmastia, separated only by a capsule beam, with complete loss of sternal adhesion. The implants were changed to ultra-high profile round prostheses 590 cc on the right and high profile 450 cc on the left. On that occasion, fat grafting was also performed on the right breast (70 cc). **Figures 6**–**11**. Subsequently, 120 cc lipografting was performed on the right on 7/7/2019 and the reconstruction of the areomamilar complex (CAM) on 7/2020 was reconstructed. Right breast previously irradiated **Table 2**.

**Figure 2.** *Case 1: Preoperative.*

**Figure 3.** *Case 1: Immediate postoperative period.*

**Figure 4.** *Case 1: Postoperative 5 months.*

**Figure 5.** *Case 1: Postoperative 3 years.*



#### **Table 2.**

*Summary of cases regarding the type of simastia, implants before and after correction of the problem, association of fat graft during implant replacement and anatomopathological examination of the implant capsule.*

**Figure 6.** *Case 2: Preoperative.*

**Figure 7.** *Case 2: Immediate postoperative period.*

**Figure 8.** *Case 2: Postoperative 3 weeks.*

Case 3: Surgery performed on 06/2020. Patient previously submitted to bilateral mastectomy in another service with resection of the nipple-areola complex on the right and placement of 440 textured anatomical implants. Bicapsular symmastia, separated only by the capsules, and disinsertion of the skin of the pre-sternal region. Correction of symmastia and placement of 455 cc super high profile microtextured round prostheses and fat grafting 110 cc on the right and 60 cc on the left. Subsequently, a new fat graft was performed (40 cc on the right and 30 cc on the left) with reconstruction of the CAM on the right and correction of scars on the left **Figures 12**–**18** and **Table 2**.

**Figure 9.** *Case 2: Postoperative 1 year.*

**Figure 10.** *Case 2: Postoperative period 1 year and 8 months.*

**Figure 11.** *Case 2: Postoperative 2 years and 6 months.*

**Figure 12.** *Case 3: Preoperative.*

**Figure 13.** *Case 3: Intraoperative detail: Marking with methylene blue for adhesion points.*

#### **Figure 14.** *Case 3: Intraoperative detail: Anterior capsule dissection.*

**Figure 16.** *Case 3: Immediate postoperative period.*

**Figure 17.** *Case 3: Postoperative 1 month.*

**Figure 18.** *Case 3: Postoperative 9 months.*

#### **6. Discussion**

There are not many case series in the literature on correction techniques for symmastia [2] discriminating symmastia after breast reconstruction.

The most likely cause of retropectoral symmastia is exaggerated dissection in the medial region of the breast [2, 7–9]. Other facts can corroborate. Some patients have the insertion of the pectoralis major muscles as thin as 3 to 4 mm at their origin, along the sternum from the 2nd to the 5th ribs, predisposing to this complication after placement of retromuscular implants. A wrong elevation of the pectoralis minor muscle (whose insertion may be less than 1 cm from the insertion of the pectoralis major by 24%, according to anatomical study [10]), with a consequent poor positioning of the implants, would result in a medial force vector for the implant [10, 11]. This fact, added to the excessive medial dissection, with involvement of the internal mammary artery and perivascular fibers, in patients with fine insertion of the pectoralis major muscle would stimulate the sliding of the implants to the midline, with dehiscence of the sternal pectoralis major muscle [11]. However, Hammond [7] disagrees with this because the pectoral muscle would always push the prostheses up and out toward the armpits and

basically credits the symmastia to a technical error. In the case of breast reconstruction, the use of expanders could favor the rupture of the medial fibers of the pectoral [12].

Excessive size and/or wide-base implants would also favor symmastia [1, 8, 13].

Recurrence after treatment of symmastia is a common problem [14]. Therefore, the integration of techniques is suggested in this work.

The simple removal of the implants and reconstruction in a second step would be the safest and most simple technique and preferred by some authors [9, 15]. However, this resource is usually left for recurring cases.

Basically, capsulotomy/capsulorrhaphy, sternal dermal adhesions, creation of a new pocket and integration of techniques (including muscle repair and use of dermal matrices) are described for the correction of symmastia [2].

The incision for approaching the implants in this study was the previous mastectomy scar (case 1) or in the breast crease. Scars in the pre-sternal area or intermammary fold must be avoided due to the poor esthetic result and the possibility of keloids [13].

Regarding adhesion techniques, after removing the implants and checking whether the symmastia was mono or bicapsular, the central region (intermammary groove) was scarified, and non-absorbable points were given between the central anterior and posterior capsule and medially to delimit the breasts, similar to Pavelecini et al. [13]. However, differently from these authors, it was decided to create a new pre-capsular space for the implant through the folding of the anterior capsule, maintaining the retropectoral space, to guarantee the correct position of the prostheses. Becker [14], in a series of 5 cases for correction of symmastia, shows only one case after breast reconstruction. It suggests central adhesion in the sternum with non-absorbable threads after anterior and posterior capsulectomy, and use of the same implant store, but with replacement for adjustable implants which were gradually filled in 1 week after surgery. It presents good results, but it is a more expensive technique (due to the use of expanding prostheses).

For the construction of a neopectoral pocket, in the reported cases, the periprosthetic capsules were "mature". Very thin capsules would make it difficult or technically make the procedure impossible, but this is rare [9]. In cases of breast reconstruction, the most usual is a relatively thick capsule, especially in irradiated cases, and this fact allowed the creation of this new retromuscular space, in the described cases, without difficulty. The new implant was repositioned, but there would also have been a contracture correction, as suggested by some authors, if it had previously been so. Furthermore, it also allows the capsules to be studied, as in cases 1 and 3. Creating a new space is technically less difficult and more accurate than trying to reduce the old space with sutures only [9, 16]. It also minimizes trauma and optimizes the size and position of the new space [17]. Changing implants while maintaining the same previous space as symmastia is probably a mistake because it would put greater pressure on the lines of correction sutures [16, 18]. This allowed that, in the reported cases, the implants were increased in size, as the patients requested it. Care was taken to use prostheses with greater projection and smaller diameter. So there was no problem in creating a larger pocket.

Regarding the technique of the neopectoral pocket, the fact that the lateralized muscle is not repaired, which could favor the force vector to push the implant medially [11], has been questioned. However, with the integration of techniques, medial capsulorrhaphy would totally or partially solve this problem.

The inability to make a new retromuscular pocket or the presence of visibly calcified capsules [9] or sick capsules (intense inflammatory process) would contraindicate the technique of making the new pectoral pocket.

In relation to other techniques, simple capsulorrhaphy, which consists of suturing between the anterior and posterior edges of the medial.

medial capsule, is not recommended due to high recurrence [19, 20]. Lateral or upper capsulectomy was not indicated in the reported cases, since with the change of plan, there was no healing restriction for the placement of implants. Bostwick suggests the correction of symmastia with excision of the central capsule and capsulorrhaphy of the flaps of the central capsules, associated with partial capsulectomies/lateral capsulotomies, in addition to textured implants for better adherence. Zingaretti et al. [21] describe a complex technique involving capsulectomy in the medial quadrant, adhesion points and medial capsulorrhaphy through transcutaneous points on the entire edge of the breast, but without changing the plan for placing the implants, which are necessarily smaller in order not to tension capsulorrhaphy points. Out of 10 retromuscular cases, it discriminates only 1 case after breast reconstruction.

Among the changes to a new pocket, the change from the submuscular plane to the subcutaneous plane, although suggested by some authors [8, 11] can be a less interesting option in many cases of primary cosmetic augmentation surgery, due to the possibility of palpation of the implant, capsular contracture or rippling development [16]. This would happen much more likely in cases of breast reconstruction. In addition, as in cases 2 and 3, it is possible to associate fat grafting in the same surgical procedure (for refinement of breast reconstruction). The option using acellular dermal matrices (ADM) to cover implants in the subcutaneous tissue would be an excellent option, but the cost is actually much higher, sometimes contraindicating the procedure. The change from the submammary to submuscular plane in cases of pre-pectoral symmastia is also widely performed [6].

Among the associated techniques, the use of dermal matrices facilitates and increases the possibility of correcting implant misplacement, in addition to integrating the matrix with the tissue [12]. However, the costs are high. Spear et al. [22], reported good results in their series of cases with the use of ADM used in breast reconstruction reviews: 5 cases of symmastia that were corrected with capsulorrhaphy with dermal graft medially (graft "onlay") or associated with confection change in the neo pectoral pocket, to avoid changing the implant to the old plan. Similarly, other authors also use a medial sling of the ROM to correct symmastia in cases of breast reconstruction [12, 23, 24] or cosmetic mammoplasty [25].

Parsa et al. [9] suggest anterior and posterior capsulectomy in the central region for its obliteration, and confection of a limited posterior capsule flap, followed by anterior capsulorrhaphy to make a new mammary board. This technique also depends on a posterior mature capsule (this dissection is already technically more difficult [9] in cases of retromuscular implants) and could also be used in retromammary stores. Foustanos and Zavrides [19] in only one case described capsulotomy and medial caspulorrhaphy associated with transcutaneous points to define the medial edges of the breasts.

The option for microtextured silicone prostheses was indicated, in principle, due to greater adherence [1] in relation to smooth implants (nanotexture). However, as a new pocket is made, these prostheses can also be used. Polyurethane prostheses could be used, especially in cases of subglandular or subfascial revision, since they do not undergo rotation or displacement, can improve rippling and capsular contracture [18]. Castello et al. [18] indicate polyurethane prostheses in the neosubpectoral pocket only in refractory cases of contracture.

As for the postoperative period, Kalaria et al. suggest that the patient rest between 4 and 6 weeks for abduction and lateral rotation of the humerus [11] due to the repositioning of the pectoralis major muscle. However, if the correction is adequate

as suggested in the reports, such prolonged rest can be debilitating [7]. Therefore, conventional postoperative rest and the use of a bra with medial support in the adhesion area for 3 months were indicated to stabilize the surgical correction [2].

The only meta-analysis found [2] in relation to symmastia, although it does not reach conclusions about which surgical techniques are more efficient to correct it, describes an algorithm for both congenital and acquired symmastia. It advises the evaluation of the capsule as a more effective surgical procedure and, eventually, the combination with a muscle repair (which was done in this series of cases). The use of ADM would be reserved in cases of recurrence or for patients who desire large volume implants. The metaanalysis concludes by advising an integration of techniques to bring better results, as described in this article.

Finally, to avoid the occurrence of symmastia, Sanchez et al. [10] advise that when the access is inframammary, in addition to careful medial dissection, to start the elevation of the pectoralis major muscle medially and proceed laterally, with direct muscular visualization so that there is no elevation of the pectoralis minor muscle, since its fibers may be close to or intertwined with the costal insertion of the pectoralis major. The choice of the size/base of the implants in relation to the patient's chest is also essential, following directions from Selvaggi et al. [15] and Tebbetts [26].

#### **7. Conclusion**

Here we describe an integration of techniques for correction of retromuscular symmastia resulting from bilateral breast reconstruction with implants, namely, points of adhesion in the pre-sternal region and alteration of the breast implant pocket with anterior capsule flap, maintaining subpectoral space. The technique is easily reproducible and versatile, and can be used to correct other misplaced breast prostheses, as well as to correct capsular contractures. Furthermore, it can be associated with lipotransfer, usually beneficial for esthetic refinement in cases of breast reconstruction.

There were no displacements of the implants in the postoperative period or capsular contractures so far, and the patients reported being satisfied.

#### **Author details**

Márcia Balbina Lorenzo Hoyos Rede de Assistência à Saúde Metropolitana, Sarandi-Paraná, Brazil

\*Address all correspondence to: mblhoyos@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
