Capsulorrhaphy for Symmastia

Capsulorrhaphy for symmastia is a surgical technique mainly used in breast augmentation revision to treat symmastia (a condition where the breasts are confluent or merged together in the middle). Symmastia is often referred to as “uniboob” or “breadloafing” since there seems to be no visual definition between the two breasts. Symmastia may be caused by a congenital defect, surgery or illness. The majority of patients get the condition from breast augmentation surgery when the implants are placed too close to each other or they slip towards each other over time. This condition often requires more than one surgery to correct the issue. Capsulorrhaphy for symmastia may also be referred to as an internal bra procedure thanks to the use of internal sutures and/or an implantable tissue support, such as Alloderm or Seri, to place the breast implants into a more desirable position and create better separation.

Am I a Good Candidate for Capsulorrhaphy for Symmastia?

A GOOD CANDIDATE includes:

• A woman in good health who is not pregnant or nursing.
• Any patient looking for a long-term surgical solution to symmastia.
• A woman who suffers from a joining of the breasts due to implant malposition. The breasts may touch in the middle or the skin may have lifted off the sternum and caused no separation between the breasts.
• Patients with large breasts implants that have caused the breast tissue to become weak or stretched.
• Women with implants that have shifted to the center due to the size of the implant pocket.
• Patients with mild discomfort in the midline with, or without, any implant rippling.
• Any patient whose nipples appear to be pointing outwards, otherwise known as walleyed, due to the implants migrating medial to the nipple rather than lateral to the nipple.

On the other hand, patients who are NOT GOOD CANDIDATES include:

• Women without a good understanding of the breast revision techniques available to them.
• Symmastia may not be correctable with one surgery so any patient looking for a single surgical solution is not ideal.
• A patient who is not able to take time off work to recover after surgery.

How is Capsulorrhaphy for Symmastia Performed?

Capsulorrhaphy for symmastia is referred to as a pocket correction procedure and is used to correct an implant that has shifted. However, a new pocket is typically not made unless the patient initially had the implants placed subglandular (above the muscle) and wishes to have the implants positioned submuscular or under the muscle. Implants, which were initially placed submuscular, and developed into symmastia, are a little harder to repair using the capsulorrhaphy technique. Therefore, many surgeons prefer to create a new pocket above the other rather than utilize the current pocket. Nevertheless, surgery for symmastia is an outpatient procedure which can take 2 to 3 hours depending on how the procedure is performed. The surgeon will cleanse and mark the area for treatment and the patient will be placed under general anesthesia.

During a typical capsulorrhaphy for symmastia procedure, an incision is made where the breasts meet the chest. Excess tissue between the breasts may be removed via surgical resection or with liposuction. Removing excess fat in the sternum area allows the area to become deep enough to create a separation between the breasts. The surgeon must be very careful when reopening the breast tissue because the current implant can act as a wedge. The breast tissue is dissected in the direction that the implant is intended to sit. Existing scar tissue will likely be removed or rolled up for extra support. Special lighted retractors are used to expand the implant pockets, both superiorly and laterally, to create room for the implants to be repositioned within the same space (but further apart from the midline). Permanent internal sutures are used to close off the portion of the breast pockets which rest medially over the sternum. The sutures are meticulously placed so that they never come into direct contact with the implants inside the body.

This internal bra technique repairs the connection of the overlying skin and muscle to the sternum or breastbone and prevents the new implants from shifting to the middle of the chest. ADM, or Acellular Dermal Matrix, is typically used in difficult cases to provide a thicker, stronger layer of tissue. ADM consists of collagen, derived from human skin, and is partially held in place with absorbable parachute sutures. This tissue helps the body to readily accept the implant. This process is sometimes finished with an additional surgery, a few months later, to allow the breast tissue time to heal before the implants are replaced. With capsulorrhaphy for symmastia, there are no new scars on the breasts since the surgeon will work from the previous scars.

Alternative Treatments

An alternative technique to treat symmastia which is caused by breast implants includes switching to a smaller implant size with elevation of the lower breast crease. Simply switching to a smaller implant, without the breast crease elevation, does not correct symmastia from breast implants since it is a malposition issue with the pocket and not a problem with the implant.

Symmastia patients with very large breasts can have breast reduction, liposuction or a combination of both.

A non-surgical method to correct symmastia consists of wearing a separator bra under the clothing. This type of bra temporarily separates the breasts and corrects the “uniboob” look. However, it only lasts for as long as the bra is worn.

What is the Cost of Capsulorrhaphy for Symmastia?

Surgical correction of symmastia can cost anywhere from $5000 to $15,000. The cost will be greater for a patient who had breast implants initially placed subglandular and now wants to have them placed submuscular. The cost also depends on the skill of the surgeon and the area of the country where it is performed.

Recovery and Downtime

The RECOVERY period after symmastia depends on the extent of the revision surgery. After capsulorrhaphy for symmastia, patients will be instructed to have plenty of bed rest along with drinking plenty of fluids to speed the recovery since it will hydrate the body and minimize the swelling. It is common for the breasts to be bruised and swollen but this will subside over a few weeks. The patient should expect some soreness or pain for the first 48 to 72 hours but pain medications will be prescribed and should be taken as directed.

In many cases, only internal sutures are used. However, if external sutures are in place, the patient will not be permitted to shower until the sutures are removed during a follow-up visit one or two days post-op. Bathing will not be permitted until one week after the treatment.

After a few days of DOWNTIME, the patient can resume light activities including light work during the first 2 weeks. The patient should refrain from lifting or raising their arms above the head. If the implants are placed immediately, they will appear slightly higher than normal. As the breasts heal, the implants will descend to a more natural position and the swelling will subside. A bra, called a “thong bra”, and a bandeau (a strip of cloth) will be worn after symmastia repair to stabilize the area. This also allows the sutured area between the breasts to heal properly without excessive pressure. The “thong bra” only covers the sternum area so it is really a post-surgical compression garment. It will be worn for 8 to 12 weeks to create adequate compression in the midline. Patients will not be permitted to drive until 1 to 2 weeks after surgery. Contact sports and heavy lifting should be avoided for 6 weeks.

Results

Patients should strictly adhere to all post-surgical instructions for the best possible outcome. Limiting physical activity, especially with the upper body, is crucial during the recovery time since a majority of the long-term tissue strength will be achieved within the first 6 weeks. Physically exerting the upper body too soon can make the breast tissue weak and cause the procedure to be a failure. Furthermore, the “thong bra” is designed to keep the tissue between the breasts compressed and should be worn as directed.

Scarring can take up to a year to settle as it progressively fades. Although the internal bra is permanent, and can provide long-term support, the breast tissue will naturally age and become lax. This can cause the implants to sit lower and the nipples to hang low and/or point outward. Weight gain or pregnancy can also alter the appearance of the breasts. To maintain breast support, and gain longer lasting results a patient should always wear a supportive underwire bra.   

Limitations of Capsulorrhaphy for Symmastia

Capsulorrhaphy for symmastia limitations include:

• Minor adjustments when the pocket is solely being altered. Patients who wish to see a bigger improvement may need to consider having a new pocket created so the implants can be placed in a greater position.
• Some cases of symmastia may be too difficult to treat because of an illness or a defect in the area.
• In some cases, the shape of the patient’s ribs may limit the improvements that can be achieved.

Risks of Capsulorrhaphy for Symmastia

Common risks include:

• Nausea and vomiting
• An allergic reaction
• Spike in blood pressure
• Pulmonary issues related to the lungs
• Bleeding
• Infection
• Scarring
• Irregularities in contour and asymmetrical breasts
• Capsular Contracture (a tightening of the tissue around the implant)
• An unsuccessful repair, or worsening of the condition, if an improper technique is used during the revision surgery
• Recurrence of the condition

Understand What is Involved with the Surgery

Since no two cases of symmastia are alike, the surgery and the recovery time vary from patient to patient. Therefore, the patient should first consider whether capsulorrhaphy for symmastia is medically necessary. Patients should have a good understanding of the procedure and the technique that will be used before deciding to have the surgery. Patients are encouraged to get several opinions to ensure that capsulorrhaphy for symmastia is right for them.

Written by Cosmetic Town Editorial Team - SP

Based on an exclusive interview with Dr. Bruce Byrne in Richardson, TX