Breast Asymmetry
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Breast Asymmetry
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Discussion[PATIENT EDUCATION: ORIGINAL ARTICLE: Discussion] Adams, William P. Jr. M.D. Dallas, Texas Received for publication March 13, 2006. William P. Adams, Jr., M.D.; 2801 Lemmon Avenue West, Suite 300; Dallas, Texas 75204; PRS@dr-adams.com This study concludes that performing procedures centered on the nipple-areola complex, according to the patient's individual characteristics, results in predictable and desirable postoperative results. I found this to be a very elegant and well-thought out study. My comments are for discussion purposes only and should not in any way detract from the obviously long hours and hard work that Dr. Youn has put into producing these data. Dr. Youn has devised a classification of asymmetries based on the position of the nipple-areola complex (types I through IV). Although it is stated in the abstract, one clarification that may not be readily apparent to the reader is that Dr. Youn devised this classification from a pilot study measuring 100 breasts. Once the classification was established, he utilized it in the subsequent 368 patients over a period of 3.5 years, to generate his conclusions. I would like to make several points regarding the measuring system and classification that Dr. Youn has proposed. The intricate and precise measurements utilized in this study are very complex. I say this as a surgeon who has repeatedly advocated measuring the breast to make sound clinical decisions; however, I have found it difficult for the majority of surgeons to embrace even five simple measurements.1 Thus, I think widespread utilization of this measurement system would not be realistic for practicing surgeons. Nevertheless, the outcome of the study and the conclusions are very relevant to all surgeons performing breast augmentation surgery. I will reference some direct quotes from the study to facilitate my discussion. For a responsible doctor, a thorough diagnostic process is imperative, both to avoid complications that could arise even many years after surgery and to provide satisfactory results to patients. This statement is extremely important for two reasons. As we have seen in other areas of plastic surgery, the female breast is inherently asymmetric, and the process of evaluating aesthetic and reconstructive breast patients requires the surgeon to make a precise and detailed preoperative analysis and to convey this analysis to the patient in a tangible way to optimize results. In describing the type I classification, Dr. Youn states, Happily for both surgeons and patients, this group does not need anything other than basic education for surgery. The reader should not be misled into interpreting basic education to mean simple or minimal. In fact, the education process for cosmetic breast augmentation patients involves by far the largest volume of material for any patient group in my practice. The relative importance of patient education compared with other facets of the breast augmentation process, such as preoperative clinical evaluation, intraoperative technique, and postoperative management, cannot be overstated. The truth is that the patient education process contributes to probably no less than 70 percent of the overall success of the procedure for the surgeon and the patient. [B]reast augmentation surgery should be performed with the implant centered on the position of the nipple-areola complex, regardless of the location of the inframammary fold. If the augmentation is based on the inframammary fold, one breast could have a natural appearance, but the other breast may not. This is an extremely important observation and statement by Dr. Youn. Given that the female breast is inherently asymmetric, this includes patients who have significant asymmetries of the inframammary fold level. The aesthetics of any individual breast is based on a relationship with the breast width and the corresponding relative relationship of the nipple-to-fold distance. Dr. Youn's observation here is the exact same one that I have found and professed in my practice and teachings: a patient with significant inframammary fold asymmetries should not be treated to equalize these inframammary folds, as this will produce one breast with a very unaesthetic appearance. This has been debated in multiple national forums, and I have heard various surgeons discuss opinions; however, the consensus remains that treating inframammary fold asymmetry can be a difficult situation. Keeping this important pearl in mind will help surgeons avoid long-term issues. Education will be very important in these situations, as patients with significant inframammary fold asymmetry must be educated about this preoperatively. They may continue to have problems with their brassiere fitting postoperatively, but this situation is preferable to a nipple pointing up to the sky or hanging out of the top of a bathing suit due to an attempt to lower a higher inframammary fold to match the lower side. The type IV patient should also be informed that both breasts' inframammary folds and nipple-areola complex positions might be as disparate as before surgery. Dr. Youn's most asymmetric classification applies to the type IV patient. Based on the data in the study, approximately 85 percent of patients had a significant degree of asymmetry, whether it was vertical, horizontal, or a combination of the two. Significant vertical and horizontal asymmetry was seen in nearly 50 percent of Dr. Youn's 368 patients studied. I do agree with his assessment; however, I would add that my experience is that patients with type IV asymmetries will be disparate after surgery, and oftentimes, when the breast is enlarged, these asymmetries may appear to be more significant. It would be helpful for Dr. Youn to provide a little more data as to implant demographics as well as other parameters, such as incision breakdown and pocket plane types. Particularly important would be a breakdown of his detailed complications and incidents and reasons for reoperation. It is not clear from the data exactly what the reoperation rate was in these 368 patients, although it is stated that seven of the patients had consultation regarding some concern about their breast shape after surgery; however, after further counseling, no reoperation to correct asymmetry was required. I would assume there were zero reoperations for asymmetry in this study group, which is quite good! [T]he answer to the question of whether it is possible to narrow the gap is no, because in a natural state the breasts look widened. This study also addresses a very common issue in breast augmentation patients--the wide gap between the breasts. Dr. Youn states that patients who want to narrow this gap should be counseled that this is indeed not possible, because the breasts look wide in their natural state, and this is addressed with education. Again, I fully agree with his conclusions here, and I think that this request for cleavage by patients is often misinterpreted and mishandled by surgeons. In fact, the female breasts are genetically placed on the chest wall, and to significantly narrow these gaps, particularly with subpectoral pocket implant placement, requires significant trade-offs that often result in uncorrectable deformities. Therefore, patients should be educated about this important tenant. If they start off with a wide gap between their breasts, this gap will remain postoperatively. Patients who desire to have more cleavage can certainly produce this by wearing a push-up brassiere postoperatively. In summary, the most significant aspects of this study are the preoperative identification of asymmetries in breast augmentation patients and then the use of a defined education process preoperatively to avoid inevitable issues postoperatively. This motif is a recurring one with breast augmentation patients, and as Dr. Youn has shown us with asymmetry, a similar approach should be taken with all breast augmentation patients for multiple variables and issues related to this type of surgery, including implant issues, capsular contracture, soft-tissue stretch, and so on. Readers should keep in mind that no matter how good the clinical evaluation, surgical procedure, and postoperative management are, if a thorough and adequate educational process has not been instituted initially, there is a significant possibility for poor outcomes postoperatively. When we look at the 15 to 20 percent reoperation rate that has been a recurring theme in premarket approval studies over the last 15 years, we see that a significant portion of these reoperation cases is due to patient dissatisfaction with size or asymmetry. With a better preoperative educational process, this rate can be significantly reduced. My approach to assessing asymmetry in breast augmentation patients has been to use a direct review of the patient's photographs with the patient, followed by documentation of the asymmetries with patient accountability and acknowledgment of these asymmetries on one photograph analysis sheet modified from a previous publication in this Journal2 (Fig. 1). I have been using this sheet for approximately 3 years now and have come to similar conclusions as Dr. Youn, that this is an extremely valuable tool for my practice in that it alleviates many of the questions and issues that may potentially surface postoperatively.
I would like to congratulate Dr. Youn on an elegant study. Aside from the hard work he has put into generating these data, his conclusions on the importance of patient education with regard to breast asymmetry and differences are essential to optimizing results with the breast augmentation procedure. DISCLOSURE Dr. Adams serves as medical director of the Mentor Corporation's cohesive gel implant trial. He is an investigator for Inamed and Mentor cohesive gel IDE trials, an Inamed Academy faculty, and a member of the Ethicon Innovation Council. REFERENCES 1. Tebbetts, J. B., and Adams, W. P. Five critical decisions in breast augmentation using 5 measurements in 5 minutes: The high five decision support process. Plast. Reconstr. Surg. 116: 2005, 2005. [Fulltext Link] [CrossRef] [Context Link] 2. Tebbetts, J. B. An approach that integrates patient education and informed consent in breast augmentation. Plast. Reconstr. Surg. 110: 971, 2002. [Fulltext Link] [CrossRef] [Context Link]
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