Correction of Synmastia
Avoidance of Synmastia
The best way to treat synmastia is not to have it happen in the first place. Although synmastia is a form of implant malposition, and implant malposition can (and does) happen to any surgeon, there are some very simple ways to prevent synmastia.
1. Avoidance of placing too large an implant – This cannot be overemphasized. If the implant is too wide for the chest, then either the implant will be too far to the sides of the chest, or too far to the sides of the chest and towards the midline. If the implant is just too far to the midline, the breast will be excessively full medially and the nipples will be pointed outwards. If the implant is too large for the chest, the nipples will point in their normal direction, but the breasts will be too close in the midline. The above is especially true for a subglandular implant.
2. Preserve as much of the sternal attachment of the muscle as possible – When the implant is below the muscle, the muscle is a strong defense against synmastia. Releasing the muscle along the breastbone will allow the implant to protrude towards the midline.
Surgical correction of synmastia
Subglandular placement – If the implants were placed above the muscle, correction of synmastia is relatively easy. Removal of the implants, creation of a new pocket under the muscle, and placing a few sutures into the old pocket to prevent migration of the implant back into that pocket is the mainstay of treatment. Using a smaller implant and elevation of the lower breast crease may also be helpful.
Submuscular pocket – This is a harder situation to correct. The muscle barrier along the breastbone by definition is compromised. Most surgeons correct this problem by placing sutures up and down the medial (towards the breastbone) side of the pocket to limit the opening in that area and direct the implant to move more to the lateral side of the chest. This makes sense in theory but there are some issues with this technique. The sutures can be uncomfortable because they need to be placed into solid tissue on the chest wall so as to securely hold the suture. Placing these sutures into the lining of the ribs (the periosteum) can be painful. There is also no guarantee that it will work. The suture line can disrupt, especially if there is pressure on it from the implant. It may be advantageous to reduce the implant size and consider opening up the lateral (outside) of the pocket (only if there is room to do so – you do not want excessive lateral protrusion of the implant because that doesn’t look good, either).
The best way that I know of to handle this situation is to create a new pocket below the muscle. This is done by peeling the breast and muscle off the scar tissue capsule, and creating the pocket to the proper dimensions. THe implant is then inserted into this new plane. By keeping the old scar tissue capsule below the implant, the implant cannot fall into the previous implant space. This may be hard to visualize, but with this technique, you do not need to rely on the integrity of a row of sutures placed into thin tissue with the implant pushing on it as you do in the technique described above. This technique is associated with a high degree of success and is not that difficult to perform.