Asymmetric Breast

The Clinical Problem ( Fig. 29.1 )

A young woman’s perception of normal body form is increasingly influenced by the media to match a somewhat stereotyped image of beauty. The Internet contains large volumes of graphic imagery available at the click of the mouse that can make any vulnerable young women, particularly those with asymmetric breasts, under even more pressure to conform. Minor asymmetry of any paired structure in the body is normal, but meeting patients’ expectations has become increasingly difficult in this litigious age.

There is no quick fix to correct most women’s breast asymmetry problems. This is because more than one breast parameter needs to be addressed.

Stepwise Approach

Understanding the Patient’s Requests

During two consultations with the patient, discuss what she perceives to be the issues with her breast asymmetry. I find a very simple but enlightening experience for the patient is to ask her to take images of herself in front, side, and three-quarter views and then compare these to online images of what she would like to be her final “ideal” result. Often, by the time of the second consultation, the tough decisions have been made about what is anatomically and financially possible.

Examination of the Patient

Like most clinicians, using a standardized template is helpful to record everything methodically so that a true representation of the preoperative status can be made. This is available when reviewing the results of surgery ( Fig. 29.2 ).

As a bare minimum, the following should be assessed and documented :

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The spine and rib cage vectors
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Projection of the breasts
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Total breast volume, and quality and quantity
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Breast measurements: sternal notch (SN) to nipple-areola complex (NAC); NAC to inframammary fold (IMF); NAC to midline; medial edge height, IMF height, NAC diameter, and skin roll test

Explaining Anatomy to the Patient

This is a crucial step in the consultation process, where I stand the patient in front of a full-length mirror and explain the anatomic differences and issues. It is wise to include a close relative and always a nurse chaperone.

I divide the asymmetry into three distinct anatomically areas:

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The breast tissue, shape, and size—these are the tissues with which we commonly, which includes the NAC.
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These the areas that we can disguise or partly change, such as a rib or chest wall deformity.
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These are areas that are beyond my surgical discipline and cannot change, such as spinal scoliosis.

Formulating the Individualized Operative Plan

A simple chart ( Table 29.1 ) helps me visualize and plan the aesthetic breast reconstruction, but with breast asymmetry this is not always possible. Specialized radiologic imaging (e.g., computed tomography [CT], magnetic resonance imaging [MRI]) may be required in more severe cases. The IC 360 camera (oVio360 Imaging System, OVio Technologies, Newport Beach, CA, USA, www.ovio360.com ) gives an excellent panoramic view that highlights the asymmetric features and provides the patient with a memory stick for private reflection.

Table 29.1

Preoperative asymmetry guide to operative planning

Parameter	Left	Right
Chest wall shape
• Normal • Asymmetric	Do nothing.	Do nothing.
	Breast implant alone	Breast implant alone
	or	or
	3D custom-made silicone implant	3D custom-made silicone implant
Breast volume
• Normal • Too big • Too small	Do nothing.	Do nothing.
	Reduce.	Reduce.
	Volumize with implant or fat transfer.	Volumize with implant or fat transfer.
Breast shape
• Like the shape • Ptotic	Do nothing.	Do nothing.
• Like the shape • Ptotic	Uplift, reshape	Uplift, reshape
Breast skin amount
• Normal • Deficient • Excess	Do nothing.	Do nothing.
	Expansion with tissue expander or implant	Expansion with tissue expander or implant
	Reduction	Reduction
Implant
• Volume, shape, base widths	Round, teardrop, conical	Round, teardrop, conical
Nipple-areolar complex
• Normal • Puffy • Inverted nipples	Do nothing.	Do nothing.
	Areolar reshaping	Areolar reshaping
	Correction	Correction