S05E95 - Addressing Breast Asymmetry: Managing Uneven Breasts

In this engaging episode, Dr. Lawrence Tong @yorkvilleplasticsurgery join his co-hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, and Dr. Sam Rhee @bergencosmetic discuss the complex issue of breast asymmetry.

They explore various causes such as genetics, weight fluctuations, injury, and previous surgeries, and delve into detailed approaches for assessment and treatment. The panelists share their strategies for achieving symmetry using techniques like fat grafting, implants, mastopexy, and discuss the importance of patient consultation and expectations.

They also touch on the decision-making process regarding the use of symmetric versus asymmetric implants, emphasizing the need for individualized treatment plans.

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S05E95 - Addressing Breast Asymmetry: Managing Uneven Breasts

TRANSCRIPT

[00:00:00] Dr. Lawrence Tong: welcome to 3 Plastic Surgeons and a 4th. My name is Dr. Lawrence Tong. I'm joined by my esteemed colleagues, Dr. Sal Pacella, who is in La Jolla, Dr. Sam Jejurikar, who is in Dallas, Texas, and Dr. Sam Rhee, who is in New Jersey. Gentlemen, please tell all of our audience what your Instagram handles are. Sal,

[00:00:32] Dr. Salvatore Pacella: At San Diego Plastic Surgeon.

[00:00:35] Dr. Lawrence Tong: Dr. Jejurikar,

[00:00:36] Dr. Sam Jejurikar: at Sam Jejurikar.

[00:00:39] Dr. Lawrence Tong: and Dr. Rhee,

[00:00:40] Dr. Sam Rhee: I'm at Bergen Cosmetic.

[00:00:42] Dr. Lawrence Tong: and I'm at Yorkville Plastic Surgery. All right. Um, Today we are going to talk about a very common, uh, subject and that is, um, uneven breasts. Um, but before we do that, we're going to start with our disclaimer. So Dr. Pacella, could you, uh, go over that please?

[00:00:59] Dr. Salvatore Pacella: Yes, sir. This show is not a substitute for professional medical advice, diagnosis, or treatment. The show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider.

With any questions you may have regarding medical care, never disregard professional medical advice or delay seeking advice because of something in the show.

[00:01:24] Dr. Lawrence Tong: Thank you very much. So we'll start with talking about, um, asymmetric breasts or uneven breasts. So there's a variety of reasons why that may occur in a woman. It might just be due to genetics. It might be due to weight fluctuations. It might be due to Um, injury, uh, it might be, uh, due to, uh, previous surgery.

So I just want to start, um, by asking, um, on the panel, what is your approach, uh, when somebody comes in and they, they say, uh, let's start with Dr. Rhee. Dr. Rhee, my breasts don't look even. How can you help me?

[00:02:00] Dr. Salvatore Pacella: of an old content machine video. Their content

[00:02:04] Dr. Lawrence Tong: what was it?

[00:02:08] Dr. Sam Rhee: on his phone or something, I think.

[00:02:09] Dr. Salvatore Pacella: Oh no, sorry, I just got a text.

[00:02:11] Dr. Sam Rhee: It's

[00:02:11] Dr. Salvatore Pacella: bad.

[00:02:12] Dr. Sam Rhee: right. Anyway, uh, when someone comes, I mean, this is very common. So, uh, as we know, uh, over 80 percent of women out there have some sort of degree of asymmetry to their breasts. And when I see someone and they're interested in doing something about it, I usually ask them first, how impactful is the breast asymmetry to their life?

Is this something that really, uh, impacts their self esteem, what they do on a daily basis, the clothes they wear, uh, act, you know, are they avoidant of certain activities because of this? If this is the case where this, uh, asymmetric breast condition, uh, really on a daily basis impacts their life, then it's something worth exploring in terms of treatment.

But otherwise, for a lot of patients, I will let them know, um, if this is not something you think about all the time, maybe this is something you think about on occasion, uh, it's not something that's particularly impactful, then you should take comfort in the fact that a lot of women, uh, more often than not have asymmetric breasts.

[00:03:18] Dr. Lawrence Tong: Dr. Jejurikar, uh, when you examine a patient, how do you, how do you go about that? How do you assess and formulate what you're going to do?

[00:03:28] Dr. Sam Jejurikar: So I think it's important to talk to the patient and get a sense as to what exactly is bothering them. You know, there's different ways. First of all that you can have asymmetry. It can be a volume mismatch where one breast might be bigger than the other. It can be a shape mismatch, where, you know, one breast is droopier than the other.

Um, you can see certain, you know, you had mentioned some congenital anomalies like a tuberous breast, where the actual lower pole of the breast looks very different. So, the first thing is to really have a lengthy conversation with the patient about, What the degree of asymmetry is, what we consider to be a normal range of asymmetry, and then how are we going to approach it?

I think, you know, the two basic ways in which you're going to, you're going to deal with it is you're going to deal with. Either you're going to make a bigger breast smaller or make a smaller breast bigger. Um, and then shape, you know, if someone has a congenital anomaly where one breast is droopy and the other is not, you might talk about doing a unilateral breast lift on one side or, or even bilateral breast lifts on both sides and try to figure out, you You know, how, how to make the shapes look different.

I think if someone has a gross degree of asymmetry, you can do a lot to make them look much more symmetric, but no one's ever going to be perfectly symmetric. You know, you guys have all heard the saying, breasts are sisters, not twins. Um, and, and, you know, it's important to have that conversation with the patient as well.

[00:04:47] Dr. Lawrence Tong: Sal?

[00:04:49] Dr. Salvatore Pacella: You know, so I think invariably what, what tends to happen is when patients come in for, um, issues related to asymmetry, I agree with Sam, it's about volume because most of the time they're seeking a breast augmentation in the setting of this asymmetry. So now we're dealing with a situation where, You know, you have two, you have asymmetric breasts and then you're adding volume to that through an implant and nine times out of 10, that asymmetry is going to get worse if you add volume, right?

So it oftentimes, like if one nipple's pointing one way, one's pointing the other way, you add volume, all of a sudden they kind of point in different directions at a, at a greater degree. So addressing that asymmetry is key. And, you know, I, I think one of the more challenging issues is. Lifting a breast or making a breast symmetric when one looks correctly proportionate.

So when you have sort of, uh, a youthful looking breast on one side and a droopy breast on the other side, oftentimes that means a periareolar incision, an incision around the nipple. And patients sometimes are not prepared for that, uh, when we start the discussion because, you know, Sometimes they just think, well, there's got to be something you can do without, with minimal access incisions, and, and unfortunately there isn't.

So, the act of placing that scar around the nipple, oftentimes, long term, can make the nipple wider, so you have to account for that, that time component of things.

[00:06:16] Dr. Sam Jejurikar: I think that sometimes, and I'm curious to see what you guys think about this. Patient's acceptance of asymmetry. is sometimes greater than our acceptance of asymmetry, meaning what Sal was just saying. Sometimes they'll say, look, yeah, I know my nipples are slightly uneven. I'm okay with that. It doesn't bother me that much.

I really just don't want those additional scars. I see that all the time. Do you guys see that too?

[00:06:39] Dr. Salvatore Pacella: Yes,

[00:06:40] Dr. Sam Rhee: I do see that. I think the, the funny thing is, is that a lot of patients accept a fairly high degree of asymmetry that they don't even notice on their body to begin with. When I see patients, not for specifically for breast asymmetry, but for breast augmentation, I will point out. Do you see how different one side is from the other?

And they're like, Oh yeah, I do. But I never really thought of it. And I think that's really important when you're doing any kind of breast procedure, because they will notice afterwards and scrutinize. And like Sal said, you add volume, that disproportion can be. magnified to a certain degree. And if that's the case, it's very important to talk to the patient and let them know you are starting with a certain degree of asymmetry and to point that out to patients.

And as Sam, as Sam said, a lot of times you're like, Oh, Oh, okay. Well, I never really noticed it. It's not really a big deal. That's not, that's not something that is a concern of mine.

[00:07:37] Dr. Lawrence Tong: Yeah, I think that that's very important. I would say that when I see a patient, my general concept and schema when I look at them is the breasts are different size. So, so, sorry, if they're different sizes, what, what does the patient want? Does the patient want to make the small one bigger or the bigger one smaller?

And then if they have drooping, um, address that. Sometimes patients will have both things. So you'll have to discuss, um, um, you know, lifting and changing the size. So if you're lifting and augmenting, that's usually a breast lift and an implant. If you're looking at lifting, but also making smaller, then that's, that's a form of breast reduction.

So there are multitudes of operations that you could do and many different permutations on how to, um, handle them. And the, the points about, um, being plastic surgeons being more critical about symmetry, I think is, um, is very true. A lot of times, um, a thing that I see is that patients come in and they want to get a breast implant and they think that's going to lift their breasts.

Can somebody comment on that?

[00:08:52] Dr. Salvatore Pacella: Yeah, so to, to some extent, I think, I think that, sorry guys, um, to some extent, I think that can lift your breast if you're deflated, right? So if, you know, one of the things I, I start to do, or I do it in my initial evaluation is do some measurements, right? And, you know, we're all sort of taught the measurement from nipple to nipple and nipple to sternal notch.

And, you know, for our viewers out there, that should be about an equilateral triangle. And I think when that distance from the nipple is down a centimeter or two, or you have very, very mild ptosis or breast droop, oftentimes adding a small implant or a modest size implant can lift the breast in an appropriate position.

I think the key, or lift the nipple in an appropriate position, I should say. But I think the key is looking at the breast parenchyma. So I, you know, when I evaluate patients, you know, I, I say to them, well, you know, let's, we got to look at all these measurements here and I'll give you an honest opinion as to whether I think you're going to need a lift after an augmentation of a particular size.

And so, you know, it's, it's, it's completely variable in every patient, I think.

[00:10:01] Dr. Sam Rhee: What do you think about fat grafting in these techniques? Um, if a patient's like, I don't want any implants, I just want to correct everything with my own tissue and make it natural.

[00:10:13] Dr. Sam Jejurikar: I do a lot of fat grafting. I think you have to set appropriate expectations for fat grafting. Um, I think with fat grafting, the amount of volume enhancement you can get is typically much less than you can get with an implant. So my general cutoff to a patient is if everything goes well and you get maximal fat graft taking, you know, you'll, you'll get half to a.

One cup size enhancement. The other thing is the shape of the breast is going to be different. A lot of patients come in. They like that round upper pole look that you can get with an implant. Even in my best back drafting cases that the ones that I'm really proud of, I don't get that same look. I get a much more natural look.

And if somebody wants that, They're still going to need to use bras to do that. But I think fat grafting is a very useful adjunct, particularly in cases of minor asymmetry where you're doing a breast lift. Um, you can, I have found that I can correct for that pretty nicely. I mean, create a look that's pretty darn symmetric afterwards without having to use an implant.

[00:11:11] Dr. Salvatore Pacella: You know, I, I think one of the most amazing things with fat grafting that I've been able to accomplish in my practice is, um, in, you know, kind of alludes to what Sam said about, you know, everything's big, which essentially said was everything's bigger in Texas, right? Everybody likes that little, but here in San Diego, so,

[00:11:32] Dr. Sam Jejurikar: Not, not everybody likes that. Some patients like that.

[00:11:35] Dr. Salvatore Pacella: you know, we,

[00:11:36] Dr. Lawrence Tong: of a sum is 90%.

[00:11:37] Dr. Salvatore Pacella: Right, right.

[00:11:38] Dr. Sam Jejurikar: no, no, that's not true. Don't fall into stereotypes, guys.

[00:11:43] Dr. Salvatore Pacella: So, you know, I, I, I tend to see a lot of kind of athletic type women, soccer moms, you know, yoga mom type of, type of look. And they, they're looking for full, fullness on the lower pole, a little bit more natural look up top. And I think, you know, the sort of combination of lipo filling the upper pole is a really, really great look.

Excellent option for them because we can get a very nice natural slope up top, but really kind of work on the projection down below. The other thing I think that has really, uh, I've really been, um, very hot on in my practice the last few years is, You know, when you, when you talk about where we place the implant, you know, I think most of us still place the implant submuscular underneath the muscle.

And there's some data behind that, right? There's, uh, definitely a reduction in capsular contracture rates, but I think that comes with a little bit of a cost. Oftentimes underneath the muscle, we're not able to get really extensive cleavage or sharp cleavage. And the implants oftentimes have a lateral displacement and inferior displacement, because when you fire the pec muscle, it's pushing everything out.

So what I have been doing is adding some fat transfer to the medial pole. pretty extensively at the time of surgery. And I think that works phenomenally because it still allows us to keep the implant under the muscle, but really work on augmenting the cleavage.

[00:13:03] Dr. Sam Jejurikar: And it can hide rippling and it can help with animation deformities too. Yeah, I agree. I do that a lot too. Um, sorry, Sam, you're about to ask a question.

[00:13:13] Dr. Sam Rhee: I was about to ask, um, how often do you do combined fat grafting slash implant? Well, it sounds like a lot of your cases now are breast aug with implant plus fat grafting. How about mastopexy and fat grafting? How often is that done? Or all three? Breast, lift, fat grafting, and implant?

[00:13:32] Dr. Salvatore Pacella: I think it's a, it's a bit of a challenge to do all three in one sitting, particularly with the extent of the mastopexy that you're doing. If I'm just doing a little bit of a, a small lollipop type of lift, it's fairly easy and safe to do fat transfer. But the, the problem sometimes is in older women, you know, the 60s, 70s, and you know, they just don't have a lot of natural architecture to your breast and we're really doing a much more aggressive mastopexy.

I think it's tough to do fat transfer with that because, you know, when you're, when you're peeling off all of the skin of the breast and reshaping the parenchyma and the setting of an implant, you know, you're really relying on pretty dismal blood supply. Um, anyway, and then adding that fat sometimes can It can damage the blood supply.

I don't know exactly where to put it sometimes because it's just not a great space to put it in. So it really depends on the extent of the mastopexy.

[00:14:27] Dr. Lawrence Tong: How, how many of you guys, I'm assuming you guys usually do this, but I do, I would say 99 percent of my breasts lift and augmentations simultaneously. I remember when we trained. A lot of people would advocate doing this in two separate operations, but the reality is patients don't want to do that. And I think it's important to let patients know that, you know, that makes it a harder operation because you're putting an implant in.

That means you're stretching the skin out. And then you're doing a lift, which means you're removing skin. So the combination of, you know, um, Successively making the skin envelope, um, more stressed, uh, you're, you have more issues with, um, blood supply as, uh, Sal just said. You have more issues with potential for symmetry, uh, asymmetry or creating asymmetries.

You have potential for more scars. But having said that, I think that, you know, most cosmetic surgeons will do it as a one stage procedure. Uh, there are various methods, uh, to do, um, surgery. Ranging from peri to, uh, which is an incision just around the areola to a lollipop incision, which, uh, Sal had mentioned all the way to an, an anchor and um, incision.

But I'm just wondering for you guys, um, what is your general approach to breast augmentation and lift simultaneously?

[00:15:53] Dr. Sam Jejurikar: I, I will say that, um, Probably 85 90 percent of the time I do it in one stage. But when the degree of droopiness is pretty significant, I quote patients a much higher rate of a complication where the implant might bottom out. The tighter the mastopexy, the more things will stretch out, just like you've said.

That being said, that still amounts to two operations, you know, and during that one operation, they generally look better in their clothes and they have a shape to the breast that they like better. So I do it more often than not. In really severe cases of ptosis or droopiness, I might think about using an implantable mesh material to try to help prevent that.

I get a different complication then called the waterfall deformity where the You know, where the tissue can fall over, um, in, in really severe cases. So there's, there's, there's no risk free way to do it. Um, but I think a good rule is the more severe someone's droopiness is, the higher chance that they might have a complication related to the implant or recurrent droopiness afterwards, if you do it in one stage.

[00:16:54] Dr. Sam Rhee: I, I generally will do them in one stage. I think what I will do in two stages is if they have a, an implant already in place and they want that out and then they want to lift with that. If, if the patient is amenable, I will generally take out that implant and then go back and do a lift secondarily.

Cause I feel the results, you can get a tighter mastopexy, um, if you allow that implant to be removed first. Yeah, and you just get, yeah, to me it's always like doing a tummy tuck. Like one day after delivering a baby, like what's the point? Like it's, everything is just so stretched out. Um, not all patients feel like that's something they want to do, but I think the results are, are better, at least in my hands in those cases.

[00:17:39] Dr. Lawrence Tong: So, so is that in the cases where you're not replacing an implant?

[00:17:42] Dr. Sam Rhee: Correct. Where they want an implant out and then they also want to lift.

[00:17:46] Dr. Sam Jejurikar: See, in that scenario, I would do it in one stage. But I would aggressively fat grab that breast a lot of the time to try to fill up some of that volume. I typically do it almost always in one stage.

[00:17:56] Dr. Sam Rhee: How much fat do you feel comfortable grafting in one shot? Volume wise?

[00:18:02] Dr. Sam Jejurikar: I mean it obviously comes down to characteristics of the patient's breast. Um, so you look for things like the turgor or the tightness being a lot more, you look for redness or erythema developing in the breast. But in general, I might do up to three or 400 mls in a, in, in a, you know, in, in one, in one stage.

I've done, I've done more than that too, but three or 400 is a, is a. Yeah, recite. I use the Viality system that came out about a year ago and my rates of fat necrosis have gone Way down using that system. Um, I think that, yeah, I, I use that in all my breast fat grafting cases and I like it a lot. Um, let me, let's, let me change the focus just, uh, uh, for a second because the scenario, you know, going back to the original topic, which was breast asymmetry, the scenario I see this the most in are patients that are coming in for a breast augmentation consult. So you guys want to talk about, like, you see a patient, you see some degree of asymmetry between the breasts.

They're in your office for a breast augmentation. How often are you using asymmetric implants? How do you determine the appropriate way to pick asymmetric implants for a patient if you're going to do it?

[00:19:18] Dr. Lawrence Tong: So I'll, I'll start off by saying that, um, if I'm doing an operation. Um, and we're also doing a lift at the same time, then I will always recommend symmetric breast implants because I believe that you can adjust the volume just by removing breast tissue at the time you're doing a lift. Um, but if, if patients have, um, significant, uh, volume differences, uh, you're going to have to, um, Talk to them about different breast implants.

And I, I think actually that's one of the hardest things to be able to estimate, uh, properly because for the viewers, as you increase the size of an implant, so if you have two different size implants, it's not just, Um, the projection, meaning how much it sticks out that changes. It's also the base width, which is the, the diameter of the implant changes.

So right there, you're already introducing another variable which can affect the symmetry. So when I'm in these scenarios, usually what I'll do is have, uh, you know, patients try on implants, um, using a, using a bra and trying to get an idea of what. Size works the best with combination, but also counsel the patients that it's not guaranteed to be perfectly symmetric.

Um, there's a likelihood that there's going to be some residual asymmetry afterwards. And I find that if they understand that and you go through it with them, then they're very accepting about, um, minor asymmetries that may exist afterwards.

[00:20:59] Dr. Sam Rhee: I, I agree with Larry. I think the base diameter, if they're markedly different, uh, from one side to the other, that can be a real challenge in terms of sizing appropriately. Uh, some of it is just experience at this point. I know what I feel comfortable in terms of how much of a difference there has to be in order to change sizes or profiles in terms of one side versus the other.

I generally say patients are fairly conservative. They don't necessarily want Um, uh, like, uh, they're pretty accepting. They, they generally will accept minor differences as long as it's, it's better or much better in terms of their asymmetry. Um, and so some of that, as Larry says, I, I try different sizers.

I, uh, I do some pretty careful measurements and I really try to get a sense of the patient's goals in terms of how close. And as Larry said, if you're doing a mastopexy at the same time, it's a lot easier to correct for volume differences at that point.

[00:22:00] Dr. Sam Jejurikar: Just to clarify, when you say you use sizers, are you talking about intraoperative sizers or preoperative sizers?

[00:22:05] Dr. Sam Rhee: Both. Both.

[00:22:07] Dr. Lawrence Tong: For me, I just use, I use only preoperative. I rarely use, um, intraoperative.

[00:22:15] Dr. Salvatore Pacella: I, I, I always use, uh, intraoperative sizers. I think it's, uh, I don't know how I could choose an implant without that. And I will say, you know, in doing a ton of breast reconstructive surgery in the setting of mastectomy, that's an absolute necessity to have a sizer. There's so many differentials in size and consistency, profile, etc.

Um, you know, getting back to the concept of what Larry was saying about using symmetric implants. So I agree with you, Larry. Um, when I'm doing a Master Pexi Aug, uh, and there are slight asymmetries in the breast in the setting of the lift. I'll always try to use symmetric implants and try to account by removing some breast tissue and sculpting it appropriately.

If it's a unilateral situation where I'm doing an Aug on one side and an Aug Pexi on the opposite side, In general, a good rule of thumb I use is one profile difference to account for the mastopexy. So, for example, if I'm using a high profile on the non lifted side, I'll oftentimes use a moderate plus profile on the lifted side.

[00:23:32] Dr. Sam Jejurikar: I totally agree with that. And I use intraoperative sizers. A lot. Even I'll use intraoperative sizers in a case that I think looks pretty symmetric at a time. I just like being able to assess the patient with sizers before I put in the definitive implants, make sure my pockets are dissected the way that I want them to.

I'd use them probably close to 100 percent of my cases. But I think it's just difference, you know, we all have differences in how we like to do things. Um,

[00:23:59] Dr. Lawrence Tong: Yeah, I think the issue, I think the issue is that. Sometimes, um, you really want to try to have the patient make the decision on the size. And that I think reduces, um, potential issues afterwards because if, if you're, if it's your responsibility to put the implant in, sometimes they can come back and say, well, this is not what I wanted.

You, you decided this. I, you know, I want to, I want to get them changed out. And so I find that Um, going through the process preoperatively and getting them to sort of make a decision on the size helps a lot. Now, of course, if there is a significant asymmetry, yes, then I will use intraoperative, uh, sizers because I won't be sure, uh, necessarily, um, how it's going to look until I actually, um, I'm doing the operation, but I think that, um, if it's, it's, if it's relatively symmetric, I don't,

[00:24:58] Dr. Sam Rhee: itched,

[00:25:00] Dr. Lawrence Tong: sizes, mostly because, A, I think it adds extra time to the surgery.

Um, and then also, um, the onus is sort of put more on the surgeon than on the patient. And I think ultimately the patient should be the one who decides what implant size they want. Yes,

[00:25:21] Dr. Sam Jejurikar: I use 3D imaging and the patients pick the sizes, but even if I think they're symmetric, I'll use sizers to make sure that my pockets are dissected the way that I want to. I'll take out, I'll take them out. I'll wash the pocket again one more time and then I'll use a Keller funnel and that way I'm not manipulating the pocket.

it all when I put in the implant and I'm not doing any sort of that last minute digit dissection that people will do. Um, and again, I have patients always pick the size ahead of time, but in, um, and I don't, it's not that I necessarily am using sizors just for the purposes of assessing asymmetry, I just think they have, in my practice, a pretty valuable role, um, in, in, um, Making sure that things are looking exactly what I want to before I commit to the final implants.

But again, we, you know, you talk to a hundred different plastic surgeons, we'll all do different things and we all think we're right. So, like, that's the great thing. We're an arrogant group who, uh, who think our way is the best. Well, do you guys have anything more you want to add to this topic? I feel like we've done a pretty good job of talking about all the nuances that are, that are actually, um, you know, present with breast asymmetry cases.

I agree. Great discussion, guys. Um, thank you all for all the viewers, uh, watching and listening. And we will, uh, see you at the next podcast.