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Symmastia after Breast Augmentation

Parsa, Fereydoun Don M.D.; Koehler, Shannon D. M.D.; Parsa, Alan A. M.D.; Murariu, Daniel M.D., M.P.H.; Daher, Prester M.D.

Plastic and Reconstructive Surgery: March 2011 - Volume 127 - Issue 3 - p 63e-65e
doi: 10.1097/PRS.0b013e31820635b5

John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii

Correspondence to Dr. Fereydoun Don Parsa, John A. Burns School of Medicine, Department of Surgery, University of Hawaii, 1329 Lusitana Street, Suite 807, Honolulu, Hawaii 96813-2421,

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Symmastia after breast augmentation has received increasing attention in the past few years.1–3 The term “symmastia” was originally introduced in this Journal in 1983 by Spence in an article by the same name. The word “symmastia” has been spelled variably either as “synmastia”2 with the prefix syn- or as “symmastia”3 with the prefix sym-. The prefixes sym- and syn- derive from Greek, meaning “together,” as in symmastia; “same,” as in synchrony; or “similar,” as in syntype. However, the correct orthographic rule to follow consists of using the prefix sym- before labials such m, b, and p. Examples are symmastia, symbiosis, and sympathy. The same prefix becomes syl- before the letter l, as in syllabus; and syn- before other words, such as synchrony and synergy.

Symmastia after breast augmentation has been defined variously as “medial confluence of the breasts”; “disruption of the midline sternal attachments”; “crossing of the midline, even if it is only on one side”; “central webbing of the breasts”; or “displacement of one or both implants beyond the midline.”1–3

In lieu of the existing terms that are often anatomically nondescript, we propose the use of the following definition: symmastia after breast augmentation is attributable to disruption of the midsternal fascia. We further define the degree of symmastia as the extent of presternal skin elevation above the sternum. This may be described as moderate (Fig. 1) or severe (Fig. 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

We have noted that the midsternal fascia is a dense, strong, whitish structure that measures approximately 3 mm in thickness and in height. It attaches firmly the midsternal skin to the underlying sternum as shown schematically in Figures 1 and 2.

We also propose subdividing symmastia after breast augmentation into two groups: bicapsular symmastia (Fig. 1) when some muscle fibers and/or soft tissue connect the midsternal skin to the underlying sternum on one side (Fig. 1, left), and monocapsular symmastia when there is communication between the two periprosthetic capsules (Fig. 2). The degree of symmastia is generally moderate in bicapsular symmastia (Fig. 1), and its correction is simpler because the repair of the more advanced side (Fig. 1, right) generally corrects the deformity. In the case of monocapsular symmastia, when the degree of symmastia is generally severe (Fig. 2), both sides require surgical correction.

To correct symmastia, we use a posterior capsular flap,4 similar in concept to the technique we had previously reported for the correction of inferior capsular ptosis.5 When a mature capsule is not present, we perform a variation of capsulorrhaphy.1

Symmastia must be differentiated from medial malposition, with which it is commonly confused. We reserve the term “medial malposition” in all instances when the midsternal fascia remains intact. To avoid symmastia and medial malposition of the implants, we have found that gentle blunt dissection of the pockets medially under direct vision preserves the relatively thin and dense midsternal fascia and also minimizes the occurrence of medial malposition resulting from overzealous dissection of the medial fibers of the pectoralis muscle.

Fereydoun Don Parsa, M.D.

Shannon D. Koehler, M.D.

Alan A. Parsa, M.D.

Daniel Murariu, M.D., M.P.H.

Prester Daher, M.D.

John A. Burns School of Medicine

University of Hawaii

Honolulu, Hawaii

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1. Chasan PE. Breast capsulorrhaphy revisited: A simple technique for complex problems. Plast Reconstr Surg. 2005;115:296–301; discussion 302–303.
2. Spear SL, Bogue DP, Thomassen JM. Synmastia after breast augmentation. Plast Reconstr Surg. 2006;118:168S–171S; discussion 172S–174S.
3. Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket for the correction of symmastia. Plast Reconstr Surg. 2009;124:695–703.
4. Parsa FD, Parsa AA, Koehler SM, Daniel M. Surgical correction of symmastia. Plast Reconstr Surg. 2010;125:1577–1579.
5. Parsa FD. Breast capsulopexy for capsular ptosis after augmentation mammoplasty. Plast Reconstr Surg. 1990;85: 809–815.

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