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Congenital Symmastia: A 3-Step Approach

Sadaka, Mohamed Saad, MD*; Allam, Atef A., MD*†

Plastic and Reconstructive Surgery – Global Open: December 2016 - Volume 4 - Issue 12 - p e1158
doi: 10.1097/GOX.0000000000001158
Case Report

Summary: Congenital symmastia is a medial confluence of the breasts. It is a rare anomaly with few reports in the literature and no standard treatment. In this article, we present a case of congenital symmastia treated by 3 steps: liposuction, fixation of the skin to the chest wall in the area of the intermammary sulcus, and postoperative intermammary compression. A successful result was achieved with normal cleavage between the breasts. So, this is considered the ideal treatment for this condition.

From the *Faculty of Medicine and Department of Plastic and Reconstructive Surgery, Tanta University, Tanta, Egypt.

Received for publication July 13, 2016; accepted October 12, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Mohamed Saad Sadaka, MD, Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Tanta University, El-Geish Street, Tanta, Egypt, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Symmastia (Greek: syn, meaning “together” and mastos, meaning “breast”) is defined as a medial confluence of the breasts.1 Congenital symmastia is a rare clinical anomaly, which represents webbing across the midline of the breasts that are usually symmetric. Like many anomalies of ectodermal origin, a broad spectrum of defects may be observed varying from an empty skin web to an apparent confluence of breast tissue across the midline.2 Few cases of symmastia were reported in the literature, with different techniques used for its correction, but there is no standard treatment for this condition.1,3–8

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An 18-year-old girl was referred with the complaint of lack of cleavage between her breasts (Fig. 1). She had no family history of similar condition or of any other breast abnormality. She had not undergone any breast operation. Physical examination revealed a medial confluence of the 2 breasts with a web of skin and fat connecting them and the absence of intermammary sulcus. The patient was satisfied with her breast size, but she wished to have the normal cleavage between the breasts.

Fig. 1.

Fig. 1.

Preoperative marking was done for the midline, the inframammary fold, and the lateral sternal border. The inframammary fold incision was marked 3 cm in length with its medial end lying 3 cm lateral to the midline.

The patient was given general anesthesia with oral intubation. Liposuction was performed in the presternal area and the web between the breasts but was not extended beyond the lateral border of the sternum. No liposuction was performed in the breast tissue. Approximately 200 mL of lipoaspirate was obtained. The inframammary fold incision was made, and dissection was performed, through this incision, toward the midline. Then, 3 quilting sutures were inserted in the intermammary area on each side of the midline between the dermis of the presternal skin and the periosteum at the lateral sternal border. Postoperatively, a compression bolster was applied to the intermammary sulcus for 2 months, 24 hours a day.

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Postoperative cleavage between the breasts was achieved, and the patient was satisfied with the result (Fig. 2). Dimpling was observed at the site of quilting sutures, but it resolved after 1 month of the operation (Fig. 3). There were no postoperative complications.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

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Congenital symmastia was reported for the first time by Spence et al1 in 2 cases with successful treatment. Piza-Katzer et al5 reported 2 cases of congenital symmastia in a mother and a daughter, and they found the abnormal arrangement of collagen fibers in the breast tissue (including Cooper’s ligament) in both cases, and so, they assumed that this condition may have a familial cause.

There is a broad spectrum of congenital symmastia varying from an empty skin web to an apparent confluence of breast tissue across the midline. So, if the deformity is minimal, the patient should be informed about the complications that could result from the operation to be weighed against the benefit that she can get from the operation. These complications include asymmetry, contour irregularities, and scarring.

Because the midline confluence of the breasts could contain fatty and glandular tissue, the degree of congenital symmastia could be affected by the fluctuations in body weight and by the breast maturity. So, the operation should be performed after breast maturity is complete, and the patient’s weight is stable.

The ideal technique for congenital symmastia correction should include 3 steps. First is the removal of the excess tissue between the 2 breasts. This is achieved either with surgical resection5,7 or with liposuction2,3,6–8 as in the case presented in this study. The use of liposuction only was reported to give successful result by 1 study,6 but in another study,7 the correction was insufficient, and a second procedure was performed with resection of the glandular-fatty tissue in the cleavage and suturing the skin to the chest wall.

Second is to fix the skin of the intermammary sulcus to the underlying periosteum with sutures either at the midline3,4,8 or at the lateral sternal border5,7 as in our case presented here. These sutures can be inserted through small inframammary fold incision,5,7,8 as in our presented case, periareolar incision,3 or vertical scar mammoplasty incision.4 However, the inframammary incision gives superior cosmetic result as it is less visible. These sutures cause some dimpling, but it resolves with time as observed in this study (Fig. 3) and other study.3

The third step is the application of postoperative compression to the intermammary sulcus to facilitate the healing between the skin and the chest wall either with a bolster5,7,8 or a sternal shaping bra.3,6

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Congenital symmastia can be successfully treated by following the 3-step approach described in this article with combination of liposuction, skin fixation to sternum, and postoperative intermammary compression.

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1. Spence RJ, Feldman JJ, Ryan JJ. Symmastia: the problem of medial confluence of the breasts. Plast Reconstr Surg. 1984;73:261269.
2. Bland KI, Howard JH, Romrell LJ. Barsky SH, Gradishar WJ, Recht A, Congenital and acquired disturbances of breast development and growth. In: The Breast: Comprehensive Management of Benign and Malignant Diseases. 2009:4th ed. Philadelphia: Saunders Elsevier; 189207.
3. Salgado CJ, Mardini S. Periareolar approach for the correction of congenital symmastia. Plast Reconstr Surg. 2004;113:992994.
4. Wong MT, Cheong EC, Lim J, et al. Creation of an intermammary sulcus in congenital synmastia. Singapore Med J. 2007;48:e29e31.
5. Piza-Katzer H, Engelhardt TO, Steiner HJ, et al. Familial congenital symmastia: ultrastructurally abnormal breast tissue. Scand J Plast Reconstr Surg Hand Surg. 2009;43:339342.
6. Karamese M, Hanci M, Abaci M, et al. An easy way for congenital symmastia correction. Aesthetic Plast Surg. 2014;38:369372.
7. Sillesen NH, Hölmich LR, Siersen HE, et al. Congenital symmastia revisited. J Plast Reconstr Aesthet Surg. 2012;65:16071613.
8. Fallon SC, Hatef DA, McKnight AJ, et al. Congenital synmastia with concurrent fibroadenomas in a pediatric patient. J Pediatr Surg. 2013;48:255257.
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.