Plastic surgeons are involved in the management of conditions that result in problems with breast development and problems with the development of the chest wall (muscles, ribs and breastbone).
These are apparent in childhood or become obvious during the teenage years, and can cause considerable distress to young people at a sensitive time in their development. A number of reconstructive techniques are appropriate for this wide-ranging spectrum of conditions from manipulation of the ribcage, muscle transfer, lipofilling, implants and breast reconstruction procedures. Each patient’s problem is unique so it is important that an individual solution is tailored to the patient.
2. Congenital breast conditions
When young women reach puberty and their breasts develop, sometimes the breast tissue does not develop correctly or breasts do not develop symmetrically. Usually this is simply a variant of normal development, some women will develop small or very large breasts, sometimes they are an unusual shape. Most women have a degree of asymmetry between their breasts. It is when these differences are very marked or when the woman is very self-conscious of their appearance that it becomes a problem. Small breasts or even absent breast development can sometimes be caused by underling genetic conditions. To develop very large breasts in the early teenage years is quite unusual, but can result in severe physical problems for which surgery is needed. Breast asymmetry can be due to Poland’s Syndrome, this is a condition where the breast tissue fails to develop on one side and is associated with a failure of complete development of the chest wall muscles and sometimes underdevelopment of the arm and hand on that side. When it affects boys it is the absence of the chest wall muscles and the associated contour problems that require correction. Girls will have the same chest wall muscle problems and then also develop breast asymmetry.
When breasts take on an unusual shape, it can be due to tubular breast deformity where the breast has a very narrow and often high base on the chest wall as well as a herniation of the nipple/areola area. This can affect one or both breasts. Surgical treatment is usually needed to reshape the breast and correct assymetry.
3. What surgery is available, and what techniques are involved?
Surgical treatment is tailored to the individual patient, often a variety of techniques are needed as growth and breast development proceeds.
Absent or very small breasts are managed by breast augmentation techniques. Often the best plan is to insert an expandable implant as the problem becomes apparent and then progressively inflate the implant as growth proceeds. Where implants are used the young woman must accept that further operations are likely to be needed to maintain the result as time goes by.
Very large breasts are managed by breast reduction techniques. Sometimes more than one reduction procedure is needed if the breasts continue to grow.
Assymetry is managed by augmentation of the smaller breast or reduction of the larger breast, or sometimes a combination of the two. If the patient is prepared to accept two breasts the same size as the smaller one then a reduction of the larger is always the simplest solution giving a lasting result.
Tubular breasts are managed by a combination of implants and reshaping of the nipple areola area.
The chest wall problems in Poland’s syndrome can be corrected by muscle transfer, custom- made implants or lipofilling. Part of the pectoralis major muscle is missing in Poland’s syndrome resulting in flattening of the front of the chest and loss of the normal contour of the front of the armpit. The latissimus dorsi muscle can be transferred from the back to correct the contour and re-establish the fold at the front of the armpit. Custom-made implants are sometimes appropriate.
Lipofilling is a relatively new technique whereby fat is aspirated from one part of the body using fine cannulae, the fat is separated into its’ component parts and the living fat cells are injected into the underdeveloped area again using fine cannulae. For larger defects multiple sessions are needed. This technique is already established as a useful adjunct in breast reconstruction and if it fulfills its early promise, it may be the ideal solution for congenital chest and breast problems.
4. Is this surgery available on the NHS?
Correction of breast problems is rationed on the NHS. In some parts of England the local Primary Care Trust (PCT) will allow consultations and operations for patients with congenital breast conditions without any restriction. However, in some areas treatments are only available in certain circumstances. These exceptional circumstances vary from region to region.
In general, patients with more marked physical problems might be considered exceptional. Your GP or PCT in your area will be able to tell you about the local rules that apply for where you live. BAPRAS is unhappy that this type of postcode rationing occurs and has worked with the Department of Health in drawing up guidelines for commissioning cosmetic procedures on the NHS. However, at present it is the local PCT that decides what is available for their population. Different rules also apply in Wales, Scotland and Northern Ireland. If NHS treatment is not available to you, you will have to consult a plastic surgeon as a private patient and pay for the operation yourself.
5. Who will I see as patient?
- Plastic surgeon
- Breast surgeon
- Clinical nurse specialist
6. What should I expect in terms of treatment, procedures and outcomes?
The correction of congenital breast conditions is often a process that may involve a series of operations. Patients must be prepared for a progressive series of interventions depending on how their problem develops and how it responds to treatment. At each stage your treating team will inform you of what is involved and discuss the aims and likely outcome of the operation. Many procedures are relatively simple day case operations, but sometimes a brief hospital stay is needed. All operations result in scarring, but operations are planned to minimise the scars and put them in inconspicuous places.
Every attempt will be made to restore perfect shape and symmetry, but it must be recognised that some imperfection is likely and will have to be accepted. If correction can be made using the patient’s own tissues the result is likely to be static and permanent. If implants are needed it is likely that further operations will be needed as the years go by in order to maintain the result.
7. Where should I go for more information?
Poland’s Syndrome Patient.co.uk – Chest deformity