Reverse breast lift for treatment of congenital symmastia

Introduction: Breasts are associated with a feeling of beauty, self-esteem, and female sexuality . Symmastia is a condition, characterized by the confluence of both breasts in the presternal region. The author demonstrates a surgical technique for correction of congenital symmastia. Methods: This is the case report of a young patient with previous history of breast hypertrophy and symmastia. She had previously undergone two mammoplasties and one liposuction of the breast, without correction of the symmastia . The author performed resection of the excess tissue in the breast and a reverse lifting of this region, with an upper abdominal advancement flap. Results: There was complete resolution of the symmastia. Conclusion: The treatment performed by the author is a safe surgical alternative for the treatment of symmastia. ■ ABSTRACT

We resected the excess tissue within the breasts, followed by a reverse lifting of the area, bringing the structures downwards, in an inferior lateral vectorial direction (Figures 3 to 5), thus lateralizing the mammary cone.We fixed the new breast at three points, with the fascia fixed to the sternal periosteum.A flap of the upper abdomen with a triangular marking was advanced, which could be modified to a lozenge if there was greater abdominal flaccidity.

INTRODUCTION
Breasts are directly associated with a feeling of beauty, self-esteem and female sexuality 1 .Symmastia is an unaesthetic breast condition, characterized by the confluence of both breasts in the pre-sternal region.First described by Spence et al. 2 , in 1984, symmastia may be classified as congenital, or acquired, the latter caused by trauma, burns and infection, or following breast augmentation 3 .
The etiology of congenital symmastia is unknown.On physical examination, a bridge joining the two breasts in the pre-sternal region is observed, caused by accumulation of the skin, fat, and gland, associated with tissue laxity in this region.Acquired symmastia after breast augmentation is classified as monocapsular, when there is a connection between the capsules in the pre-sternal region, and bicapsular, when there is no communication between the capsules 4,5 .

OBJECTIVE
The author reports the treatment of a case of congenital symmastia, in which resection of the loose intermammary tissue, and a reverse lifting of the area was performed with an upper abdominal advancement flap.This provided a better anchor to the breasts and maintained the scar in the intermammary sulcus.

METHODS
A female patient, aged 28 years, without co morbidities, presented with a history of breast hypertrophy associated with symmastia.She underwent two previous mammoplasties, at 18 and 23 years of age, and was satisfied with the volume of her breasts, but not with the persistent symmastia (Figures 1 and 2).She underwent a liposuction with breast enlargement at 24 years, but the symmastia persisted.We did not change the shape of the areolas as desired by the patient.We did not use any type of breast pocket or breast brace to deviate the breasts, except the conventional postoperative bra.The surgery was performed by the author in the Beneficent Association -University Hospital in Marília, SP, in 2016.

RESULTS
There were no complications in the postoperative period.The shape of the breasts was aesthetic and satisfactory, with resolution of symmastia (Figures 6 and 7).

DISCUSSION
The treatment of congenital symmastia is poorly described in the literature and the condition is difficult to treat, as described by Spence in 1984 2 , who used a "V-Y" flap.Mc Kissock 6 described an M-shaped flap, in contrast with Salgado and Mardini 7 who, in 2014, treated a case using a periareolar approach, associated with liposuction.On the other hand, the treatment of acquired symmastia after breast implantation has been demonstrated to be simpler by Spear et al. 8 and Parsa et al. 4,5 .
The reverse lifting of the breast with an upper abdominal advancement flap is another surgical option for the treatment of this difficult aesthetic breast condition.It is easy to execute, is safe, and preserves the scar in the intermammary sulcus.We believe in its effectiveness both when used alone, without the need to reduce the breast volume, and in association with reduction mammoplasties.

CONCLUSION
The treatment proposed by the author is just a first step and another safe therapeutic option for mammoplasties.

Figure 4 .
Figure 4. Traction of the breast in the inferolateral direction.

Figure 5 .
Figure 5. Extended resection of the marking for better compensation.