Teenage Breast Problems
By Susan E. Downey, MD,
University Plastic Surgeons, Los Angeles, CA 90004
To be a teenager and have anything that makes you feel like you are different is extremely difficult. Teenagers with breast assymetries often hide this condition and are extremely embarrassed about it. Teenagers sometimes mention to their mothers that something is different about one of their breasts, and the mother often will downplay this saying that most women are slightly asymmetric, while in fact the teenager is trying to tell the mother that she has a significant problem. Commonly the mother often does not realize the teenager has a marked difference in the size of her breasts until the mother accidently walks in on the teenager while she is getting changed.
Teenagers tend to feel isolated and often have a marked improvement in their personalities, becoming more outgoing and more confident following breast reconstruction. It is for these reasons that it is important to identify early on any breast anomalies and to expedite the teenagers receiving treatment.
The most common breast problem that teenagers present with is asymmetry. In severe cases this may be a difference in several cup sizes however even milder asymmetries are often very distressing to the teenager.
As soon as a significant discrepancy in breast size is noted, the underdeveloping breast can be treated with placement of a tissue expander. The tissue expander can remain in place throughout the teenagers developing years and serially inflated as needed, to keep symmetry between the two breasts. Once breast development is completed on the opposite side, the tissue expander can be removed and a permanent saline implant can be placed. In girls who have finished development and have only a small discrepancy a one stage reconstruction can be done by simply pacing an implant in the smaller breast.
In cases of severe congenital asymmetry, sometimes a reduction can be done on the larger side, as well as a tissue expander and subsequently an implant placed on the smaller side. Most cases of asymmetry however can be handled primarily by placing a tissue expander in the affected breast. The tissue expander can then be filled slowly first to match the size of the opposite breast and then to maintain symmetry as growth proceeds. This process is well tolerated by teenagers in the outpatient clinic and does not require an anesthetic. The incision is placed in the inframammary area and is not visible even when the teen wears a bikini or is naked, as it is hidden by the natural overhang of the breast. Most commonly the tissue expander is placed above the pectoralis muscle, just under the breast tissue. If the implant is placed under the pectoralis muscle it often ends up being too high and the droop of the reconstructed breast does not match the non-operated upon side. Once breast symmetry has been achieved in the initial postop period with inflation of the tissue expander, the teen is usually seen in three to six month intervals, depending upon how much growth is seen in the opposite breast. Once stabilized for approximately one year and there is good symmetry between the two sides, a final permanent breast implant can be placed. Occasionally a crescent mastopexy (or breast lift) is done on the opposite breast in order to improve symmetry.
PolandÂ’s syndrome can also sometimes be diagnosed for the first time in teenagers. PolandÂ’s syndrome consists of the congenital absence of the pectoralis major muscle and can be associated with ipsilateral brachiosyndactaly (short , webbed fingers)as well as rib anomalies. There is no breast development on the involved side and in severe cases there is not even a nipple areolar complex. The absent breast can be corrected with again, placement of a tissue expander and subsequent placement of a breast implant and in some cases, the transfer of the latissimus muscle from the back to the breast side to recreate the anterior axillary line. I have found that breast reconstruction can also camouflage the absence of the muscle significantly so that transfer of the latissimus muscle is not always needed. In boys, the recreation of the anterior axillary line in the chest wall contour by the pectoralis muscle must be weighed against the loss of the normal contour of the back with the loss of the latissimus muscle.
Traumatic injury to the developing breasts can also occur from previous surgeries such as thoracotomies in infancy, deep second or third degree burns to the chest area, irradiation to the chest wall for treatment of a tumor as an infant, or even from a hemangioma in the breast area. Each of these cases must be treated individually.
In the case of a hemangioma, the atrophic tissue from the hemangioma can be partially excised. This may restore the nipple into a position more commensurate with the opposite side. An implant may be necessary to supplement the volume of the developing breasts as lack of development can be seen subsequent to a hemangioma.
Previous scars from surgery can be released, as well as burn scars. If burn scars are tethering the breast tissue, full release of the breast tissue with a skin graft releasing the nipple to the same level as the normal nipple which usually allows full development of the breast. In these cases an implant or tissue expander is usually not necessary. Of course in severe cases where the nipple and areolar area have been destroyed, usually the breast bud has also been destroyed and both of these would need to be reconstructed.
In cases where the child has received radiation as an infant, the rib cage as well as the breast usually does not develop to the same extent as the opposite side. In these cases it is important to point out the asymmetries to the child and to the parents, so that they will understand that the overall chest dimensions are different and therefore perfect symmetry would be difficult to achieve on either side.
Currently under the US Food and Drug Administration (FDA) guidelines, both silicone and saline implants are available for reconstruction but only saline implants are available for augmentation. Although adolescents with congenital asymmetry would fall under the category of reconstruction, in general I have used only saline implants for teenagers with marked asymmetry. If there is adequate breast tissue over the implant, rippling which is a problem associated with saline implants, is not seen and therefore saline implants are an excellent choice for these patients.
Correction of breast asymmetry has been associated with relatively few complications. The major complication is deflation of the tissue expander, which must be replaced. This can be very traumatic to the teenagers and I warn them that this can happen at some time, although it is relatively rare. I have left tissue expanders in for as long as five to seven years and have noted no other adverse complications. The saline is absorbed by the body and in some cases if the teen has or is close to our time of planning to place a permanent implant, I remove the deflated tissue expander and place the permanent implant, obviating the need for an extra surgical procedure.
With this type of surgery, the scars in general do well and there is a minimal risk of loss of nipple sensation and or breast feeding ability. When the teenager is old enough to eventually need mammography, she should inform the mammographer that she has an implant in place, so that an additional view can be obtained to maximize visualization of breast tissue.
The overall positive response to teenagers undergoing this surgery has been overwhelming. Due to the intense psychological effect of any breast anomaly, the earlier the diagnosis is made and the child receives treatment, I feel the better off for all involved. There is no reason to delay treatment until the teenager reaches full development and this only further prolongs the psychological difficulties of the teenager.