In June 2006, a 26-year-old woman was referred to us requesting correction of bilateral amastia (see Figures , , , and ).
Preoperative frontal view, showing complete amastia with the presence of a hint of bilateral nipples.
Preoperative view. Note thin skin with visible superficial vascular weave and hypofunction of pectoralis muscle.
Preoperative lateral view, showing total absence of the mammary mound.
Our patient presented amastia associated with pectus excavatum and ectodermal alterations that included: complete alopecia, dystrophic nails, and convergent strabismus. An abnormal adipous tissue distribution with an increased deposition focused on superior arms and sacrolumbar region and hypotrophy of Bichat's fat pad (Corpus adiposum buccae) were also present. Patient's skin appeared thin with visible superficial vascular weave all over the body. The linea alba, a fibrous structure composed mostly of collagen connective tissue, was strictly adherent to the upper layers of the skin, without fat interposition.
At birth she also suffered from hypodeveloped auricles and lips and corneal ulcerations caused by bilateral absence of superior and inferior eyelids (see ). These alterations were treated with several reconstructive surgeries in her childhood. When she was one-month-old, two cutaneos biopsies showed hypotrophic cutaneous appendages, especially sweat glands. Karyotype analysis was normal. Clinical and histologic data allowed genetists and dermatologists to make a diagnosis of ectodermal dysplasia.
Amastia in this patient was treated with mammary reconstruction in one surgical stage, adapting standard techniques of breast augmentation to this particular case. No subpectoral tissue expansion was performed before the implantation of silicone gel prostheses.
Preoperative tests included haematochemical parameters, electrocardiogram, and anesthesiologic visit. The patient also performed a thorax Nuclear Magnetic Resonance to evaluate chest wall and the major pectoralis muscle trophysm. Antibiotic prophylaxis was performed by 2 g of Cefazolin i.v. before surgery. Cefixime 400 mg 1 per day was administered orally for 8 days after surgery.
The procedure was performed in general anesthesia. A bilateral cutaneous periareolar-like incision was made at the level of the fifth rib. After skin incision, dissection with an electro-knife followed, stopping just above the external fascia of the pectoralis muscle. The lateral border of the pectoralis major muscle was identified and a subpectoral dissection was performed, creating bilateral partial submuscular pocket. In particular, the VI and VII costal origins were disinserted. After accurate haemostasis and the placement of bilateral drains, implants (Allergan style 410 MF 255 cc) were inserted into the previously created partial submuscular pockets. Subsequently, a new mammary mound and an inframammary fold were created. The inframammary fold resulted simply by the placement of the implant, without fixing sutures. The overlying skin was partially recruited from the surrounding regions (i.e., abdomen), due to its particular laxity and sliding properties. Wounds closure was completed in layers, using intradermic suture in monocryl 3–0 for skin closure.
After 6 months a bilateral areola-tattoo was performed with a tattoo machine.
Patient was followed up for 18 months and at each clinical examination the results were photographically documented (see Figures , , and ).
Postoperative view 18 months after one sugical stage mammary reconstruction and a bilateral areola-tattoo.
Postoperative lateral view, showing a good projection of the reconstructed breast.