ORIGINAL PAPER

Review of implant sizes in 146 consecutive asymmetricalaugmentation mammoplasties

Umar Daraz Khan

Received: 15 August 2013 /Accepted: 3 January 2014# Springer-Verlag Berlin Heidelberg 2014

AbstractBackground Breast and chest asymmetries have been reportedwith varying incidences in patients requesting augmentationmammoplasty. However, there is a paucity of informationregarding the sizes of different implants used, their relativedistribution on either side, complications and revision rates inthis cohort when compared with primary augmentationmammoplasty using similar size implants.Methods A retrospective data using the Excel spreadsheetwas performed. All patients had muscle splitting techniquefor augmentation mammoplasty in asymmetrical breasts. Pa-tients requiring augmentation with mastopexy, sternal notch tonipple areolar complex level discrepancy of more than 1 cm,and patients having same size implants were excluded fromthe analysis. Insignificant asymmetries, not noticed bypatients, were not chosen for two different size implants.Patients, who chose two different size implants formammoplasty, were divided into three groups based on therelative difference in the size of different implants used.Results A total of 164 patients had primary augmentationmammoplasty between 2005 and 2011, using two differentsize implants for augmentationmammoplasty in asymmetricalbreasts. Mean age of the patients (n=164) was 29.2±7.79 years (range 18–50), and 46 (28.0 %) were smokers.Complete data on differential implant sizes used was availablein 146 patients. Mean size of the implant on the right (n=146)was 346.27±70.581 cc (range 220–605). The mean size of theimplant on the left (n=146) was 333.46±74.419 cc (range200–655). Out of these 146 patients, 46 (31.5 %) patients hadlarger implants on the left as compared to 100 (68.5 %)patients on the right. Mean volume difference between the

two sides when larger implants were used on left side was55.76±37.785 cc as compared to 44.35±26.166 cc whenlarger implants were used on the right side. Low profilecombination was used in 2.73 %, moderate size implantcombination was used in 9.58 %, mixed profile combinationwas used in 3.42 % and high profile combination was used in84.24 % of the patients. Overall revision surgery was per-formed in three patients (1.8 %), and out of these threerevisions, only one (0.6 %) patient needed surgery for volumecorrection.Conclusions Primary augmentation mammoplasty in asym-metrical breasts using differential size implants is a procedurewith low revision rates, provided that strict exclusion criteriaare used along with adequate informed consent in this group.Level of Evidence: Level IV, risk/prognostic study.

Keywords Breast asymmetries . Chest asymmetries .

Mammoplasty inasymmetricalbreasts .Musclesplittingbreastaugmentation

Introduction

Chest and breast asymmetries are common in patientspresenting for augmentation mammoplasty procedure. Themost common asymmetries are related to breast volume,chest dimensions, sternal notch to nipple areolar complexmeasurements and nipple to inframammary crease distancedifferences. These asymmetries and their relative distribu-tion have been studied and described in the past [1]. Othercauses for less commoner asymmetries are inframammarycrease level discrepancy, nipple areolar complex size dif-ferences, tuberous breasts and muscle hypoplasia [1]. The-se asymmetries combined together may exist in 87 % ofthe patients [1]. Despite the high prevalence of thesedifferences found in breast and chest anatomy, only small

U. D. Khan (*)Reshape House, 2-4 High Street, West Malling,Kent ME19 6QR, UKe-mail: Mrumarkhan@aol.com

Eur J Plast SurgDOI 10.1007/s00238-014-0928-6

numbers of patients require different size implants whenaugmentation mammoplasty is performed in this cohortof patients [1]. Major discrepancy on two sides is read-ily noticed by surgeons and patients alike; however,smaller differences are easily missed by surgeons andquite often patients are not aware of these asymmetrieseither. It is mandatory to have a meticulous preoperativeexamination along with a detailed documentation of allthese findings. Quite often, underlying ribs and bonyasymmetries are missed by clinicians. A thorough ex-amination can identify these differences and a detailedand accurate assessment of underlying ribs and bonydiscrepancies and breast volumetric asymmetries canalso be complimented using 3D or 4D imaging [2, 3]. Implantsizers can be used intraoperatively or adjustable expanders canbe used to correct these asymmetries in primary [4–6] andsecondary augmentation mammoplasties [6].

A detailed examination and evaluation does help to plana comprehensive surgical approach and to reduce reopera-tion and dissatisfaction in this group of patients. Thesesurgical approaches may require unilateral mastopexy, re-duction or mastopexy with or without implants, either as asingle or a two-staged procedure. Intraoperative use ofsizers in asymmetrical augmentation mammoplasty hasbeen described. The cohort included primary augmentationmammoplasty, revision augmentation mammoplasty as wellas augmentation with mastopexy [4]. However, there isa lack of information of implant sizes used on eachside, the mean difference of implants used between thetwo sides and relative distribution of larger implantsused in these asymmetrical breasts. The current studyanalysed 146 bilateral primary mammoplasties presentingwith breast asymmetries.

Material and methods

A retrospective analysis of data prospectively collectedusing the Excel spreadsheet was performed. Muscle split-ting technique was used for augmentation mammoplasty.Patients requiring augmentation with mastopexy, tuberousbreasts and having same size implants were excluded fromthe analysis. Insignificant asymmetries, not noticed by pa-tients or not concerned about the difference, were notchosen for two different size implants. Patients with asym-metrical breasts who had two different size implants weredivided into three groups based on the volume difference ofthe implants.

Methodology

Consultations were carried out in an office setup with anaverage time of 45 min to an hour. After taking complete

general history, patients were asked about the reasons forimplant surgery with special reference to the effect ofbreast size on their confidence, choice of clothing, holi-days and relationship with their partners. Details about thebreast’s physical changes starting from puberty, duringpregnancy and breast feeding, effect of weight gain orloss on cup size and the current bra size were noted.Breast measurements were carried out and the distancefrom the suprasternal notch to nipple and nipple toinframammary crease, breast width and cup size and po-sition of nipple and its relation to inframammary foldwere noted. Chest walls were examined for any differencein its dimensions or any localised abnormality. Patientshaving symmetrical breast, tuberous breasts or those withclass “B” or “C” ptosis and requiring mastopexy wereexcluded from the current series. Mothers with youngerthan 6 months babies were deferred due to anticipatedchanges in breasts’ physical characteristics. Implant widthis given paramount importance and chosen with a view toensure that its midpoint coincides with the midline of thebreast. Relevant implant sizers are tried with patient instanding position in the chosen cup size sport brassiereand patients are asked to view themselves from threedifferent angles in a life size mirror in dark- and light-coloured vests. The implants used for preoperative simu-lations were round, textured cohesive gel and belonging tohigh, moderate or low profiles. The sizes of the trialsample implants ranged from 200 to 525 cc with incre-ments ranging from 20 to 30 cc and differential implantswere used simultaneously. Several combinations usingsame and asymmetrical implants allowed patients to com-pare and check for the best combination. Once the sizesof implant are selected, patients are shown preoperativeand postoperative photographs of the patients with similarage, cup size, breast and chest asymmetries and selectedimplant sizes, when available. Postoperative sets of photosinclude right lateral, front and left lateral views taken at4 weeks, 3 months, 6 months and at 1 year followingsurgery. Patients were generally advised to select an im-plant size likely to enhance at least two cup sizes on thesmaller side to prevent and avoid postoperative disappoint-ment. All general and specific information including riskswere outlined as a routine.

All primary augmentation mammoplasties were per-formed consecutively under general anaesthetic throughinframammary incision using author’s muscle splittingbiplane technique with full muscle relaxation. After secur-ing haemostasis, pockets were irrigated with normal saline.No intra-operative sizers were used. Preoperatively selectedimplants were immersed in Betadine before their insertionas a routine, and all procedures were performed as aday case and most were treated without drains. Allpatients had single intravenous antibiotics, preferably

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second-generation cephalosporin followed by an oralcourse of antibiotics and analgesia for 5 days, and weredischarged in an appropriate size support brassiere.

Statistical analysis

The data was entered in Excel spreadsheet (Microsoft)and analysed using SPSS version 17.0 (CPSS, an IBACompany, Chicago, IL). The categorical variables arepresented as frequency and percentages, while the nu-merical variables are presented as mean ± standarddeviation. Statistical analysis was performed for age and im-plant volumes using the Student’s t test. A p value of <0.05was considered statistically significant for all the statisticaltests.

Results

The results were assessed by comparing preoperativeand postoperative pictures for volume difference andits correction, respectively, and patient’s satisfactionwith the outcome. A total of 164 (14.6 %) patientsreceived two different size implants between 2005 and2011. Mean age of the patients was 29.2±7.79 years(range 18–50), 46 (28.0 %) were smokers, 2 (1.2 %)had non-progressing haematoma and were treated con-servatively, 7 (4.3 %) had superficial wound healingproblems and 8 (4.9 %) had drains (Table 1). Full dataon differential implants was available in 146 patients.Overall mean size of the 292 implants in 146 patientswas 339.6±67.75 cc (range 230–630). The mean size ofthe implant on the right (n=146) was 346.27±70.581 cc(range 220–605) as compared to 333.46±74.419 cc(range200–655) on the left (n=146) (Table 2). Out ofthese 146 patients, 46 (31.5 %) patients had largerimplants on the left and 100 (68.5 %) patients hadlarger implants on the right. Mean difference of thevolume between two sides, when larger implants usedon left side, was 55.76±37.785 cc as compared to44.35±26.166 cc when larger implants were used onthe right side (Table 3). Low profile combination was

used in 2.73 %, moderate size implant combination wasused in 9.58 %, mixed profile combination was used in3.42 % and high profile combination was used in84.24 % of the patients (Table 4). Patients were dividedin three groups, groups A, B and C, on the basis of thedifference of size of the implants used. Group A includ-ed 35.6 % (n=52) with a difference of less than 30 cc.Of these, 39 patients had larger implants on the right ascompared to 13 patients who had larger implants on theleft side. Group B included 71 patients who had im-plants with a difference between 30 and 60 cc. Of these71 patients, 49 had larger implants on the right side ascompared to 22 patients who received larger implantson the left side. Group C included 23 patients who hadimplants with a difference of 60 cc or above. Of these,12 patients had larger implants on the right as com-pared to 11 patients who had larger implants on the leftside (Table 5). Overall revision surgery was performedin three patients (1.8 %), and out of these three revisions,only one (0.6 %) patient needed surgery for volumecorrection.

Discussion

Re-operation following primary augmentation mammoplastyis well documented and a 3-year re-operation rate of 0,2 and 15.4 % has been reported [7–9]. The request forbigger size or profile changes constitutes the secondmost common reason for re-operation, and implant size

Table 1 Table showinggeneral distribution ofcomplications seen fol-lowing mammoplasty inpatients with asymmetri-cal breasts

No. (%)

Total patients 164

Smoker 46 (28.0 %)

Haematoma 2 (1.2 %)

Infection 0 (0 %)

Drains 8 (4.9 %)

Revision/reoperations 3 (1.8 %)

Table 2 Statistics on differential implants used on each side in 146patients

Implants used on the rightbreast, n=100 (cc)

Implants used on the leftbreast, n=46 (cc)

Mean 346.27 333.46

Median 345.00 325.00

Mode 300 300

Standard deviation 70.581 74.419

Minimum 220 200

Maximum 605 655

Table 3 Table showing relative distribution of the larger size implantsused and the mean difference of the sizes between two sides in eachscenario

Side withgreater sizeimplant

Number Mean difference ofthe implants betweentwo sides (cc)

Standarddeviation

p value

Left side 46 55.76 37.785 0.068

Right side 100 44.35 26.166

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selection during preoperative consultation has beenemphasised to reduce this nonclinical cause for re-operation [8]. On the other hand, breast asymmetriesare common and have been described on the basis oftheir embryological and developmental origin [10] andon the basis of their morphology [1, 11, 12]. Theincidence of breast asymmetries varies from 87 % onphotographic evaluation alone [13] to 100 % when 4Dphotography was used [3]. Most commonly observedasymmetries are due to breast and chest volume dis-crepancy, nipple areolar complex to inframammarycrease and sternal notch to nipple areolar complex dif-ferences [1] (Figs. 1, 2, 3). Other common but oftenmissed asymmetries are due to chest asymmetries [1]and asymmetrically placed nipple areolar complex inhorizontal axis [12]. The relative incidence and distri-bution of these asymmetries on either side were includ-ed with a detailed morphological, volumetric and mus-culoskeletal system of classification [1]. A previouslypublished series by the author included 312 bilateralaugmentation mammoplasties, of these 145 (46.6 %)had breast volumetric asymmetries. Among these volu-metric discrepancies, 93 (29.8 %) had larger breasts onthe left as compared to 52 (16.7 %) on the right(p<0.001). Similarly larger chest/rib cage, increasedsternal notch to nipple areolar complex and nipple toinframammary crease distance, was noted on the left ascompared to the right. The chest and rib cage asymme-try was assessed using clinical methods of inspection

and palpation only. Despite a high incidence of breastasymmetries, only 9 % of the patients needed differentsize implants in the series [1]. Similarly in the currentseries and despite of the high incidence of breast andchest volume asymmetries, only 14.6 % of patients

Table 4 Table showingdistribution of the im-plant profiles used in theseries

Implant profile in146 patients

n (%)

High 123 (84.24 %)

Moderate 14 (9.58 %)

Low 4 (2.73 %)

Combination 5 (3.42 %)

Table 5 Table showing relativeincidence of larger implant usedon respective sides based on thevolume of the prosthesis used

Difference in implant sizes (cc) Side with greater implant size Total p value

Left side Right side

Up to 30 counts 13 39 52 0.27% With side with greater implant size 28.3 % 39.0 % 35.6 %

31–60 counts 22 49 71

% With side with greater implant size 47.8 % 49.0 % 48.6 %

60–90 counts 5 6 11% With side with greater implant size 10.9 % 6.0 % 7.5 %

>90 counts 6 6 12% With side with greater implant size 13.0 % 6.0 % 8.2 %

Total count 46 100 146% With side with greater implant size 100 % 100 % 100 %

Fig. 1 a–dA 22-year-old patient with breast hypoplasia presenting withchest and breast asymmetry, left side beingmore prominent than the right.e–g Six months postoperative results following mammoplasty using300 cc (left) and 350 cc (right) of high profile, cohesive, textured, siliconegel implants

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received two different size implants. Implant sizes inthese patients were selected preoperatively by using acombination of differential size implants in a desiredsize brassiere. The most appropriate pair was selectedonce the patient had a trial of various combinations ofdifferent size implants. Other approaches, described forimplant size selection in asymmetrical breast mammoplasties,are the use of adjustable implants [5, 6] or the use ofsizers intraoperatively [4]. The volumetric difference canalso be established preoperatively using 4D photographyto delineate and establish more accurate volumetric differ-ences [3]. A high quality of life and self-esteem has beenreported following a surgical intervention in patients pre-senting with breast asymmetry [14]. The single denomina-tor for an adequate outcome is the level of the nippleareolar complex distance from the sternal notch. Patientspresenting with volumetric difference with a symmetrical

nipple areolar complex distance from sternal notch arelikely to get the best outcome when mammoplasty is doneusing different size implants [1] (Figs. 4 and 5). In thesepatients, adjustment of implant volume alone is needed.When patients present with a difference of less than acentimetre of sternal notch to nipple areolar complex,acceptable results can be obtained with volume adjustmentalone, provided patient is not keen on extra scarring onthe breast and happy to accept minor nipple areolar leveldiscrepancy (Fig. 3). For patients presenting with a differ-ence of more than 1 cm of nipple areolar level discrepan-cy, mastopexy is mandatory for an adequate and accept-able result. The process of implant selection has beenreported for mammoplasties in patients with symmetricalbreasts and similar process is used by the author for theselection of implants in asymmetrical breasts [8]. Thecurrent study involves a single surgeon using the musclesplitting technique [15] for primary augmentationmammoplasty in asymmetrical breasts. A previously pub-lished study has reported a median size of 350 cc implants

Fig. 2 a–d A 31-year-old patient presenting with moderate to severechest and breast asymmetry. The patient had hemithoracic disjunction inanteroposterior dimension along with larger breast on her left side andwas interested in augmentation mammoplasty following a child birth andbreast feeding. e–g Postoperative views following augmentationmammoplasty using high profile, textured, cohesive, silicone gel im-plants. Patient had 270 and 330 cc of implants on her left and right side,respectively

Fig. 3 a–d A 35-year-old patient presenting with asymmetrical ptotictuberous breast with medial breast fold flaring. Her left breast was largerwith nipple areolar complex 1 cm lower than the right. e–g Six monthsfollowing augmentation mammoplasty using 345 and 365 cc of cohesive,high profile, textured gel implants on her left and right side, respectively

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(range 125–650) along with the percentage of the profilesof implants used in these mammoplasties who presentedwith asymmetrical breasts; however, the information waslacking in regards to the detail of differential sizes orrelative distribution of these implants used on either side.The article also noted that a revision was needed in fourpatients despite the persistence of asymmetry in 21 % ofthe patients in asymmetrical breast cohort. The article didnot delineate the group of patients requiring revision sur-gery in this mixed cohort [4]. In current study, there wasa 6-year re-operation rate of 1.8 % when mammoplastywas performed in asymmetrical breasts as compared to apreviously reported incidence of revision rate of 1.2 %when same size implants were used for primarymammoplasty using the muscle splitting technique [16].The difference was not significant (p value 0.722) whensame technique was used in these two cohorts. The meansize of the implant used on the right side was 346.27 ccas compared to 333.46 cc on the left, suggesting thatwhen differential implants were used, left breast neededless volume (Table 2). The data was further analysed andrevealed that 46 patients needed larger implants on the leftside as compared to the 100 patients requiring largerimplants on the right side, showing that larger breastsare likely to be present on the left side and almost intwice as many patients. The mean difference of the

volume between the two breasts, when larger implantswere used on the right side (n=100), was 46 cc ascompared to 55.76 cc, when larger implants were usedon the left side (n=46; Table 3). Even though the resultwas insignificant statistically (p=0.68), the data suggeststhat when right breast is larger, more volume was neededto correct hypoplasia on the left breast. When data wasfurther broken down into three groups, A, B and C, onthe basis of the difference of volume of implant insertedon either side, the result showed that when the differenceof implant size was 30 cc or less on two sides, 13 patientsneeded larger implants on the left side as compared to 39patients on the right side, and when the difference ofimplant sizes was between 30 and 60 cc, 22 patientsneeded larger implants on the left side as compared to49 patient on the right side, again emphasising that whenleft breast is larger, the volumetric difference is not assevere and generally does not require a difference of morethan 60 cc. On the other hand, when the difference of

Fig. 4 a–c A young 19-year-old patient who presented with breastasymmetry with an interest for augmentation mammoplasty. Her leftbreast was moderately larger than the right. d–f Two months followingaugmentation mammoplasty using 380 and 410 cc of textured, highprofile, cohesive, silicone gel implants on her left and right side,respectively

Fig. 5 a–dA 36-year-old patient presenting with pseudoptosis and lackof upper pole fullness. She had left breast reduction with mastopexy usingWise pattern markings. e–g Postoperative views showing results follow-ing augmentation mammoplasty. The patient had 230 and 260 cc of highprofile, textured, cohesive, silicone gel implants on her left and right side,respectively

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implant size used was more than 60 cc, the relativedistribution of larger breast changed. Of the 23 patientswho received implants with a difference of more than60 cc, only 11 patients needed larger implants on the leftside as compared to 12 patients on the right side (Table 5).The results quite clearly suggest that it is more commonto have the left breast larger than the right as reported in apreviously published study [1]. When volumetric differ-ences are small or when 60 cc or less difference sizeimplants were used, left breast tends to be more common-ly larger than the right breasts. However, when the volu-metric difference exceeded 60 cc or when larger than60 cc implants were used for the correction of asymmetry,the distribution of larger breast on either side almost levelsout. The volume difference between the two asymmetricalbreasts has been calculated using 4D photography. Thefindings concluded that difference of 25 cc or less wasfound in 24.1 % patients, volume difference between 25and 50 cc was in 28.9 %, difference of 51–100 cc wasfound in 29.3 % and over 100 cc difference was seen in17 % of the patients [3]. The findings clearly indicate thatmajority of the breast asymmetries are less than 100 cc,and only 17.7 % of breasts had a volumetric difference ofgreater than 100 cc. However, the study did not look intothe relative distribution of these breast asymmetries. Find-ings in the present article correlate well with the overallfindings seen when the 4D photography was used [3].

In a previously reported study where differential size im-plants were used for augmentation mammoplasty for asym-metrical mammoplasty, of the 38 patients principally consid-ered asymmetric, 27 received differential size implants. Ofthese 27 patients, high profile implants were used in 54 %,moderate profile implants in 18 % and low profile implants in25 %. None of the patient needed a combination of profiles inthis series [4]. In the current series, high profile implants wereused in 84.24 %, moderate profile implants were used in9.58 %, low profile implants were used in 2.73 % and acombination of profile was used in 3.42 % of the patients(Table 4). The choice of profile selection was purely made onthe patient’s desire for her intended cup size, existing breastand chest asymmetries and preoperative base of the breast.Combination of profile was used only in those patients whohad preoperative chest volumetric or dimensional differences,previously described by the author as hemithoracic disjunc-tion (Fig. 2). In this type of asymmetry, a patient may presentwith different dimensions of the chest. This difference mayexist in anteroposterior or horizontal dimension ormay show acombination of both [1].

Limitation of study Even though the use of 3D or 4Dphotography has been described for more accurate preop-erative and postoperative assessment for the differenceand its correction, respectively, the current series involved

careful preoperative assessment and use of differential sizeimplants for simulation and volume correction. A postopera-tive questionnaire would have been desirable to validate theresults; however, with a redo rate of 0.6 % for volume correc-tion, the process of preoperative implant selection alone isreproducible.

Conclusion

Breast and chest asymmetries are extremely common. De-spite the high number and type of asymmetries, only afraction requires asymmetrical breast augmentation. Thecurrent series deals with a select group of such patientswhere single stage mammoplasties were performed. Mostof these patients presented with larger breasts on the leftside. Patients presenting with smaller differences had twiceas commonly larger breasts on the left side. In theseasymmetrical mammoplasties, majority of the patients need-ed a combination of implants with a difference of 60 cc orless. Simultaneous mastopexy with augmentation as asingle- or two-staged procedure is required in patientswho present with unilateral or bilateral grade B or C ptosisfor an acceptable outcome.

Conflict of interest None.

Ethical standards All patients gave their informed consent prior to theirinclusion in this study.

References

1. Khan UD (2011) Breast and chest asymmetries: classificationand relative distribution of common asymmetries in patientsrequesting augmentation mammoplasty. Eur J Plast Surg 34:375–385

2. Koch MC et al (2011) Breast volumetry using a three-dimensional surface assessment technique. Aesthetic Plast Surg35:847–855

3. Gabriel A, Fritzsche S, Creasmen C, BaqaiW,Mordaunt D,MaxwellP (2011) Incidence of breast and chest wall asymmetries: 4D pho-tography. Aesthet Surg J 31:506–510

4. Gore SM, Lamberty GH (2012) PERTHESE implant-identicalcohesive-gel sizers in breast augmentation: a prospective report on200 consecutive cases and implications for treatment of breast asym-metry. Aesthet Surg J 32:310–318

5. Maxwell GP (2001) Breast asymmetry. Aesthet Surg J 21:552–5616. Becker H (2000) Adjustable breast implants provide postoperative

versatility. Aesthet Surg J 20:332–3347. Tebbetts JB (2006) Achieving a zero percent reoperation rate at 3

years in a 50-consecutive-case augmentation mammoplastypremarket approval study. Plast Reconstr Surg 118:1453–1457

8. Khan UD (2013) The impact of preoperative breast implant sizeselection on the three year reoperation rate. Eur J Plast Surg 36(8):503–510

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9. Cunningham B (2007) The Mentor Core Study on siliconeMemoryGel breast implants. Plast Reconstr Surg 120:19–29S

10. Reilly AF (2006) Breast asymmetry: classification and management.Aesthet Surg J 26:596–600

11. Arco A, Gravante G, Araco F, Gentile P, Castri F, Delagu D, FillingeriV, Cervelli V (2006) Breast asymmetries: a brief review and ourexperience. Aesthetic Plast Surg 30:309–319

12. Khan UD (2009) Breast augmentation in asymmetrically placed nip-ple areolar complex in horizontal axis: lateralisation of im-plant pocket to offset lateralised nipples. Aesthetic Plast Surg 33:591–596

13. Rohrich RJ, HartleyW, Brown S (2005) Incidence of breast and chestall asymmetry in breast augmentation: a retrospective analysis of 100patients. Plast Reconstr Surg 48:229–237

14. Neto MS, da Silva ALA L, Garcia EB, Freire M, Ferreira L (2007)Quality of life and self-esteem after breast asymmetry surgery.Aesthet Surg J 27:616–621

15. KhanUD (2007)Muscle splitting breast augmentation. A new pocketin a different plane. Aesthetic Plast Surg 31:553–558

16. Khan UD (2013) Muscle splitting, subglandular and partialsubmuscular augmentation mammoplasties: 12-year retrospectiveanalysis of 2026 primary cases. Aesthetic Plast Surg 37:290–302

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