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Medial confluence of the breasts, known as symmastia, occurs when two breast implants touch or are very close to one another in the center of the chest just above the sternum in the cleavage area. This occurrence, which can produce a web across the midline, is commonly referred to as bread loafing or uniboob, giving the appearance of tow breasts connected underneath the skin as the skin and tissue is pushed up. A possible consequence of unopposed muscle action with overzealous medial release causing aesthetic disfigurement and additional issues with discomfort and apparel problems, symmastia is a difficult surgical complication to address.
Patients with multiple breast operations, excessively large implants or overaggressive medial dissection are susceptible to developing symmastia. Symmastia seems to be more prevalent among thin women mainly due to the fact that thin women usually have less tissue or fat covering the sternum. Also, patients with pectus excavatum, a depressed breastbone, are more prone to symmastia. Pectus excavatum may cause the implants to slope inward, toward the cleavage area, creating more pressure on the tissues in that area, resulting in symmastia. Attempts to increase cleavage by releasing the soft tissues or inner origins of the pectoralis muscles lead to symmastia by surgically interrupting the natural barriers of tissue and muscle at the medial location of the breasts where the cleavage is normally defined. For instance, if the horizontal muscle, which lies on top of the sternum dividing the implants, is cut, then the possibility of the implants settling towards the middle of the chest is increased. This complication may occur when implants are placed either underneath or above the pectoral muscle.
Symmastia is difficult to treat and recurrence is common. Correction requires combined restoration of the initial presternal subcutaneous integrity and medial closure of the pocket. In order to repair symmastia, the space between the 2 implants must be securely closed off. The combination of medial closure of the breast implant pockets and suturing of the preseternal soft tissue to the sternum periosteum provides one satisfactory option to the surgical reconstruction of symmastia. Often, it is necessary to “open” the breast implant pocket laterally (to the sides) to decrease pressure along the cleavage area. There are several methods used to correct the deformity, such as allogenic dermal grafting, fibrin-based tissue glue, and delayed filling of an adjustable implant.
Before the surgical procedure, careful markings are done with the patient in the upright and laying position. Often, symmastia co-exists with other breast implant malposition problems and breast asymmetry. These issues should be addressed as well.

In the operating room, the implants are removed and the external drawings are transposed internally with needle and dye technique (tattoo). This allows accurate placement of sutures to close off the overly expanded breast implant pocket. Prior to suture placement, however, the excess breast implant pocket capsule (scar) is removed (capsulectomy). This creates a “raw” surface that may help with tissue adhesion/scar formation and decrease the risk of re-occurrence of the symmastia. The edges of capsule remaining are sutured to one another (capsuloraphy). Often, a “mirror image” capsulectomy is required to expand the pocket laterally, decreasing pressure on the symmastia correction and improving appearance and position of the nipple-areola on the breast mound. A temporary breast implant sizer is placed and inflated to assess for correct positioning of the sutures and correction of the implant malposition.

Once satisfactory correction