Breast asymmetry correction

Breast asymmetry correction is the collective name for the operations used to reduce a difference in volume, shape or position between the two breasts. This article covers how the difference is assessed, why different operations may be done on each breast, the choices between augmentation, reduction, lift and fat transfer, recovery, scars and risks. How the result changes over time, breastfeeding and the follow-up needed where an implant is used are also addressed.

What is breast asymmetry correction?

Breast asymmetry is not simply one breast being larger than the other. The nipples may sit at different heights, the inframammary folds may not be level, or one side may droop more. The shape of the chest wall is also part of the difference that is seen from outside. The assessment is therefore not confined to volume.¹²

Small differences do not in themselves mean disease or a need for surgery. Where an assessed difference does not trouble the person, observation without surgery can be chosen. External support worn inside a bra, or an external breast prosthesis, is also an option; the research on that approach is more limited than on the surgical methods.¹

This page covers benign differences that arise during development, or become more marked after pregnancy, weight change and previous surgery. Rebuilding the breast after cancer treatment is a separate reconstructive plan.

Who is it suitable for?

Surgical options can be considered in people who have difficulty choosing bras and clothes because of a marked difference, or who are troubled by the appearance. The decision rests not only on measurement but on the person's expectations, whether they accept surgical scars, and how they view the possibility of further procedures later.

Breast development is expected to be complete. How long the size has been stable, weight changes and the person's physical and emotional maturity are assessed together.

Timing is not set by chronological age alone. The opinion of the American College of Obstetricians and Gynecologists (ACOG) on breast surgery in adolescents asks that physical maturity and emotional readiness be assessed together and that the person be screened for body dysmorphic disorder; where there is doubt, referral to a mental health professional is advised.³ To this are added the breast having settled in development and volume, the decision resting on the person's own wish, and the expectation being realistic.

Where pregnancy is being considered in the near future, postponing surgery is sensible. Pregnancy and breastfeeding can change the shape achieved.

Where there is active infection, an uncontrolled illness or an unassessed breast finding, those are addressed first. Where there is new or rapidly increasing one-sided enlargement, a palpable lump, bloody discharge from the nipple or new retraction, breast assessment is needed before any aesthetic planning. A long-standing difference and a change that has developed recently are not handled in the same way.

What does the examination look at?

The consultation begins with how long the difference has been present, whether it has changed, and which feature troubles the person most. Previous operations, pregnancy and breastfeeding history, weight changes, medication used and any family history of breast disease are recorded.

Each breast is assessed separately at examination. The width of the base, the projection, excess skin, tissue thickness, the position of the nipple and its distance from the inframammary fold are all examined. The size and shape of the areola, the coloured area around the nipple, are compared as well. Breasts of the same volume can look different because of a different base or nipple position.

In a tuberous breast, a narrow base and a difference in the development of the lower pole can change the plan. In conditions that affect the development of the chest muscle, such as Poland syndrome, the chest wall is assessed too. The decision is therefore not made by looking at the larger side alone or by going on bra size.¹²

Where a lump is found at examination, diagnostic imaging is selected according to age and finding. The criteria of the American College of Radiology for palpable breast masses support choosing the method according to the clinical situation rather than applying the same test to every patient.⁴

How is the operation planned?

How are the target volume and shape decided?

The first decision is which breast volume and which shape are being worked towards. If the larger breast is the preferred size, adding volume to the smaller breast can be considered; if the smaller breast is the preferred size, reducing the larger breast can be considered. Sometimes the aim is not to copy one of the existing breasts but to bring both closer to a common shape by changing each to a different degree.

The aim of the plan is a more balanced appearance. Which of the differences in the nipple, the inframammary fold, the base and the chest wall can be corrected, and which may remain, should be explained before surgery.

Is one breast operated on, or both?

Operating on both sides is not compulsory. Where the volume and position of the other breast are suitable, a one-sided procedure can be chosen. Where a change to both breasts is wanted, or where the difference cannot be met by changing one side alone, a two-sided plan can be made.

Operating on both sides does not mean the same operation is performed on each. One breast may be reduced while the other is lifted; an implant may be placed on one side while the skin and nipple position are adjusted on the other. The choice depends on the examination findings and the goal.

Is the smaller breast enlarged or the larger one reduced?

Adding volume and removing tissue bring different results and different scars. Where the smaller side is to be enlarged, the suitability of the existing skin and breast base for the added volume is assessed. Where the larger side is to be reduced, the tissue to be removed and the shape to be preserved are planned together. Where there is drooping, changing volume alone may not be enough.

In corrections that involve reduction or removal of breast tissue, the tissue removed is sent for pathological examination. Pathological examination is the assessment of the tissue under a microscope. In breast reduction this practice is recommended in the evidence-based guideline of the American Society of Plastic Surgeons (ASPS).⁵

Is volume added with an implant or with fat transfer?

An implant is a foreign material placed in the body. Its volume, base width, projection, surface and the plane it will sit in are chosen together. Where implants are placed on both sides, their sizes do not have to be the same. Implants of different volumes are not, however, a solution that on their own resolves a difference in the nipple or the chest wall.

In fat transfer, fat taken by liposuction from another part of the person's body is transferred to the breast tissue. Having a suitable donor area and the volume the breast tissue can accept are part of the plan. An implant and fat transfer can also be used together. The detail of both methods is set out in the breast augmentation article.

In a meta-analysis pooling data from 4,425 people across 47 studies, an average of 53 per cent of the transferred fat per breast was reported to remain. That review covers aesthetic augmentation together with symmetrising the unaffected native breast after reconstruction; it does not belong to patients with developmental asymmetry alone. The variation between studies is very high, and the result should not be read as a personal expectation at any given year of follow-up.⁶

A further session of fat transfer may be needed to reach the volume wanted or to reduce a remaining difference.⁷ The implant option also carries follow-up and the possibility of further surgery later.⁸ The choice is not made on the volume to be added at the first operation alone.

Is a lift or moving the nipple needed?

Where the nipple sits lower on one breast, where there is excess skin, or where the breast tissue is distributed differently, a lift can be considered. The size of the coloured area around the nipple can also be adjusted within that plan. Adding volume and moving the nipple upwards are separate decisions.

Preserving the blood supply to the nipple and its tissue connections is part of the planning. The aim of a smaller scar and the tissue adjustment required are weighed together; the method is not chosen by scar length alone.

How do the inframammary fold and chest wall differences affect the plan?

The inframammary fold is the lower border where the breast meets the chest wall. Where the folds are at different heights, the lower borders may not look the same even if equal volume is added. A chest that projects more on one side also affects how far the breast comes forward.

These features are recorded separately from breast volume. The part of the correction that stays within the breast tissue and skin, and the limit set by the chest wall, are explained to the person. No promise is made that a chest wall difference will disappear entirely.

Where is the incision made?

For an implant the incision may be in the inframammary fold or, depending on the approach chosen, elsewhere. In a lift or a reduction there may be an incision around the areola, a vertical line running down from it and, where needed, one in the inframammary fold. In fat transfer there are small entry points in the areas the fat is taken from and placed into.

Where different operations are done on each side, the position and length of the scars can differ as well. Which scar is expected on each breast should be shown separately before surgery.

Is it done in one operation or in stages?

The correction can be completed in one operation or planned in stages. The state of the skin and breast tissue, the volume change required and the procedures being combined determine the decision. A lift with an implant can be carried out in the same session or as separate operations.⁹

A planned second stage and a correction made because of an unexpected problem are not the same thing. The possibility of a further session in fat transfer should be considered before the first procedure.⁷

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁰ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹¹ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹² Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹³ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Weight: Weight is expected to be stable before surgery.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Imaging: Depending on your age and history, breast imaging may be requested beforehand.

Measures to prevent infection and clot formation are planned according to the person's risks and the extent of the operation. The instructions given for medication and follow-up visits should be followed. The same preventive medicine or the same duration of use does not apply to every patient.

What is recovery like?

The periods below are a general framework. They can vary with the extent of the operation performed, the person's work, how quickly they heal and the surgeon's practice.

• The operation is carried out under general anaesthesia and takes 1-3 hours depending on the procedures performed
• The hospital stay is planned as 1 night; discharge is decided after examination
• Stitches that need removing are removed within 2 weeks; dissolving stitches do not need removing
• 1-3 weeks are set aside for returning to work; the physical demands of the job and the procedure performed are taken into account
• Allow 1-2 weeks before driving; the ability to move without pain is assessed separately
• Return to strenuous sport is assessed at 4-6 weeks
• Full return to daily life is planned at about 6 weeks
• The shape of the breast can take 3-6 months to settle

These ranges cover all the methods. The recovery burden of a limited volume correction and of an operation involving tissue removal and a lift on both sides may not be the same. In fat transfer the state of the donor area, as well as the breast, contributes to the decision on returning to work and sport. With an implant beneath the muscle, movements that strain the chest muscle are considered separately, as is the healing of the incision lines in a reduction or a lift.

There is no fixed rule for the use of a drain or the timing of its removal; the decision is made according to the procedure performed and the follow-up findings. The timing of the first check-up and of subsequent examinations is set by the surgeon who performed the operation.

Where different procedures have been done on each breast, swelling and the softening of the tissues may not progress at the same rate. The result is not judged from the first appearance. Rapidly increasing one-sided swelling or steadily increasing pain should not, however, be taken as ordinary healing.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Bra: A supportive bra or a band is worn after surgery. How long it is worn varies with practice; wearing it around the clock and continuing for months may be asked of you.¹⁴ Your surgeon will say when to move to an underwired bra.

The donor area: Where fat transfer has been done, a compression garment is worn over the donor area for the period the surgeon sets. The support used for the breast and the compression of that area are considered separately.

Sleeping: Lying on the back, or with the upper body slightly raised, is more comfortable for most people in the first weeks. When you can move to sleeping on your side or front depends on how healing is going and on your surgeon's advice.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Arm movement: The arms can be used for everyday tasks within the limits of pain. In the first weeks, sudden and forceful arm movements, heavy lifting and activities that stretch the chest are avoided. Where the implant sits beneath the muscle, returning to movements that work the chest muscle takes longer. Staying still for long periods is not right either. Short walks are encouraged early on and lower the risk of clots.

Pain: Pain and a feeling of pressure in the chest are expected in the first days and are controlled with the painkillers provided. Sharp pain usually eases within 1 to 5 days; tightness and swelling can last a few weeks.¹⁵

That interval for pain is general information relating to augmentation with an implant. Pain from a reduction, a lift or the donor area does not have to follow the same timetable.

Returning to work and sport: 1-3 weeks are set aside for returning to work. The time for returning to desk work and to work involving heavy lifting is not the same. Heavy lifting and strenuous sport are postponed for 4-6 weeks. The return to movements that work the chest muscle hard can come later, depending on which plane the implant was placed in and how healing is going. Returning to exercise starts with walking and low-impact movement, leaving running and chest work until last.

Driving: Allow 1-2 weeks before driving, depending on the procedure performed. You can drive once you can wear the seatbelt comfortably, perform steering movements and an emergency stop without pain, and are no longer taking painkillers that cause drowsiness.

Sexual activity: Sexual activity can resume once you feel comfortable and everyday movements no longer cause marked pain. In the first weeks, pressure on the breasts and forceful movement should be avoided.

Smoking and weight: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete. Gaining weight after surgery can change the shape of the breast.

What is normal: Swelling, bruising, a feeling of firmness and tightness in the breast, numbness at the nipple and in the breast skin, occasional stabbing pains and a temporary difference in swelling between the two breasts are all expected. The final shape of the breast takes months to settle.

How do the scars change?

Where the scar lies depends on the procedure performed. Where different incisions have been used on each breast, the scars will look different too. Even in fat transfer, with its small entry points, no promise of a completely scar-free result is made.

The scar looks red and raised in the first months, then fades and softens. This can take up to 1 year. Its final appearance depends on how the person heals, on skin colour and on the area; how well it will settle cannot be predicted with certainty beforehand.

Some measures can be used to reduce the chance of a scar becoming raised, widened or prominent. Once the wound has closed completely and on your surgeon's advice, silicone-based gel or silicone sheeting and scar massage may be suggested. These measures do not guarantee the outcome. Starting too early can harm the wound, so your surgeon sets the timing.

Direct sun darkens a scar, so it needs protecting during the first year.

Risks and complications

The risks vary with the procedures performed. Rupture of an implant or capsular contracture do not arise in someone who has no implant. The headings below are there to separate which risk belongs to which procedure; they are not a single complication rate shared by everyone.

Problems of shape, symmetry and sensation

Residual difference and shape irregularity: A difference in breast volume, nipple position or the lower fold can remain; further correction may be needed.⁹ The limits set by the chest wall difference present at the outset also form part of assessing the result.

Change in sensation: Numbness, reduced sensation or heightened sensitivity can occur in the nipple or the breast skin. These changes can be temporary or permanent; after a reduction, nipple sensation improves over time in most people.¹⁶ The sensory outcome of one technique cannot be presented as the outcome of every asymmetry operation.

A conspicuous scar: A scar can widen or stay raised.¹⁶ Because one breast can heal differently from the other, the scars are assessed separately as well.

Problems of wound healing and tissue circulation

Blood collection (haematoma): It shows itself in the first hours or first days after surgery as rapidly increasing swelling, firmness and pain in one breast. A return to theatre may be needed to drain what has collected.⁸

Fluid collection (seroma): Fluid collecting in the operated area. Small collections may settle on their own; large collections need draining.¹⁶⁸

Infection: Presents with redness, warmth, increasing pain and discharge. It can appear in the first days after surgery but also much later. Where an implant has been used and an infection does not respond to antibiotics, the implant may need to be removed.⁸

Wound separation and tissue loss: Wound healing can be delayed in the area where a reduction or a lift has been performed; where the blood supply to the nipple, areola or skin is impaired, partial or complete tissue loss can develop.¹⁶⁹ This can call for further dressings, treatment or surgery. Where an implant has been used, loss of the tissue over it can progress as far as the implant becoming visible through the skin.⁸

Implant-related problems

Capsular contracture: The body forms a thin layer of scar tissue around the implant. If that layer thickens and tightens, the breast hardens, its shape distorts and there may be pain.¹⁴

The implant can also move, rupture, become palpable at its edge, or produce a rippled appearance in the skin.¹⁴

Animation deformity: Where the implant sits beneath the chest muscle, the shape of the breast can change temporarily when the muscle contracts. This is called animation deformity and occurs with planes that place the implant under the muscle.¹⁷

Implant-associated lymphoma: BIA-ALCL is a cancer of the immune system, distinct from breast cancer. It can develop in the capsule or the fluid around the implant, and the risk is higher with textured implants. The United States Food and Drug Administration (FDA) advises that persistent late swelling, a lump and pain be assessed. With early diagnosis, treatment by removing the implant and the capsule can be achieved in many patients; some patients need further treatment.¹⁸

Squamous cell carcinoma and other lymphomas have also been reported in the implant capsule. The FDA states that these are rare, but also that their frequency and risk factors are not known. Removing implants from people without symptoms is not advised on the basis of that concern alone.¹⁹

Systemic symptoms: Some people with implants report complaints such as fatigue, joint pain and difficulty concentrating. Their definite relationship with implants has not been established; it cannot be said that everyone improves when the implant is removed.²⁰

Problems relating to fat transfer and the donor area

After fat transfer, some of the fat cells can lose their viability, which is fat necrosis, and cysts and calcification can develop.⁷ In a meta-analysis of 47 studies, fat necrosis per participant was reported at about 4.7 per cent. Because the variation between studies is high, that figure is not one person's risk.⁶

A new area of firmness should not be accepted as being "from the fat transfer" alone; it needs assessing. Imaging or tissue sampling can be carried out where needed. Bruising, swelling, changes in sensation and surface irregularity can also occur in the donor area.²¹

General surgical and anaesthetic problems

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.¹⁶

Anaesthesia and other risks: Problems related to general anaesthesia, allergic reactions and pain persisting after surgery can occur.¹⁶

Can the difference between the breasts increase again?

Pregnancy and weight changes can alter the appearance achieved by surgery.¹⁶ Breast tissue and skin continue to change over time. Where different procedures have been done on each side, the change on each side is assessed separately as well.

A decision to operate is not taken straight away for a difference that remains or becomes marked again. The shape is allowed to settle and the cause of the difference assessed first. Where there is new firmness, a lump or a rapidly changing appearance, assessment is not postponed. The possibility of further correction should be known before the first operation.⁹

What does long-term follow-up involve if an implant is used?

An implant cannot be guaranteed to last a lifetime. Although it may be carried for many years without trouble, further surgery may be needed because of rupture, capsular contracture or a change in shape.⁸ The implant card should be kept and the characteristics of the implant declared at later examinations.²⁰

On the FDA recommendation, in people carrying silicone gel implants and having no complaints, the first ultrasound or magnetic resonance imaging (MRI) is performed 5 to 6 years after surgery and repeated every 2 to 3 years thereafter. This is a schedule for assessing silent rupture and does not replace breast cancer screening.²⁰

That schedule is stated for silicone gel implants only. It does not apply to asymmetry correction without an implant. Where there is new pain, swelling or a change in shape, assessment should be carried out without waiting for the scheduled year.²⁰

Is breast cancer screening affected?

Correcting breast asymmetry does not remove the need for breast cancer screening appropriate to age and personal risk. Where there is an implant, the person performing the mammogram should be told; the technique may need adapting to assess the breast tissue the implant covers.¹⁴

Calcifications after fat transfer can be seen on imaging. These findings have been reported in a review of fat transfer performed for aesthetic purposes; that data is not specific to asymmetry correction.²² The type and date of the previous operation and what was done to which breast should be told to the radiologist, and earlier images provided for comparison where they exist. A suspicious finding is not treated as unimportant merely because surgery has been performed.

Imaging that examines the integrity of the implant and breast cancer screening serve separate purposes. One having been carried out does not remove the need for the other.²⁰

Is breastfeeding possible?

Breastfeeding may be possible; it cannot, however, be guaranteed that the milk supply will be entirely unaffected. Breast augmentation, reduction and lift can affect the milk ducts and the nerves. In addition, poorly developed glandular tissue at the outset can limit milk production independently of surgery. That feature is not present in every asymmetric breast.²³

In a review of 51 observational studies on breast reduction, the median breastfeeding success across studies was 4 per cent in techniques where the continuity of the tissue beneath the nipple was not preserved, 75 per cent where it was partly preserved and 100 per cent where it was fully preserved. These are medians of studies carried out with different techniques and definitions; they are not the personal probabilities of groups compared under the same conditions. The figure of 100 per cent in particular does not mean that breastfeeding is guaranteed. The findings are indirect evidence relating to procedures involving reduction, not to every asymmetry correction.²⁴

A scar around the areola does not on its own show that the nipple was fully detached. A plan to breastfeed should be raised before surgery; after birth, milk transfer and the baby's weight gain should be monitored. Breastfeeding support and a supplementary feeding plan can be arranged where needed.²³

What can be expected from the result?

The aim is a more balanced breast appearance suited to the person's build. An exact mirror image in size, shape, nipple height and scars cannot be guaranteed. In assessing the result, what is looked at is not volume alone but how far the goals set before surgery have been met.

In a cohort following 45 young women operated on for benign breast asymmetry and 101 controls without asymmetry, significant improvement in self-esteem and in some quality of life domains was reported in the surgical group. Those improvements were reported to have lasted at least 5 years. The control group did not have surgery; the study does not prove that everyone will see the same benefit or that a technique is superior.²⁵

A 2023 systematic review examined the results of 1,237 patients from 13 studies and could not perform a meta-analysis because of differences in method and outcome measurement. It states that there is no consensus on a single method.¹ The decision should therefore be made on the person's anatomy, goal, scars and long-term responsibilities rather than on a general success rate.

When should you contact a doctor?

In the early period you need to reach the team that performed the operation in the following situations:

• Fever
• Increasing redness, warmth, discharge or a bad smell at the wound
• Rapidly increasing swelling, firmness or pain in one breast
• Marked separation of the wound
• Darkening, bruising or blackening in the colour of the nipple or areola
• Pain that keeps increasing despite painkillers

Later on, swelling in the breast that does not settle, a new lump, firmness or a change in shape need assessment. Where there is an implant, these signs should be taken seriously even if they appear years after surgery.¹⁸

The following two findings need urgent assessment:

• One-sided pain or swelling in the leg
• Sudden shortness of breath or chest pain

About the numbers in this article

The times for the operation, the hospital stay and the return to daily life are a general care framework covering the methods. They are not the measured result of a single technique in research. Which interval is right for you is determined by the procedure performed and by healing.

The research figures, for their part, come from different patient groups. In fat transfer, the volume retained per breast and the rate of fat necrosis per person are different measurements. The percentages in the breastfeeding review are medians across studies. The quality of life finding in young women cannot be carried across to every age and method with the same certainty either.

The numbers here therefore do not predict one person's result. They give only a general framework.

References

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