- Email: [email protected]
Idiopathic scoliosis and breast asymmetry
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1303e1308
Idiopathic scoliosis and breast asymmetry C. Denoel a,*, M.F. Ismael Aguirre a, G. Bianco a, P.H. Mahaudens a, R. Vanwijck a, S. Garson b, R. Sinna c, A. Debrun d a
Cliniques Universitaires Saint-Luc, Universite´ Catholique de Louvain. Avenue Hippocrate, Brussels, Belgium Service de chirurgie plastique, Clinique Sainte Genevie`ve, Paris, France c Service de chirurgie plastique reconstructrice et esthe´tique, CHU Nord Place Victor Pauchet, Amiens France d De´partement de medecine de l’appareil locomoteur et du centre de de´viations verte´brales. CHC Clinique de l’Espe´rance, Montegne´e e Lie`ge, Belgique b
Received 8 October 2007; accepted 5 April 2008
KEYWORDS Breast asymmetry; Idiopathic scoliosis; 3D surface scan
Summary The aim of this study is to describe the semiology for the assessment of breast asymmetry in the presence of scoliosis. Twenty-four women with right idiopathic scoliosis treated with bracing alone (23 out of 24) or with bracing and spine surgery (1 out of 24) were evaluated by physical and morphological examinations and three-dimensional (3D) surface scan. Physical examination revealed a smaller right breast in 20 women. A left costal protrusion was observed in 18 patients. Anthropomorphic analysis revealed that the right breast was higher in 19 cases, and smaller in 18 cases. The calculations from 3D scan showed the right breast to be smaller in 19 women. A strong correlation is found between clinical parameters, anthropomorphic measurements and 3D scan analysis, suggesting that a meticulous clinical examination is sufficient to evaluate breast asymmetry in patients with idiopathic scoliosis. A patient who is properly diagnosed and informed of her skeletal deformity and breast asymmetry is more likely to have realistic expectations from breast surgery. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Scoliosis is defined as a lateral deviation of the spine, causing the rotation of vertebral bodies and the deformation of thoracic cage as well as the surrounding soft tissue.13 Breast asymmetry is defined as a difference in
* Corresponding author. Service de Chirurgie Plastique, Avenue Hippocrate, 10, 1200 Brussels, Belgium. Tel.: þ32 (0)472 775977; fax: þ32 (0)4 2220612. E-mail address: [email protected] (C. Denoel).
form, position and/or volume of the breast. It may be primary or secondary to thoracic deformity. An association of these two clinical signs is often observed.8e10 Breast asymmetry remains an underused indicator of structural idiopathic scoliosis.11,12 The association is more easily established in clinically diagnosed scoliosis, with Cobb angles greater than 10 . In deviations smaller than 10 with no clinical symptoms, however, there is usually no previous diagnosis of scoliosis, and yet there may be a certain degree of breast asymmetry.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.031
1304
C. Denoel et al.
The aim of this study is to describe reproducible, valid clinical signs and two-dimensional (2D) anthropomorphic measurements when examining asymmetric breasts, validated by 3D surface scan acquisition analysis. Data from 24 women with diagnosed adolescent idiopathic scoliosis were used. These measurements help the practitioner suspect subclinical idiopathic scoliosis, and therefore correctly and realistically inform the patient of the postoperative outcome.
Patients and methods This study included 24 patients diagnosed of thoracic adolescent idiopathic scoliosis. The mean age of the patients was 19 years (range: 17e32 years), and all of them presented right scoliosis with a mean Cobb angle of 36 (range: 17 e57 ). Out of 24 patients, 23 were treated by bracing and one with bracing and spine surgery. All the patients spontaneously accepted to participate in the study. Each patient was evaluated by physical and morphological examinations and 3D surface scan. The physical examination of the patient in lying and standing positions was performed by three investigators. Five parameters were chosen for anthropomorphic measurements: (1) the suprasternal notch-to-nipple distance, (2) the inframammary crease, (3) the nippleto-inframammary crease, (4) the comparative position of the left and right inframammary folds and (5) the hemithoracic circumference at the level of the lowest point of the inframammary crease (Figure 1). Each parameter was recorded on the left and the right sides, and the difference
Figure 2
Three-dimensional surface scan.
was calculated D(L e R) and divided by the left measurement (D(L e R))/L. The first three parameters have a significant linear correlation with nonpathologic breast volumes.15,16 They may be extrapolated for an evaluation of asymmetric breasts. The last two parameters characterise thoracic deformity. The 3D surface acquisition was used to quantify the differences in breast volumes independently from the thorax volume. Two InSpeck digitisers connected to a PC Compacrt were used to analyse the data using FAPs 4.6.17 We used a structured light projection with a Moire effect. The patients were asked to stand straight, with hands on the hips, immobile and holding their breath during the procedure, which was performed and repeated by the same investigators (Figure 2).
Results During physical examination, all the 24 patients were asked to stand straight with their hands on their hips. By doing so, 20 patients levelled their shoulders. The volume of the right
1
3
2 4
5
Figure 1 Assessment of asymmetry between the right and left breast. Anthropomorphic parameters: 1. suprasternal notch-to-nipple distance, 2. inframammary crease length, 3. nipple-to-inframammary crease, 4. the horizontal comparative position of the left and right inframammary fold and 5. the hemithoracic circumference at the level of the most inferior point of the inframammary crease.
Figure 3 Rib hump: an anterior costal projection was identified in a majority of patients either visually or by palpation (if mammary ptosis).
Idiopathic scoliosis and breast asymmetry Table 1
1305
Anthropomorphic measurements R
L
RZL
Suprasternal notch-to-nipple distance (1) Breast base distance (2) Areola to inframammary distance (3) Hemithoracic circumference (5)
19 18 21 6
2 2 2 16
3 4 1 2
Cranio-caudal position of the inframammary fold (4)
Right breast higher 20
left breast higher 2
Same height 2
breast was subjectively smaller in 20 patients, whereas the left breast was smaller in two cases. External dystopia of the left breast was observed in 21 patients. An anterior costal hump was visible or palpable under the inframammary left fold (Figure 3). The results of the anthropomorphic measurements are presented in Table 1. In 19 cases, the right breast was higher, with a shorter suprasternal notch-to-nipple distance: average (L e R)/R Z 4.2%, SD Z 3.8%. The base of the right breast was smaller in 18 cases. The third segment was shorter in 21 cases. The position of the right inframammary fold was higher in 20 cases. The left hemithoracic circumference was smaller in 16 cases. The 3D surface scan graph (Table 2) compares the right and left breast volumes in each patient. The right breast was found to be smaller in 19 patients. Table 3 compares the anthropomorphic measurements with the 3D surface scan data. A strong correlation between clinical and scan measurements is observed in all cases, except three, with regards to the lateralisation of the breast asymmetry.
Table 2
Discussion Most women (50e88%, depending on the studies) have some degree of unnoticeable asymmetry. The aetiology of mild breast asymmetries is unknown, and they are gathered in a clinical entity called ‘idiopathic breast asymmetry’. Breast asymmetry is also associated with specific but more rare pathologies such as Poland syndrome1e5 or tuberous breast.6,7 The usefulness of breast asymmetry as an indicator of scoliosis remains largely underestimated. Scoliotic attitude must be distinguished from structural scoliosis on the basis of whether the anatomic deformation is reducible or permanent, respectively. Scoliotic attitude is a scoliosis which is reducible either by decubitus or by compensation of limb length inequality. In this case, the thoracic vertebral anatomy is not altered. Patients with scoliotic attitude are therefore not included in this study. Structural scoliosis, on the other hand, is characterised by permanent deformation. It may be either idiopathic or secondary to
Three-dimensional surface scan Left breast smaller than right breast
Right breast smaller than left breast
R
−200
−100
0
100
200
300
1306 Table 3
C. Denoel et al. Correlation between anthropomorphic measurement and 3D surface scan Anthropomorphic measurement
3D surface SCAN
Cm
congenital vertebral deformations, but the majority (more than 85%) are idiopathic.14 Idiopathic scoliosis is divided into three groups based on patients’ age. The most frequent form (80%) is adolescent idiopathic scoliosis (AIS), and is commonly right convex. No clear definition of scoliotic pathology and its relation with breast asymmetry has been described. The association is ill defined since most studies make a visual estimation of the asymmetry, are biased by various investigators, and are without corroboration of breast volume measurements. Furthermore, no descriptive or semiological studies have been published to date.8,11 In this study, we find that meticulous physical examination is mandatory during the assessment of breast asymmetry. The usual error is the incorrect positioning of the patient (Figure 4). It is essential that the patients lay their hands on their hips (i.e., iliac crests) to obtain the adequate shoulder level.18 We disagree with some authors who consider that difference in shoulder level is a typical clinical sign in scoliosis.12 The anterior inframammary costal hump observed in 18 patients seems to be an essential clinical sign in breast asymmetry bound to scoliosis. There are other objective clinical signs that evoke a potential association between scoliosis and breast asymmetry. If these signs are observed, an X-ray of whole spine in standing position is indicated along with the measurement of the Cobb’s angle to rule out idiopathic scoliosis. The anthropomorphic measurements clearly support the reliability of physical examination in that they confirm an obvious lateralisation of the asymmetry. The right breast was found to be consistently smaller. Coincidently, idiopathic scoliosis is usually right convex. The 3D surface scan results confirm the morphologic data, except in three cases. One patient underwent spine surgery at age 14 before full development of the breasts. The other two might be related to the limitation of the 3D surface scan technique, which integrates the thoracic wall as an imaginary flat plane. This technique was used in the
Cm
present study only to corroborate the clinical observations, and not as a useful clinical tool in itself. Breast asymmetry associated with scoliosis is due to both a difference in breast volume and thoracic deformation bound to scoliosis. The 3D surface scan provides evidence that disparity in mammary volume is independent of thorax deformity. This study helps objectify the presence and characteristics of breast asymmetry in scoliotic patients. Furthermore, we note that the asymmetry present in scoliosis is most often lateralised so that the right breast is smaller. Considering the frequency of breast asymmetry in scoliosis, we suggest that idiopathic scoliosis should be suspected in case of breast asymmetry.
Figure 4 Classic misleading error: A tilted posture will necessarily entail positional breast asymmetry. Always ask the patient to place her hands on her hips.
Idiopathic scoliosis and breast asymmetry
1307
Right breast smaller than left breast
THINK
SCOLIOSIS Right breast -mammary base shorter and more cranial -shorter sternomammary distance -shorter third segment -smaller areola
Left breast -external mammary distopia
Thoracic Cage -left inframammary rib hump -shorter right hemicircumference
Chest X-Ray -standing -full spine -Cobb’s angle
Figure 5
Guideline for asymmetric breasts.
Whereas breast asymmetry alone is a common and unspecific sign, its association with other more objective clinical signs further evokes underlying scoliotic pathology. Left mammary dystopia, rib hump just inferior to the left inframammary crease, more cranial and longer right inframammary crease length, smaller right areolar diameter and a shorter right semicircumference, shorter sternomammilary distance, shorter right segment III and a shorter right mammary base are all signs of asymmetry possibly related to scoliosis. If these signs are observed, the possibility of idiopathic scoliosis should be further studied (Figure 5). Correct diagnosis is critical in patients requesting breast surgery in order to provide realistic postoperative expectations.
Acknowledgements We thank the members of the Plastic Surgery and Physical Therapy departments of the Cliniques Universitaires SaintLuc (UCL) Brussels, Belgium for their help in this study. We especially thank Miss Emilie Donaghy for her generosity and time.
References 1. Issaivanan M. Subclavian artery supply disruption sequenceKlippel-Feil and Mobius anomalies. Indian J Pediatr 2002 May; 69:441e2. 2. Spear SL, Pelletiere V, Lee ES, et al. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg 2004 Jan;113:69e77 [discussion 78e9].
3. Alexander A, Robocsek F. Poland’s syndrome revisited. Ann Thorac Surg 2002;74:2218e25. 4. Rosa RF, Travi GM, Valiatti F, et al. Poland syndrome associated with an aberrant subclavian artery and vascular abnormalities of the retina in a child exposed to misoprostol during pregnancy. Birth Defects Res A Clin Mol Teratol 2007 Jun;79: 507e11. 5. Bouvet JP, Maroteaux P. Briard-Guillemot Poland’s syndrome. Clinical and genetic studies; physiopathologic considerations. Nouv Presse Med 1976 Jan 24;5:185e90. French. 6. Grolleau JL, Lanfrey E, Labigne B, et al. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999 Dec;104:2040e8. 7. Denoe ¨l C, Soubirac L, Lopez R, et al. The tuberous breast: a review. Rev Med Liege 2002 Oct;57:655e60. Review. French. 8. Normelli H, Sevastik J, Ljung G, et al. The symmetry of the breasts in normal and scoliotic girls. Spine 1986 Sep;11: 749e52. 9. Hodgkinson DJ. The management of anterior chest wall deformity in patients presenting for breast augmentation. Plast Reconstr Surg 2002 Apr 15;109:1714e23. 10. Sanders SR. Frequently unrecognized causes of breast asymmetry. Plast Reconstr Surg 2004;113:448 (author’s reply 449). 11. Bricout N. Chest morphology and breast augmentation. Ann Chir Plast Esthet 2005 Oct;50:441e50. Epub 2005 Sep 21. French. 12. Dionyssopoulos A. The non-perfect results of breast implants. Ann Chir Plast Esthet 2005 Oct;50:534e43. Epub 2005 Sep 27. French. 13. Berard J, Kohler R. Scoliose Idiopathique. Monographie du groupe d’e ´tude en orthope ´die pe ´diatrique. Sauramps Medical; 1997. 14. Sevastik JA, Aaro Stig, Normelli H. Scoliosis. Experimental and clinical studies. Clin Orthop Relat Res 1984 Dec;191: 27e34.
1308 15. Westreich M. Anthropomorphic breast measurement: protocol and results in 50 women with aesthetically perfect breasts and clinical application. Plast Reconstr Surg 1997 Aug;100: 468e79. 16. Sigurdson LJ, Kirkland SA. Breast volume determination in breast hypertrophy: an accurate method using two anthropomorphic measurements. Plast Reconstr Surg 2006 Aug;118:313e20.
C. Denoel et al. 17. Garson S. 3D evaluation and mammary augmentation surgery. Ann Chir Plast Esthet 2005 Oct;50:643e51. Epub 2005 Sep 21. French. 18. Rohrich RJ. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Plast Reconstr Surg 2006 Dec;118(Suppl. 7):7Se13 [discussion 14S, 15Se17S].
Idiopathic scoliosis and breast asymmetry C. Denoel a,*, M.F. Ismael Aguirre a, G. Bianco a, P.H. Mahaudens a, R. Vanwijck a, S. Garson b, R. Sinna c, A. Debrun d a
Cliniques Universitaires Saint-Luc, Universite´ Catholique de Louvain. Avenue Hippocrate, Brussels, Belgium Service de chirurgie plastique, Clinique Sainte Genevie`ve, Paris, France c Service de chirurgie plastique reconstructrice et esthe´tique, CHU Nord Place Victor Pauchet, Amiens France d De´partement de medecine de l’appareil locomoteur et du centre de de´viations verte´brales. CHC Clinique de l’Espe´rance, Montegne´e e Lie`ge, Belgique b
Received 8 October 2007; accepted 5 April 2008
KEYWORDS Breast asymmetry; Idiopathic scoliosis; 3D surface scan
Summary The aim of this study is to describe the semiology for the assessment of breast asymmetry in the presence of scoliosis. Twenty-four women with right idiopathic scoliosis treated with bracing alone (23 out of 24) or with bracing and spine surgery (1 out of 24) were evaluated by physical and morphological examinations and three-dimensional (3D) surface scan. Physical examination revealed a smaller right breast in 20 women. A left costal protrusion was observed in 18 patients. Anthropomorphic analysis revealed that the right breast was higher in 19 cases, and smaller in 18 cases. The calculations from 3D scan showed the right breast to be smaller in 19 women. A strong correlation is found between clinical parameters, anthropomorphic measurements and 3D scan analysis, suggesting that a meticulous clinical examination is sufficient to evaluate breast asymmetry in patients with idiopathic scoliosis. A patient who is properly diagnosed and informed of her skeletal deformity and breast asymmetry is more likely to have realistic expectations from breast surgery. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Scoliosis is defined as a lateral deviation of the spine, causing the rotation of vertebral bodies and the deformation of thoracic cage as well as the surrounding soft tissue.13 Breast asymmetry is defined as a difference in
* Corresponding author. Service de Chirurgie Plastique, Avenue Hippocrate, 10, 1200 Brussels, Belgium. Tel.: þ32 (0)472 775977; fax: þ32 (0)4 2220612. E-mail address: [email protected] (C. Denoel).
form, position and/or volume of the breast. It may be primary or secondary to thoracic deformity. An association of these two clinical signs is often observed.8e10 Breast asymmetry remains an underused indicator of structural idiopathic scoliosis.11,12 The association is more easily established in clinically diagnosed scoliosis, with Cobb angles greater than 10 . In deviations smaller than 10 with no clinical symptoms, however, there is usually no previous diagnosis of scoliosis, and yet there may be a certain degree of breast asymmetry.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.031
1304
C. Denoel et al.
The aim of this study is to describe reproducible, valid clinical signs and two-dimensional (2D) anthropomorphic measurements when examining asymmetric breasts, validated by 3D surface scan acquisition analysis. Data from 24 women with diagnosed adolescent idiopathic scoliosis were used. These measurements help the practitioner suspect subclinical idiopathic scoliosis, and therefore correctly and realistically inform the patient of the postoperative outcome.
Patients and methods This study included 24 patients diagnosed of thoracic adolescent idiopathic scoliosis. The mean age of the patients was 19 years (range: 17e32 years), and all of them presented right scoliosis with a mean Cobb angle of 36 (range: 17 e57 ). Out of 24 patients, 23 were treated by bracing and one with bracing and spine surgery. All the patients spontaneously accepted to participate in the study. Each patient was evaluated by physical and morphological examinations and 3D surface scan. The physical examination of the patient in lying and standing positions was performed by three investigators. Five parameters were chosen for anthropomorphic measurements: (1) the suprasternal notch-to-nipple distance, (2) the inframammary crease, (3) the nippleto-inframammary crease, (4) the comparative position of the left and right inframammary folds and (5) the hemithoracic circumference at the level of the lowest point of the inframammary crease (Figure 1). Each parameter was recorded on the left and the right sides, and the difference
Figure 2
Three-dimensional surface scan.
was calculated D(L e R) and divided by the left measurement (D(L e R))/L. The first three parameters have a significant linear correlation with nonpathologic breast volumes.15,16 They may be extrapolated for an evaluation of asymmetric breasts. The last two parameters characterise thoracic deformity. The 3D surface acquisition was used to quantify the differences in breast volumes independently from the thorax volume. Two InSpeck digitisers connected to a PC Compacrt were used to analyse the data using FAPs 4.6.17 We used a structured light projection with a Moire effect. The patients were asked to stand straight, with hands on the hips, immobile and holding their breath during the procedure, which was performed and repeated by the same investigators (Figure 2).
Results During physical examination, all the 24 patients were asked to stand straight with their hands on their hips. By doing so, 20 patients levelled their shoulders. The volume of the right
1
3
2 4
5
Figure 1 Assessment of asymmetry between the right and left breast. Anthropomorphic parameters: 1. suprasternal notch-to-nipple distance, 2. inframammary crease length, 3. nipple-to-inframammary crease, 4. the horizontal comparative position of the left and right inframammary fold and 5. the hemithoracic circumference at the level of the most inferior point of the inframammary crease.
Figure 3 Rib hump: an anterior costal projection was identified in a majority of patients either visually or by palpation (if mammary ptosis).
Idiopathic scoliosis and breast asymmetry Table 1
1305
Anthropomorphic measurements R
L
RZL
Suprasternal notch-to-nipple distance (1) Breast base distance (2) Areola to inframammary distance (3) Hemithoracic circumference (5)
19 18 21 6
2 2 2 16
3 4 1 2
Cranio-caudal position of the inframammary fold (4)
Right breast higher 20
left breast higher 2
Same height 2
breast was subjectively smaller in 20 patients, whereas the left breast was smaller in two cases. External dystopia of the left breast was observed in 21 patients. An anterior costal hump was visible or palpable under the inframammary left fold (Figure 3). The results of the anthropomorphic measurements are presented in Table 1. In 19 cases, the right breast was higher, with a shorter suprasternal notch-to-nipple distance: average (L e R)/R Z 4.2%, SD Z 3.8%. The base of the right breast was smaller in 18 cases. The third segment was shorter in 21 cases. The position of the right inframammary fold was higher in 20 cases. The left hemithoracic circumference was smaller in 16 cases. The 3D surface scan graph (Table 2) compares the right and left breast volumes in each patient. The right breast was found to be smaller in 19 patients. Table 3 compares the anthropomorphic measurements with the 3D surface scan data. A strong correlation between clinical and scan measurements is observed in all cases, except three, with regards to the lateralisation of the breast asymmetry.
Table 2
Discussion Most women (50e88%, depending on the studies) have some degree of unnoticeable asymmetry. The aetiology of mild breast asymmetries is unknown, and they are gathered in a clinical entity called ‘idiopathic breast asymmetry’. Breast asymmetry is also associated with specific but more rare pathologies such as Poland syndrome1e5 or tuberous breast.6,7 The usefulness of breast asymmetry as an indicator of scoliosis remains largely underestimated. Scoliotic attitude must be distinguished from structural scoliosis on the basis of whether the anatomic deformation is reducible or permanent, respectively. Scoliotic attitude is a scoliosis which is reducible either by decubitus or by compensation of limb length inequality. In this case, the thoracic vertebral anatomy is not altered. Patients with scoliotic attitude are therefore not included in this study. Structural scoliosis, on the other hand, is characterised by permanent deformation. It may be either idiopathic or secondary to
Three-dimensional surface scan Left breast smaller than right breast
Right breast smaller than left breast
R
−200
−100
0
100
200
300
1306 Table 3
C. Denoel et al. Correlation between anthropomorphic measurement and 3D surface scan Anthropomorphic measurement
3D surface SCAN
Cm
congenital vertebral deformations, but the majority (more than 85%) are idiopathic.14 Idiopathic scoliosis is divided into three groups based on patients’ age. The most frequent form (80%) is adolescent idiopathic scoliosis (AIS), and is commonly right convex. No clear definition of scoliotic pathology and its relation with breast asymmetry has been described. The association is ill defined since most studies make a visual estimation of the asymmetry, are biased by various investigators, and are without corroboration of breast volume measurements. Furthermore, no descriptive or semiological studies have been published to date.8,11 In this study, we find that meticulous physical examination is mandatory during the assessment of breast asymmetry. The usual error is the incorrect positioning of the patient (Figure 4). It is essential that the patients lay their hands on their hips (i.e., iliac crests) to obtain the adequate shoulder level.18 We disagree with some authors who consider that difference in shoulder level is a typical clinical sign in scoliosis.12 The anterior inframammary costal hump observed in 18 patients seems to be an essential clinical sign in breast asymmetry bound to scoliosis. There are other objective clinical signs that evoke a potential association between scoliosis and breast asymmetry. If these signs are observed, an X-ray of whole spine in standing position is indicated along with the measurement of the Cobb’s angle to rule out idiopathic scoliosis. The anthropomorphic measurements clearly support the reliability of physical examination in that they confirm an obvious lateralisation of the asymmetry. The right breast was found to be consistently smaller. Coincidently, idiopathic scoliosis is usually right convex. The 3D surface scan results confirm the morphologic data, except in three cases. One patient underwent spine surgery at age 14 before full development of the breasts. The other two might be related to the limitation of the 3D surface scan technique, which integrates the thoracic wall as an imaginary flat plane. This technique was used in the
Cm
present study only to corroborate the clinical observations, and not as a useful clinical tool in itself. Breast asymmetry associated with scoliosis is due to both a difference in breast volume and thoracic deformation bound to scoliosis. The 3D surface scan provides evidence that disparity in mammary volume is independent of thorax deformity. This study helps objectify the presence and characteristics of breast asymmetry in scoliotic patients. Furthermore, we note that the asymmetry present in scoliosis is most often lateralised so that the right breast is smaller. Considering the frequency of breast asymmetry in scoliosis, we suggest that idiopathic scoliosis should be suspected in case of breast asymmetry.
Figure 4 Classic misleading error: A tilted posture will necessarily entail positional breast asymmetry. Always ask the patient to place her hands on her hips.
Idiopathic scoliosis and breast asymmetry
1307
Right breast smaller than left breast
THINK
SCOLIOSIS Right breast -mammary base shorter and more cranial -shorter sternomammary distance -shorter third segment -smaller areola
Left breast -external mammary distopia
Thoracic Cage -left inframammary rib hump -shorter right hemicircumference
Chest X-Ray -standing -full spine -Cobb’s angle
Figure 5
Guideline for asymmetric breasts.
Whereas breast asymmetry alone is a common and unspecific sign, its association with other more objective clinical signs further evokes underlying scoliotic pathology. Left mammary dystopia, rib hump just inferior to the left inframammary crease, more cranial and longer right inframammary crease length, smaller right areolar diameter and a shorter right semicircumference, shorter sternomammilary distance, shorter right segment III and a shorter right mammary base are all signs of asymmetry possibly related to scoliosis. If these signs are observed, the possibility of idiopathic scoliosis should be further studied (Figure 5). Correct diagnosis is critical in patients requesting breast surgery in order to provide realistic postoperative expectations.
Acknowledgements We thank the members of the Plastic Surgery and Physical Therapy departments of the Cliniques Universitaires SaintLuc (UCL) Brussels, Belgium for their help in this study. We especially thank Miss Emilie Donaghy for her generosity and time.
References 1. Issaivanan M. Subclavian artery supply disruption sequenceKlippel-Feil and Mobius anomalies. Indian J Pediatr 2002 May; 69:441e2. 2. Spear SL, Pelletiere V, Lee ES, et al. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg 2004 Jan;113:69e77 [discussion 78e9].
3. Alexander A, Robocsek F. Poland’s syndrome revisited. Ann Thorac Surg 2002;74:2218e25. 4. Rosa RF, Travi GM, Valiatti F, et al. Poland syndrome associated with an aberrant subclavian artery and vascular abnormalities of the retina in a child exposed to misoprostol during pregnancy. Birth Defects Res A Clin Mol Teratol 2007 Jun;79: 507e11. 5. Bouvet JP, Maroteaux P. Briard-Guillemot Poland’s syndrome. Clinical and genetic studies; physiopathologic considerations. Nouv Presse Med 1976 Jan 24;5:185e90. French. 6. Grolleau JL, Lanfrey E, Labigne B, et al. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999 Dec;104:2040e8. 7. Denoe ¨l C, Soubirac L, Lopez R, et al. The tuberous breast: a review. Rev Med Liege 2002 Oct;57:655e60. Review. French. 8. Normelli H, Sevastik J, Ljung G, et al. The symmetry of the breasts in normal and scoliotic girls. Spine 1986 Sep;11: 749e52. 9. Hodgkinson DJ. The management of anterior chest wall deformity in patients presenting for breast augmentation. Plast Reconstr Surg 2002 Apr 15;109:1714e23. 10. Sanders SR. Frequently unrecognized causes of breast asymmetry. Plast Reconstr Surg 2004;113:448 (author’s reply 449). 11. Bricout N. Chest morphology and breast augmentation. Ann Chir Plast Esthet 2005 Oct;50:441e50. Epub 2005 Sep 21. French. 12. Dionyssopoulos A. The non-perfect results of breast implants. Ann Chir Plast Esthet 2005 Oct;50:534e43. Epub 2005 Sep 27. French. 13. Berard J, Kohler R. Scoliose Idiopathique. Monographie du groupe d’e ´tude en orthope ´die pe ´diatrique. Sauramps Medical; 1997. 14. Sevastik JA, Aaro Stig, Normelli H. Scoliosis. Experimental and clinical studies. Clin Orthop Relat Res 1984 Dec;191: 27e34.
1308 15. Westreich M. Anthropomorphic breast measurement: protocol and results in 50 women with aesthetically perfect breasts and clinical application. Plast Reconstr Surg 1997 Aug;100: 468e79. 16. Sigurdson LJ, Kirkland SA. Breast volume determination in breast hypertrophy: an accurate method using two anthropomorphic measurements. Plast Reconstr Surg 2006 Aug;118:313e20.
C. Denoel et al. 17. Garson S. 3D evaluation and mammary augmentation surgery. Ann Chir Plast Esthet 2005 Oct;50:643e51. Epub 2005 Sep 21. French. 18. Rohrich RJ. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Plast Reconstr Surg 2006 Dec;118(Suppl. 7):7Se13 [discussion 14S, 15Se17S].