Patients presenting for correction of breast and chest wall asymmetries may have undergone numerous thoracic procedures in early childhood and may have suffered profound psychosocial effects. Complex congenital syndromes as well as mild breast asymmetries should be carefully documented using objective measurements, photography, and 3-dimensional simulations when available. Shaped highly cohesive breast implants offer plastic surgeons more possibilities and precision by fine-tuning the gel distribution and specific volumes required to correct the hypoplastic elements. Long-lasting correction of asymmetry can be obtained when patients are not oversized, and care is taken to avoid visibility, palpability, and malposition problems.
Key points
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Patients presenting for correction of breast and chest wall asymmetries may have undergone numerous thoracic procedures in early childhood and some may have suffered profound psychosocial effects.
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Care must be taken to evaluate these patients using objective criteria and biodimentional principles. Long-lasting correction of asymmetry can be obtained when patients are not oversized, and care is taken to avoid visibility, palpability, and malposition problems.
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Complex congenital syndromes often require a more comprehensive preoperative work-up, as well as a detailed history of any previous thoracic or breast procedures.
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Patient education needs to be comprehensive, and patients should be encouraged to have realistic expectations and accept what can and cannot be corrected.
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Shaped highly cohesive breast implants offer plastic surgeons more possibilities and precision by fine-tuning the gel distribution and specific volume required to correct the hypoplastic elements.
Overview
Today, most children born with mild to severe congenital deformities of the chest survive well into adulthood. Rarely, deep thoracic wall depression leads to displacement or compression of the heart and lungs, and thoracoplasty is indicated. Most affected children survive into adolescence, and the indications for correction of breast and chest wall defects are based on psychological difficulties and issues of self-esteem. As technical skills improved over the last half a century, minimally invasive procedures such as those of Nuss (minimally invasive repair of pectus excavatum) and Ravitch gained popularity, and common chest wall defects are now routinely treated. The spectrum of chest wall abnormalities varies, from complex congenital musculoskeletal deformities to the more common defects like anterior thoracic hypoplasia. The correction of chest wall and breast deformities with breast implants dates back to the early 1970s, and although originally reserved for mild chest wall and breast asymmetry, the availability of shaped highly cohesive breast implants that allow a surgeon to select a specific width, projection, and height independently, may provide a single-stage option to correct more complex deformities.
Overview
Today, most children born with mild to severe congenital deformities of the chest survive well into adulthood. Rarely, deep thoracic wall depression leads to displacement or compression of the heart and lungs, and thoracoplasty is indicated. Most affected children survive into adolescence, and the indications for correction of breast and chest wall defects are based on psychological difficulties and issues of self-esteem. As technical skills improved over the last half a century, minimally invasive procedures such as those of Nuss (minimally invasive repair of pectus excavatum) and Ravitch gained popularity, and common chest wall defects are now routinely treated. The spectrum of chest wall abnormalities varies, from complex congenital musculoskeletal deformities to the more common defects like anterior thoracic hypoplasia. The correction of chest wall and breast deformities with breast implants dates back to the early 1970s, and although originally reserved for mild chest wall and breast asymmetry, the availability of shaped highly cohesive breast implants that allow a surgeon to select a specific width, projection, and height independently, may provide a single-stage option to correct more complex deformities.
Embryology of chest wall and breast development
The development of the musculoskeletal system of the trunk is a multistep process that occurs between the fourth and eighth weeks of development. The paraxial mesoderm divides into 2 subpopulations, the dorsolateral subpopulation (dermomyotome) and the ventromedial subpopulation (sclerotome). Myoblasts within the dermomyotome differentiate into the skeletal musculature, while the sclerotome develops into the vertebrae and ribs. The sternum is derived from somatic mesoderm. The ribs and sternum fuse in the midline in the sixth week of development, and fusion occurs in a cranial–caudal direction completed by the tenth week. Failure to fuse leads to a cleft sternum. The manubrium is formed by primordia between the developing clavicles. The breasts develop during the sixth week of gestation from ectodermal cells along the milk line, which extends from the axilla to the groin. The upper and lower parts of these ridges atrophy, with only the middle or pectoral ridges developing into breast tissue. The exact etiology of chest wall and sternum deformities remains controversial. Causes include overgrowth of costal cartilages, sternal twisting, and a relative weakening of the costal cartilages. The growth and development of the sternum are influenced by both genetic factors and biomechanical factors. Although no specific gene locus has been yet identified for conditions like Poland syndrome and cleft sternum, there is a definite mutation associated with some chest wall and breast deformities. Chest wall and breast deformities can be classified as either monogenic, disruption sequences, isolated chest wall deformities, or acquired chest and breast deformities ( Table 1 ).
| Origin of Deformity | Anatomic Site | Disorder |
|---|---|---|
| Monogenic syndromes | Ventral body wall–rib Sternum Breast Spine | Marfan syndrome Noonan syndrome |
| Disruption sequences | Thoracic musculature Ventral body wall- rib Breast Spine | Poland syndrome Moebius syndrome |
| Genetic associations (chromosome aberrations) | Ventral body wall–rib Sternum | PHACE (posterior fossa brain malformations) Cantrell pentalogy Asphyxiating thoracic dystrophy (Jeune syndrome) Cleft sternum |
| Isolated chest wall deformities | Breast Ventral body wall–rib Sternum Spine | Pectus excavatum Pectus carinatum Thoracic hypoplasia Supranumerary breasts Congenital absence breast Tuberous breast Constricted base breast Gynecomastia |
| Acquired | Ventral body wall Thoracic musculature Breast | Tetralogy of Fallot |
Historical management
Early reconstructive efforts to correct chest wall deformities were primarily performed for improvement in cardiopulmonary function. Aesthetic considerations were usually reserved until patients reached puberty and maximum sternal development. Surgical corrections of chest wall defects were usually delegated to pediatric surgeons, and early invasive procedures have evolved toward more minimally invasive techniques. The 2 most common procedures used today are the Modified Ravitch procedure (transverse sternal osteotomy with subperichondrial costal cartilage resection) and the Nuss procedure (minimally invasive repair of pectus excavatum). With advances in local muscle flaps, contour defects of the chest wall and hypoplastic or absent musculature were replaced with local flaps, including the latissimus dorsi flap. Beginning as early as the 1970s, custom-made silicone implants were used requiring the fabrication of a chest wall mold or moulage. It is interesting to note that early silicone rubber chest wall prostheses were firm, having the consistency of muscle tissue. Custom implants were often inserted deep to the serratus, occasionally with a second implant stacked on top to augment the breast. Early custom implants were most often shaped and textured. Several manufacturers supplied custom implants to plastic surgeons until the late 1990s. Inamed (Allergan-Actavis: Irvine, CA, USA and Rockaway, NJ, USA) stopped importing custom implants in 1997, as did Sientra (Santa Barbara, CA, USA) between 2010 and 2011, and Silimed (Rio de Janeiro, Brazil) ceased production of custom silicone implants in 2014. Adjustable saline implants played a significant role in the treatment of chest and breast asymmetry due to the ability to add more volume to the affected hypoplastic chest and breast. Round silicone gel implants have grown in popularity and have largely replaced saline implants, which have high rates of visibility and palpability. The development of shaped highly cohesive gel breast implants has further steered breast augmentation surgeons away from the older volumetric management of asymmetries toward that of shaping the chest and breast with biodimentional planning. Anatomic implants provide not only the increase in volume required to correct the hypoplastic elements, but because surgeons can select the implant by height, base width, and projection, the ability to correct individual chest wall anomalies.
Acquired chest wall deformities
Although rare, breast and chest wall asymmetry may be the result of pediatric thoracic surgery. Breast bud injuries can result from chest tube placement as well as thoracotomy procedures. Open thoracotomies can produce significant musculoskeletal morbidity, including atrophy of the serratus anterior muscle and pectoralis due to surgical incisions ( Fig. 1 ). Patients may also present to the office after multiple attempts to correct a pectus excavatum or similar sternal deformity, and may have already undergone a breast augmentation with revisions. These cases are certainly more difficult to approach, and patients should be informed that some deformities produced by detachment of muscles, scarring, or thinning of overlying soft tissues may be uncorrectable ( Fig. 2 ).
Related posts:
The Process of Breast Augmentation with Special Focus on Patient Education, Patient Selection and Implant Selection
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Strategies and Challenges in Simultaneous Augmentation Mastopexy
Surgical Approaches to Breast Augmentation
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