Aesthetic and functional correction of female, asymmetric funnel chest – A combined approach

The changes of distance between nipples following correction of women pectus excavatum

The breasts in women pectus excavatum patients frequently appear to be slanting medially along the inclination of the distorted ribs. This study aims to evaluate changes in the distance between the nipples and to find out whether medially slanting breasts are corrected in women pectus excavatum patients following modified Nuss procedure. This case series analysis enrolled 22 young women patients with pectus excavatum between October 2011 and September 2020. We measured all the patients' distances from the sternal midline to the right and left nipples, based on chest computerized tomography. We calculated the distances between nipples as being the sum of the right and left distances. The mean age of patients was 16.50 ± 4.73 years, and the follow-up periods were 35.59 ± 20.23 months. The postoperative Haller indices (2.89 ± 0.43) were significantly lower than the preoperative Haller indices (5.14 ± 1.96) (p = 0.000). The distances between the nipples before and after Nuss procedure were 145.17 ± 17.73 mm and 172.29 ± 19.11 mm, which is a significant increase following surgery. (p = 0.000). Our results demonstrated that skeletal correction with modified Nuss procedure in pectus excavatum increased the distance between nipples, indicating that medially slanting breasts had been corrected.

Gender differences in objective measures of adult patients presenting for pectus excavatum repair

BACKGROUND

Women have a reported incidence of pectus deformities 4-5 times less than men. Gender differences have not been well studied.

METHODS

A retrospective review was performed of adult patients (≥18 years) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010-December 31, 2019).

RESULTS

In total, 776 adults underwent pectus repair with 30% being women. Women presented older (mean age 35 vs 32 years, p=0.007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher VO2 max and O2 pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, p<0.001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between genders with the majority occurring in patients ≥30 years of age (11.5% in ≥30, 1.7% in <30, total 7%). Women were also less likely to require 3 bars for repair (12% vs 42%, p<0.001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively women reported a greater daily intensity of pain, but only on the initial postoperative day used significantly more opioids than men. Cardiopulmonary exercise testing in 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both genders.

CONCLUSIONS

Women presented for pectus excavatum repair older and with greater symptoms and severity. Despite this, women required fewer bars, with no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both genders.

Is There an Association Between Breast Hypoplasia and Breastfeeding Outcomes? A Systematic Review

Introduction: Insufficient milk supply is the most common reason for premature breastfeeding cessation. Breast hypoplasia is one reason why women may be inherently unable to make a full milk supply. This review aimed to systematically explore the relationship between breast hypoplasia and breastfeeding duration, milk supply, and lactation onset. Materials and Methods: Medline, CINAHL, ProQuest Central, and the Cochrane Library databases were searched using the keywords "insufficient glandular tissue" or "mammary hypoplasia" or "breast hypoplasia" or "mammary gland hypoplasia" or "droopy breasts" or "snoopy deformity" or "tubular breast*" or "tuberous breast*" AND breastfeeding or "breast feeding" or breast-feeding or lactation. After initially screening 20 records, including reference lists, 9 full texts were assessed for eligibility; 2 were excluded as no breastfeeding outcomes were reported, leaving 7 studies (N = 42 women). Results: The studies in this review drew on results from the oldest included study and plastic surgery literature to define breast hypoplasia. Most women in this review (40/42) ceased exclusive breastfeeding before 1 month postpartum. One case study reported 24-hour milk production, which was 52 mL at 26 weeks postpartum. Conclusion: The relationship between breast hypoplasia and breastfeeding outcomes is underresearched. The co-occurring medical conditions (e.g., polycystic ovary syndrome) of some women provide avenues for future research into the possible pathogenesis of breast hypoplasia resulting in insufficient milk supply. Research is needed to evaluate the reliability of measuring and classifying markers of breast hypoplasia, and prospective studies can help determine the role of breast hypoplasia in milk production. PROSPERO registration number CRD42020191228.

Three-Dimensional Simulation for Breast Augmentation of Female Asymmetric Pectus Excavatum: A Case Report

Breast augmentation for women with asymmetric pectus excavatum (PE) has a characteristic problem in that surgeons need to select implants while considering the left-right difference in breast volume, contour, and position. We herein report a 33-year-old woman with severe asymmetric PE who presented with residual breast asymmetry after chest wall correction using the Nuss procedure. Her right breast appeared hypoplastic and the right anterior chest wall remained depressed. Augmentation of the right breast with a silicone implant was performed, selecting the inserted implant preoperatively with the assistance of three-dimensional (3D) simulation. The breast asymmetry and anterior chest wall depression were improved to a natural appearance. Three-dimensional simulation represents an advantageous way to preoperatively select optimal implants for breast augmentation in asymmetric PE women with breast asymmetry.

Level of Evidence: 5

Minimal cosmetic revision required after minimally invasive pectus repair

BACKGROUND

Despite surgical correction procedures for pectus deformities, remaining cosmetic asymmetry may have significant psychological effects. We sought to evaluate factors associated with plastic surgery (PS) consultation and procedures for these deformities at an academic institution.

METHODS

We reviewed patients aged 0-21 diagnosed with a pectus excavatum or carinatum deformity at our institution between January 2001 and October 2016. Pectus diagnoses were identified by ICD-9/ICD-10 codes and surgical repair by CPT codes; patients receiving PS consultation were identified by clinical note service codes. Student's t tests, Fisher's exact tests, and Chi-squared tests were utilized.

RESULTS

2158 patients were diagnosed with a pectus deformity; 442 (20.4%) underwent surgical correction. 19/442 (4.3%) sought PS consultation, either for pectus excavatum [14/19 (73.7%)], carinatum [4/19 (21.0%)], and both [1/19 (5.3%)], (p = 0.02). Patients seeking PS consultation were more likely to be female (p < 0.01), have scoliosis (p = 0.02), or undergo an open repair (p < 0.01). The need for PS consultation did not correlate with Haller index, p = 0.78.

CONCLUSION

PS consultation associated with pectus deformity repair was rare, occurring in < 5% of patients undergoing repair. Patients who consulted PS more commonly included females, patients with scoliosis, and those undergoing open repair. These patients would likely benefit most from multidisciplinary pre-operative discussions regarding repair of the global deformity.

Improvement in Existing Chest Wall Irregularities During Breast Reconstruction

Mastectomies for both cancer resection and risk reduction are becoming more common. Existing chest wall irregularities are found in these women presenting for breast reconstruction after mastectomy and can pose reconstructive challenges. Women who desired breast reconstruction after mastectomy were evaluated preoperatively for existing chest wall irregularities. Case reports were selected to highlight common irregularities and methods for improving cosmetic outcome concurrently with breast reconstruction procedures. Muscular anomalies, pectus excavatum, scoliosis, polythelia case reports are discussed. Relevant data from the literature are presented. Chest wall irregularities are occasionally encountered in women who request breast reconstruction. Correction of these deformities is possible and safe during breast reconstruction and can lead to improved cosmetic outcome and patient satisfaction.

Challenging Breast Augmentations: The Influence of Preoperative Anatomical Features on the Final Result

BACKGROUND

Achieving satisfactory results may be difficult in augmentation mammaplasty patients in the presence of breast, chest wall, or vertebral deformities. These deformities have not been classified previously, and the impact of each deformity or combination of deformities has not been defined.

OBJECTIVES

The aims of this study are to determine the complicating factors in augmentation mammaplasty, to classify these factors according to their influence on surgical outcome, and to develop an identification system for simplifying the recognition of challenging cases.

METHODS

We retrospectively analyzed photographs and records of 100 consecutive patients who underwent augmentation mammaplasty. We observed suboptimal results in 18 cases. Preoperative deformities of the breast, chest wall, and vertebra were recorded in order to determine which factor or factors had complicated the surgeries. Eventually, the relationship between suboptimal surgical results and complicating factors was evaluated.

RESULTS

We observed that some deformities alone caused suboptimal results, whereas others did not. Deformities that caused suboptimal results alone were called major complicating factors, and any others were called minor complicating factors. We observed that suboptimal results were also obtained in patients who had four minor complicating factors. Patients who had suboptimal results because of major or minor complicating factors were considered challenging cases.

CONCLUSIONS

In this study, complicating factors for augmentation mammaplasty were defined and classified as major or minor depending on their effect on the surgical outcome. We suggest an identification system that simplifies the recognition of challenging cases in breast augmentation.

Is breast asymmetry caused by volume differences in women with pectus excavatum?

This study determined the breast volumes of female patients with pectus excavatum that led to asymmetry and hypoplasia compared with normal women. This retrospective study enrolled 13 patients diagnosed with pectus excavatum and 13 normal women, randomly selected from a healthcare centre (n = 26), between January 2012 and December 2014. We measured breast volumes (n = 52) based on chest computed tomography (CT) of all patients using Image J software and divided them into four groups according to the side and presence of pectus excavatum. The mean volumes of the right and left breasts of patients with pectus excavatum were 209 ± 64 mL and 218 ± 67 mL, respectively, with no significant difference between the two groups (P = 0.736). The mean volumes of the right and left breasts of normal women were 415 ± 197 mL and 439 ± 197 mL, respectively, with no significant difference between the two groups (P = 0.754). The breasts of patients with pectus excavatum were significantly smaller than those of normal women (P < 0.001). Both breasts of patients with pectus excavatum were similar in size but were smaller than the breasts of normal women. Skeletal correction for breast asymmetry correction, followed by breast augmentation for breast hypoplasty correction, with a one- or two-step approach may be useful to improve the aesthetics of breast deformities in women with pectus excavatum.

Pectus excavatum in adult women: repair and the impact of prior or concurrent breast augmentation

BACKGROUND

Women present with pectus excavatum five times less frequently than men. Adult women may have additional, associated cosmetic factors, including hypoplastic or asymmetric breasts, or prior augmentation. The authors evaluated the impact of prior or concurrent cosmetic breast surgery in an adult female cohort undergoing repair of pectus excavatum deformity.

METHODS

A retrospective review was performed of women (≥18 years old) who underwent pectus excavatum repair at a single institution from January of 2010 to September of 2013.

RESULTS

Pectus excavatum repair was performed on 47 women with a median age of 35 years (range, 18 to 63 years). Mean pectus severity index was 6.2 (range, 3.1 to 16). All patients had physiologic symptoms as the primary purpose for seeking repair. Twenty patients (43 percent) presented with existing implants or the desire for implants at the time of repair. Fifteen patients (32 percent) had a history of implant placement including prior breast augmentation (n = 14) and/or pectus implant (n = 4). Concurrent augmentation (n = 5), breast implant exchange (n = 8), and/or removal of chest wall implants (n = 4) was performed during repair. Morbidity included one implant-related hematoma. Complications and hospital stay were not significantly different for patients undergoing primary repair alone versus those with prior or concurrent augmentation.

CONCLUSIONS

Breast cosmesis was a concern in nearly half of adult women presenting for pectus excavatum repair. The authors' experience suggests neither prior nor concurrent breast augmentation increases the risk of complications in repair. The authors recommend that cosmetic breast surgery be performed concurrently with pectus excavatum repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Breast asymmetry and pectus excavatum improvement with fat grafting

BACKGROUND

In women, pectus excavatum malformation can cause modified breast morphology, resulting in mammary asymmetry, which can be increased by placing mammary implants alone. Fat transfer can be an elegant solution to increase the volume and projection of the breast.

OBJECTIVES

The authors discuss their experience treating pectus excavatum with fat transfer (lipomodeling) since 2000.

METHODS

The charts of 19 consecutive patients with a pectus excavatum breast asymmetry who underwent lipomodeling treatment at the authors' facility between January 2000 and November 2011 were retrospectively reviewed. Patients were separated using the Chin classification (type 1, 2, and 3). Data points for each patient included age and body mass index, number of interventions and volume of fat injected during each session, total volume transferred, and postoperative complications. The clinical result was evaluated by the patient and the surgical team on a 4-point scale: very good, good, fair, or poor.

RESULTS

Most (74%) patients in this series had type 3 Chin pectus excavatum. The average age was 28 years, and the average body mass index was 20.3. The average number of lipomodeling sessions was 1.63, and the average volume of fat transferred was 230 mL per session and 375 mL total. The patients and the surgical team were very satisfied or satisfied in 95% of cases and considered the result fair in 5% of cases. There were no complications.

CONCLUSIONS

Fat transfer for treatment of pectus excavatum yields very good (natural and stable) results and high patient satisfaction rates, which makes this technique our preferred method for treating thoracomammary malformations in pectus excavatum.

Correction of pectus excavatum with breast hypoplasia using simultaneous pectus bar procedure and augmentation mammoplasty

Most women with asymmetric pectus excavatum suffer from hypoplastic breasts. Hence, aesthetic correction of pectus excavatum has to address thoracic wall deformity, breast hypoplasia, and asymmetry.In retrospective series, 21 patients with a diagnosis of pectus excavatum with hypoplastic breasts were corrected using the pectus bar procedure and subpectoral augmentation mammoplasty. Results were assessed by analyzing prospectively collected data and calculating pectus indices from computed tomographic scans. At 12 months postoperatively, cosmetic evaluations were performed by the patients and by an independent, board-certified plastic surgeon using score from 0 (very poor) to 4 (very good).Cosmetic results evaluated by plastic surgeon were good (3.33 ± 0.03) and patient satisfaction was high (3.52 ± 0.03). Furthermore, indices of pectus excavatum were corrected to near normal.The authors consider that the pectus bar procedure with subpectoral augmentation mammoplasty is useful for the aesthetic correction of pectus excavatum with hypoplastic breasts.

Treatment of bilateral mammary ptosis and pectus excavatum through the same incision in one surgical stage

CONTEXT

Congenital deformities of the anterior thoracic wall are characterized by unusual development of the costal cartilages. All these medical conditions are frequently associated with a variety of breast deformities. Several surgical techniques have been described for correcting them, going from sternochondroplasty to, nowadays, minimally invasive techniques and silicone prosthesis implantation.

CASE REPORT

The present article reports the case of a young female patient who presented bilateral mammary ptosis and moderate pectus excavatum that caused a protrusion between the eighth and the tenth ribs and consequent esthetic disharmony. The proposed surgical treatment included not only subglandular breast implants of polyurethane, but also resection of part of the rib cartilage and a bone segment from the eighth, ninth and tenth ribs by means of a single submammary incision in order to make the scar minimally visible. Correction through a single incision benefited the patient and provided an excellent esthetic result.

CONCLUSIONS

The techniques used to repair bilateral mammary ptosis and pectus excavatum by plastic and thoracic surgery teams, respectively, have been shown to be efficient for correcting both deformities. An excellent esthetic and functional result was obtained, with consequent reestablishment of the patient's self-esteem.

Smooth and textured silicone surfaces of modified gel mammary prostheses cause a different impact on fibroproliferative properties of dermal fibroblasts

Our study addressed the question of whether surface properties of modern standard gel prostheses may have a measurable impact on the fibrogenic properties of cultured human dermal fibroblasts. Fibroblasts were isolated from breast implants by using the explant culture technique and incubated either on smooth or on textured silicone elastomere surfaces. Fibroblast growth was observed 4 weeks following incubation. Expression of transforming growth factor (TGF)-β1 was measured after cell culture. Incubated fibroblasts on textured surfaces showed a fivefold lower growth rate during all experiments. TGF-β1 expression was lowered in smooth surface fibroblasts compared with textured surface cultures. Our results show that smooth and textured silicone surfaces of modified gel breast implants have a different impact on the fibroproliferative properties of dermal fibroblasts. These preliminary results seem promising and we aim to further perform qualitative and quantitative analyses of the inflammatory processes in the environment of the implant and their link to the TGF-β pathway.

The nuss procedure after breast augmentation for female pectus excavatum

Pectus excavatum, the most common congenital chest wall malformation, has a higher incidence among men. Since 1987, when Donald Nuss performed his technique for the first time, the minimally invasive approach has become the most widely used technique for treating pectus excavatum. Few reported studies have focused on the repair of female pectus excavatum. Women with pectus excavatum often present with breast asymmetry that may require breast augmentation, either before or after pectus excavatum repair. To the authors' knowledge, no reports on the Nuss procedure after breast implant surgery have been published. This report describes the case of a 26-year-old woman who underwent minimally invasive repair after breast implant surgery. The authors believe that for women with severe pectus excavatum, the Nuss procedure should be the first choice for surgical correction. Moreover, for breast implant patients, this technique is absolutely feasible without major complications.