Breast Augmentation in Chest Malformation

Abstract

Chest malformation represents a keystone in breast augmentation practice, being, even for the experienced surgeons, a permanent challenge. There are many factors involved in this complex anomaly, from biomechanical forces to connective tissue disorders, each of them affecting spine, sternum, and ribs, with different severity grades. In this field of diversities, the author introduced, for chondrosternal malformations, a new classification system, defining the true protrusion, the true concavity, and the compensatory protrusion and compensatory concavity, according to their location related to a reference line. This is a straight line starting from suprasternal notch to the epigastric area. There are VII types of chondrosternal malformations, each of them with three severity grades (minor, moderate, and severe deformity), according to the aesthetic complains, functional impairment, and surgical indication for sternal correction. A series with nine significant clinical cases with pectus excavatum, pectus carinatum, and ribs deformity are presented.

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Introduction

The sternum is an elongated, flattened bone, forming the middle portion of the anterior wall of the thorax. Its upper end supports the clavicles, and its margins articulate with the cartilages of the first seven pairs of ribs. It consists of three parts, named from above downward, the manubrium sterni, the corpus sterni or gladiolus, and the processus xiphoideus; in early life, the corpus sterni consists of four segments or sternebrae (Fig. 22.1). Its average length in the adult is about 17 cm and is rather greater in the male than in the female [1].

Fig. 22.1

Sternal parts

Sternal Embryological Development

During embryonic development, the sternum arises independently of the ribs from paired mesenchymal bar present by 6 weeks of gestation. These parallel bars migrate to midline, where they undergo chondrification and fusion by 9 weeks of gestation. The fusion process occurs in cephalocaudal direction and is followed by approximation of the ventrally growing ribs [2–4].

Independent of the development of the sternal bands, a single midline condensation of mesenchyme develops, which later forms the manubrium sterni. Sternal defects result from failure of fusion of the sternal bands (Fig. 22.2).

Fig. 22.2

Failure of complete sternal ossification

The sternum originally consists of two cartilaginous bars, situated one on either side of the median plane and connected with the cartilages of the upper nine ribs of its own side. These two bars fuse with each other along the middle line to form the cartilaginous sternum, which is ossified from six centers: one for the manubrium, four for the body, and one for the xiphoid process [3–5].

The ossific centers appear in the intervals between the articular depressions for the costal cartilages, in the following order: in the manubrium and first piece of the body, during the sixth month of fetal life; in the second and third pieces of the body, during the seventh month of fetal life; in its fourth piece, during the first year after birth; and in the xiphoid process, between the fifth and eighteenth years [1]. The time for sternal parts union starts soon after puberty until old age (Fig. 22.3).

Fig. 22.3

Time of sternal parts union

Chest Wall Deformities

Since, into the chest malformations, several anatomical elements may be involved (Table 22.1), there are various congenital chest wall anomalies (Table 22.2), ranging from unnoticeable to life-threatening [6]. Even if the chest malformation etiology still remains unknown, in the chondrosternal asymmetry, there are several factors involved (Table 22.3). The systemic weakness of connective tissue (Table 22.4) may explain the role of imbalanced biomechanical forces into these malformations [5, 6].

Table 22.1 Anatomical elements involved in chest malformation

Table 22.2 Chest wall abnormalities

Table 22.3 Chondrosternal asymmetry etiology

Table 22.4 Congenital malformations associated to chest wall deformities

Evaluating the schematic representation of the normal chest, in a frontal view, with the biomechanical forces acting from outside (Fig. 22.4) and from inside the sternum (Fig. 22.5), in the transversal view (Fig. 22.6), we may understand the fragility equilibrium of this system. Sternal body is like a plate pulled from outside by pectoralis major, pectoralis minor, sternocleidomastoid, and rectus abdominis muscles and from inside by transversus thoracis, transversus abdominis, sternothyroid, and sternohyoid muscles and pushed by growing costal cartilages.

Fig. 22.4

Normal chest with the biomechanical forces acting from outside

Fig. 22.5

Normal chest with the biomechanical forces acting from inside

Fig. 22.6

Normal chest with a good biomechanical forces balance

Who is “first guilty” in this process? The muscle weakness attracting the cartilage overgrowth, the muscular imbalance determining the asymmetry, or the stimulated osseous or cartilaginous nucleus overgrowth induces the asymmetry and secondary muscular imbalances.

There is a predisposing small growing anomaly, which will be fully expressed at the moment of rapid growing, at pubertal time. The systemic weakness of connective tissue is part of this puzzle. This may explain also the association of chest malformation with different tubular breast situations.

Concerning the chondrosternal zone, congenital chest wall anomalies fall into two groups: those with overgrowth of the rib cartilages causing either a depression or protuberance and those with varying degrees of either aplasia or dysplasia.

In this complex field of anomalies, the author introduces a new system of classification using, for the beginning, the terms of definition (Table 22.5). The reference line comes from the suprasternal notch level to the epigastrium (being on the triangle represented by the xiphoid and costal margins). According to this situation, seven types of sternal malformations are described (Table 22.6), which include protrusion (pectus carinatum, PC), concavity (pectus excavatum, PE), and their association, with compensatory excavation or protrusion (Fig. 22.7). The malformation severity can be on the range from minor to severe (Figs. 22.8, 22.9, 22.10, 22.11, 22.12, 22.13, and 22.14), using aesthetic (objective and psychic evaluation), functional (of intrathoracic organs), and anatomic criteria (Haller index, thoracic depth measurements, or anthropomorphic index) [7–10]. Representative cases for this classification are presented from Fig. 22.15, 22.16, 22.17, 22.18, 22.19, 22.20, and 22.21.

Table 22.5 Terms of definition for chondrosternal anomalies

Table 22.6 Sternal malformation classification

Fig. 22.7

Dual plane representation of sternal malformations. Minus in front of reference line represents the compensatory excavation, while plus in front of reference line represents the compensatory protrusion (in Type V)

Fig. 22.8

Chondrosternal malformation Type I A

Fig. 22.9

Chondrosternal malformation Type II B

Fig. 22.10

Chondrosternal malformation Type III C

Fig. 22.11

Chondrosternal malformation Type IV A

Fig. 22.12

Chondrosternal malformation Type V A

Fig. 22.13

Chondrosternal malformation Type VI A

Fig. 22.14

Chondrosternal malformation Type VII B

Fig. 22.15

(a) Apparently normal-looking patient from the front. (b) Completely deformed from the back view. Severe scoliosis, with posterior ribs arches rotation and protrusion on right side, excavation on left side, and scapular asymmetry

Fig. 22.16

(a, b) Severe thoracic deformity with chondrosternal malformation Type IIIC

Fig. 22.17

(a) Severe chest malformation associated with breast asymmetry. (b) Severe chest malformation with breast asymmetry showing “inverted triangles.” (c) Severe breast asymmetry

Fig. 22.18

Pectus excavatum scheme demonstrating pectoralis muscle relative weakness comparative with transversus thoracis muscle, costochondral relative prominence, and sternal gap widening

Fig. 22.19

(a) Haller index for pectus excavatum severity (data collected from CT scan). (b) Inferior vertebral severity index in pectus excavatum. (c) Anthropomorphic severity index in pectus excavatum

Fig. 22.20

Prepectoral breast augmentation in pectus excavatum

Fig. 22.21

Retropectoral breast augmentation in pectus excavatum

Patient Examination

Apart of a routine chest and breast examination, as we are doing in a case with an aesthetic surgery planned to be done on the breast, when we recognize a chest malformation, we have to include complementary examinations and pictures, from different angles, to emphasize the defect. Some patients may look normal from the front but completely deformed from the back view (Fig. 22.15). At a more detailed frontal examination, one may notice the sternal asymmetry referring to the manubrium to umbilicus line, but this should not be a major problem for the breast augmentation. When the sternal deformity is associated with a spinal malformation, the case is much more complicated, and the breast augmentation should be carefully planned and postoperative connected problems explained to the patient (Figs. 22.11 and 22.16).

CT scan and cardiopulmonary evaluation with severity index appreciation of the malformation are mandatory before a thoracic surgery indication [7–10]. Usually, this should be solved before the breast augmentation. This is a complex chest reconstruction using combined procedures. Breast asymmetries associated with severe chest malformation (Fig. 22.17) represent a strong support of connective tissue involvement in this etiology.

Pectus Excavatum

Also called “funnel chest,” pectus excavatum represents the most common chest wall deformity (it occurs in 1:400 children) affecting males more than females (4:1) [11] and ranging from Type V to Type VII chondrosternal malformation (Fig. 22.7). In Goretsky’s [6] series of patients, pectus excavatum accounts for more than 87 % of the deformities since pectus carinatum, a chest wall protuberance, constitutes approximately 5 % of chest wall deformities. Combined excavatum/carinatum deformities constitute 6.1 % of chest wall anomalies [6], including Type II, Type III, and Type V chondrosternal malformations (Fig. 22.7).

Pectus excavatum can be present at birth but is most frequently recognized during early childhood. During rapid adolescent growth, many patients experience a marked increase in the severity of the depression until full skeletal maturity is achieved, being more than a cosmetic deformity. Despite well-documented reports to the contrary, the longstanding misconception persists that pectus excavatum is a cosmetic defect with no physiological consequences. This misconception has resulted in patients reaching adulthood with uncorrected defects. Some patients will develop cardiopulmonary symptoms for the first time as they age, and others will experience a worsening of symptoms they have endured for years [12]. Pectus excavatum and the biomechanical forces acting on sternum are schematically represented in Fig. 22.18.

Based on the pectus excavatum severity, evaluated by different procedures (Fig. 22.19) and clinical investigations, several procedures can be selected (Table 22.7) ranging from sternal manipulation to adipoimplant to filling the defect [13–16]. This can be done as a single procedure, associated procedures isolated in steps [13], or associated in the same time, with significant improvement, as shown by Park [14], using pectus bar and subpectoral augmentation mammoplasty.

Table 22.7 Pectus excavatum surgical repair procedures

Breast augmentation using silicone implants in pectus excavatum has some particularities pending on the shape of the anterior chest. In the prepectoral position (Fig. 22.20), the implant lies over the pectoralis major muscle with its axis perpendicular on it, attenuating the chest deformity. The pocket dissection may go closer to the sternal midline without jeopardizing the perforator vessels coming from internal mammary artery, and the full implant projection is free to expand the breast. As a result, the augmented breast looks parallel, in front of the chest, with a narrow cocktail view. By contrast, the retropectoral implant pocket (Fig. 22.21) will apply the device perpendicular to the ribs, losing a part of projection. Sitting over the costochondral distortions, because of mechanical friction, the textured implant will generate in time the chondrosynovial metaplasia and late seroma syndrome [17].

Considering the comparative preoperative NAC and breast position on pectus excavatum and pectus carinatum (Fig. 22.22), we may understand better the breast augmentation visual effect.

Fig. 22.22

NAC and breast position on malformed chest

Cases

Case 1 (Fig. 22.23)

Fig. 22.23

(a and b) Preoperative. (c) Six months following breast augmentation with textured anatomical implants CPG style 215 mL, in a dual plane pocket

This patient, with Type V A chondrosternal malformation, shows a minor deformity on sternum and spina. A dual plane breast augmentation with anatomical implants 215 mL produced a normal-looking breast.

Case 2 (Fig. 22.24)

Fig. 22.24

(a) Type V B chondrosternal malformation. (b) Preoperative view from different angles. (c) After retromusculo-glandular dual plane breast augmentation using textured anatomical implants, CPG 323 style, with 225 mL. (d) Comparative (top) before breast augmentation and (bottom) during the pregnancy. (e) One year after delivery and stop breast-feeding

This patient has a Type V B chondrosternal malformation and shows mild pectus excavatum with chondrosternal prominence on the left side. A dual plane breast augmentation using anatomical implants, CPG style with 225 mL, has been done. One year later, the patient becomes pregnant and the physiological breast augmentation completes the picture. The breasts look better and the chest malformation is hard to be seen. After delivery, loosing much weight, even the breast comes back to a smaller volume, the appearance is acceptable.

Case 3 (Fig. 22.25)

Fig. 22.25

(Top) Preoperative mild sternal excavation with bilateral ribs prominence on midclavicular line. (Bottom) Postoperative after retrofascial breast augmentation using textured anatomical implants 322 style, 195 mL

This patient has a Type VII B chondrosternal malformation and shows mild sternal excavation with bilateral ribs prominence on midclavicular line. To avoid the costochondral problems, a retrofascial breast augmentation with textured anatomical implants 322 style and 195 mL was done. The implant pocket should not go over the twisted ribs on the anterior axillary line. Postoperatively there is the natural appearance achieved with a small implant volume, but using the patient problem as a friend.

Case 4 (Fig. 22.26)

Fig. 22.26

(a) Chondrosternal malformation VII B. (b) Preoperative patient with moderate sternal excavation, rib prominence on midclavicular line accentuated on left side, moderate thoracic scoliosis, and breast asymmetry. (c) (Upper) Early postoperative following bilateral breast augmentation with different volumes and styles (on the right side textured anatomical implant 323 style, high projection, 260 mL and on the left side textured anatomical implant, 322 style medium profile, 255 mL), in a retrofascial pocket. (Lower) Six months postoperative

This patient, with a Type VII B chondrosternal malformation, shows mild sternal excavation with bilateral ribs prominence on midclavicular line and scoliosis with breast asymmetry. Bilateral breast augmentation with different volumes and styles (on the right side textured anatomical implant 323 style, high projection, 260 mL and on the left side textured anatomical implant, 322 style medium profile, 255 mL) in a retrofascial pocket has been used. Postoperative result at 6 months demonstrates a compensatory natural appearance.

Pectus Carinatum

Pectus carinatum describes a spectrum of protrusion abnormalities of the anterior chest wall (Table 22.8), ranging from Type I to Type III, depending on the site of greatest prominence (Fig. 22.7). Pectus carinatum deformities are associated with overgrowth of the rib cage during development of the chest wall and pectoralis muscle relative weakness comparative with transversus thoracis muscle (Fig. 22.27). Some other associated lesions (Table 22.9) demonstrate the connective tissue disorder [2–6, 11, 16].

Table 22.8 Pectus carinatum incidence

Fig. 22.27

Pectus carinatum demonstrating pectoralis muscle relative weakness comparative with transversus thoracis muscle, chondrosternal relative prominence, and sternal protrusion

Table 22.9 Associated connective tissue disorders

Parents or the patient may report that pectus carinatum has been present since birth or early childhood, but most children present at age 11–15 years. The degree of deformity may worsen during adolescence and most patients are asymptomatic. Once adult growth has occurred, the severity of the deformity generally remains stable. Symptomatic patients with severe pectus carinatum report exertional dyspnea and tachypnea (Table 22.10) as well as decreased endurance [18–21].

Table 22.10 Pulmonary associated problems to the severe pectus carinatum

For aesthetic reasons, breast augmentation using silicone implants may attenuate the problem, but patients have to understand that it will be difficult to achieve a narrow Cocktail view since the chest wall is divergent. The NAC will get a larger distance between them as well as the implant volume will increase (Fig. 22.22). Retrofascial position of the implant will be friendlier in this case (Fig. 22.28) as the retropectoral one (Fig. 22.29). The pectoralis major act as a platform in front of the ribs, correcting with few degrees the sternal angle. This advantage will be lost in retropectoral position of the implant, accentuating the distance between breasts, and the device will have an unnatural position toward the axillary line.

Fig. 22.28

Pectus carinatum – prepectoral breast augmentation scheme

Fig. 22.29

Pectus carinatum – retropectoral breast augmentation scheme

Case 5 (Fig. 22.30)

Fig. 22.30

(a) Patient with a chondrosternal malformation Type I A. (b) (Top) Preoperative. (Bottom) After retrofascial breast augmentation using anatomical implants style 323 and 300 mL. (c) Cocktail and Beach view after breast augmentation

This patient has a chondrosternal malformation Type I A and shows a minor deformity with pectus carinatum. Retrofascial breast augmentation using anatomical implants style 323 and 300 mL reestablishes the aesthetic breast proportion with patient body, with an acceptable aesthetic result on Cocktail and Beach view.

Case 6 (Fig. 22.31)

Fig. 22.31

(a) Patient with chondrosternal malformation Type IV A. (b) Preoperative. (c) Postoperative following breast augmentation using an anatomical implant, CPG style, 225 mL, placed in a retro-musculofascial dual plane pocket

This patient has a chondrosternal malformation Type IV A and shows a minor sternal deformity, associated with a significant costal arch protrusion on 6–8 ribs medioclavicular line on the left side and minor scoliosis. Using an anatomical implant, CPG style and 225 mL placed in a retro-musculofascial dual plane pocket, the aesthetic result shows an improvement. The sternal width being smaller (narrow) allows the retropectoral dissection to be closer to the midline.

Case 7 (Fig. 22.32)

Fig. 22.32

(a) Patient with chondrosternal malformation Type V A. (b) Preoperative. (c) (Top) Preoperative. (Bottom) Postoperative following retrofascial breast augmentation with anatomical implants, 255 mL. (d) Cocktail and Beach view after breast augmentation

This patient has chondrosternal malformation Type V A and shows a minor sternal protrusion on the manubrium, a minor excavation on corpus, and flattened ribs arch on midclavicular line, accentuating the defect. Also, the breast mound position is lower than normal. Retrofascial breast augmentation with anatomical implants, 255 mL, was used. The postoperative result demonstrates the NAC position pointing to the breast mound but the breast upper pole still under filled. A larger implant volume will produce a more ptotic effect, worsening the situation in time.

Rib Deformity

Rib deformity is almost always associated with a chondrosternal or spinal malformation, being sometimes more accentuated than the associated defects. Breast asymmetries are also noticed to it. Planning a breast augmentation, the surgeon should be careful because these small and sometimes hidden defects can become apparent and accentuated after the surgery.

Case 8 (Fig. 22.33)

Fig. 22.33

(a) Patient with rib concavity on left midclavicular line and prominence of right ribs arch on anterior axillary line level. Hypotrophy of the whole left side, left breast being also smaller and lower situated on the chest wall. (b) Comparative with (top) preoperative and (bottom) 6 months postoperative after retrofascial breast augmentation with textured anatomical implants, different volumes (195 mL on right breast and 225 mL on left breast)

This patient shows a chest malformation with the whole left side hypotrophy, ribs concavity on left midclavicular line, and prominence of right ribs arch on anterior axillary line level. There is also breast asymmetry, the left breast being smaller and lower situated on the chest wall. Retrofascial breast augmentation with anatomical implants and different volumes (195 mL on right breast and 225 mL on left breast) has been used, with an acceptable aesthetic result at 6 months.

Case 9 (Fig. 22.34)

Fig. 22.34

(a) Preoperative. (b) Six months postoperative (top) following retropectoral dual plane breast augmentation using 195 mL anatomical implants and (Bottom) 10 years postoperative after gaining 12 kg in weight

This patient shows mild thoracic malformation with scoliosis, inframammary ribs excavation, and induced breast asymmetry. Retropectoral dual plane breast augmentation with 195 mL anatomical implants shows a good aesthetic result, is stable after 10 years, and has 12 kg weight gained.

Conclusions

For breast augmentation procedures on chest malformation, several key points can be mentioned (Table 22.11).

Table 22.11 Breast augmentation key points in chest malformation