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An anatomic feature that most women do not think about is their chest shape.  The shape of the chest is determined by the rib cage and sternum.  With breast tissue and pectoralis muscle overlying, the true shape is difficult to assess.  Most people have a fairly flat anterior with a rounded transition to the side wall.  This makes a nice platform for breast implants for augmentation patients, or for  expanders and then implants for reconstruction patients.

Many women, however, have significant asymmetries and shape differences which impact how a device fits their chest.  The sternum may be prominent (pectus carinatum), or deeply indented (pectus excavatum),  but these findings are unusual.  More commonly, one side of the rib and sternum junction is more prominent than the other and contributes to the overall breast asymmetry which is very normal.

Another very common variant which I see is what we refer to as a keel (like the underside of a boat) shaped chest.  This is where the sternum may be prominent and the ribs drop off more quickly to give a more triangular appearance.  This is not a problem functionally and most women are  not even aware of it.  It becomes much more apparent, however, after a mastectomy.

Proper planning to address the keel shaped chest is important for the Plastic Surgeon.  First, the patient must be made aware of the shape and its implications.  With a flat surface, an implant or expander is more likely to stay where I put it.  With the keel shaped chest, the device wants to slide to the side, like a rock off of a peaked roof.  As I tell patients, gravity always wins.  So, what to do?

For augmentations, using a textured device to encourage gripping to the chest wall and ingrowth of surrounding tissue may be helpful.  Also, limiting size helps to limit gravitational pull.  The lateral chest is minimally dissected and the inframamary fold incision is closed securely.  The patient should then wear an underwire bra when instructed to help maximally support the implant until a scar capsule is well formed.

For delayed reconstruction, the same approach is used.  For immediate reconstruction, a bra like sling may be formed with human cadaver dermis (almost a standard maneuver now), or with a latissimus flap.  If possible, the expander is then filled slowly.

I have found these approaches to be helpful, and most patients do well (see the case of the month).  Nonetheless, a keel shaped chest puts the patient at a higher risk for lateral movement of her implant.

Water Fight at the Eagle Fun Days Parade

The patient is a young woman with breast cancer who underwent bilateral mastectomy with aesthetic delayed reconstruction.  She has a keel shaped chest which is evident only post mastectomy.

AP pre op

AP post mastectomy

AP post reconstruction

Oblique pre op

Oblique post mastectomy

Oblique post reconstruction

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Chalk Art in the Park

Chalk Art in the Park

Memorial Day Ceremony, Veteran's Cemetery

Revision Surgery, a second ( or more ) surgery to improve the original result, may be a major or minor issue for both patient and surgeon.  Most Plastic Surgeons take ownership of their operative results.  I frequently tell my patients, “That’s not just your nose (or whatever the appropriate body part) anymore, it’s our nose.”  While my desire to have a patient happy with his or her result is primary, my ego driven desire to have a result that I am happy with comes in a close second.

I think that this is a good motivator, provided that my ego stays in second place.  Why is that… Because a patient’s result may at times be improved with another procedure and I must impartially assess the situation.  That is why it’s also almost always emotionally easier to improve another surgeon’s difficulty than my own.

Revision surgeries come in several flavors.  Minor ones may be done in the office setting under a local anesthetic.  Major ones require a return to the operating room.  Early post op period revisions are relatively unusual.  They are to improve an obvious problem or to treat a complication like infection or bleeding.  Intermediate period operations to improve an aesthetic problem are usually at 6 to 12 months out.  The waiting period is necessary as most early issues will improve to a point where another surgery is either no longer needed or the problem is so minor that the down sided of revision do not justify the upsides.  Late revisions are on surgeries which occurred several years ago.  The improvements needed may or may not be related to problems with the original operation.  More often, another operation is needed to treat changes secondary to aging, pregnancy, or breast implant problems.  Most of these operations occur on another surgeon’s patient.  Late revisions are frequently more complicated and costly than the original procedure.  This information is both new and disturbing to most patients.

All surgeons have to do revision surgeries on their own patients.  I certainly try to keep them to a minimum, but if a surgeon tells you that he or she never has any problems, he or she just started operating… or is lying.  Some operations have a high revision rate while others are low.  I try to avoid the high revision rate ones.  So what if a few patients have a potentially big problem?  Well, it doesn’t matter much unless you are the one with the problem.  In the end I want my patients to have as smooth a course as possible, be happy with their results, and know that I am there to help with any problems they may have.  Our office policies for revision surgery are presented in detail on our surgery quotes and on our web site.

Memorial Day Ceremony, Veteran's Cemetery

The patient is a man in his 50’s who had a silicone gel chin implant placed by another surgeon.  He was dissatisfied with asymmetry ( anatomic right higher than left ).  He had revision surgery to remove the implant, recontour the mandible, and place a larger Porex implant secured by 2 titanium screws.

Before

After