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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

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

Team Wigod Plastic Surgery before the Komen Race for the Cure

The office staff, patients, and friends formed a 52 person team and took part in the Komen Race for the Cure.  We all had a great time and raised a total of $2350.  Much of the team building and fund raising was accomplished by some very dedicated post mastectomy reconstruction patients.  Because of everyone’s hard work, I had the honor of accepting recognition for forming the largest team and raising the most money in our category (corporate less than 25 employees - and we have fewer than 10).  I feel guilty taking credit for others work, but I did hand out some really stylish team hats that I am sure will soon become a highly sought after fashion accessory.  Thank you to everyone on the team for your help and we hope that this will become a Wigod Plastic Surgery annual tradition.

Dr. Wigod accepting recognition on behalf of the team

A partial team shot

Ensenada Coast

Approximately 3 years ago, the FDA released silicone gel implants back onto the market after studying them for greater than a decade.  Their reintroduction has greatly benefited women seeking breast surgery, especially patients with thin coverage over their implants.  I find that I recommend silicone implants for most reconstructive patients as they have thin coverage after their mastectomies.  Silicone helps to minimize rippling and it feels better than saline.  I recommend silicone to augmentation patients about 50% of the time.  Those patients usually have particularly small breasts  and or have thin skin.  In augmentation patients who have a lot of breast tissue, silicone is largely unnecessary as the implant is well covered.  I sometimes cannot tell if these patients have silicone or saline implants when I examine them at their 6 month follow up.

Well conducted studies have concluded that leaking silicone implants do not lead to any diseases, mysterious or otherwise.  It is thought, however, that leaking silicone can put patients at higher risk for capsular contracture.  Therefore, the FDA has recommended that all patients have an MRI at 3 years post op and then every 2 years thereafter to look for leaking.  Those first patients to get silicone implants are now coming due for their MRI’s.  Reconstruction patients should have their studies through their primary care physicians or their oncologists.  Augmentation patients are responsible for arrangement and payment for their own MRI’s.  Local radiology groups offer less expensive MRI’s that are specifically tailored to look for silicone leaks only and not for any breast tissue problems such as cancer.  If a leak is found, implant exchange is recommended.

When the 3 and 2 year MRI guideline was made, there was skepticism on the part of most plastic surgeons. Were so frequent exams really necessary?  We know that leaking gel does not cause systemic disease.  Now that the first 3 year period is up, there has been more push back from Plastic Surgery Leadership and recognized authorities in the field.  MRI is a useful study to detect a leak.  Unlike saline, when a silicone implant leaks, it does not deflate, and is basically undetectable otherwise.  There can, however, be false positive studies.  That is, the MRI can say there is a leak, but there may not really be one.  In that case, an expensive operation with all the usual risks is performed when it did not really have to be done.

So what do I tell my patients?  I’m the type of person who asks permission first rather than forgiveness later, so I dutifully present the recommendations as part of the required additional silicone gel consent document supplied by the manufacturer and mandated by the FDA.  Medicine is no longer as paternalistic as it once was.  Patients demand information and choice.  With these rights, however, come responsibilities. Therefore, it is up to each individual patient to evaluate the science as well as the guidelines and come to her own conclusion.  After all, the FDA will not be organizing shuttles to the MRI machine, nor will they be paying for the studies.