Chest wall deformity following maximal tissue expansion for breast reconstruction

Coronal, Sagittal, and Horizontal Classification of the Chest Shape and Its Role in Selection of Proper Implants

Background

The number of female breast correction procedures has been steadily increasing. Despite extensive literature being available on these procedures, few authors have discussed the role of preoperative chest wall analysis in relation to postoperative outcomes. To date, no comprehensive classification of chest shape has been introduced in the literature. The aim of this study was to present a novel classification of chest shapes, based on three basic planes: coronal (C), sagittal (S), and horizontal (H), hence the proposed name "CSH classification."

Method

In this study, a retrospective analysis of 1000 randomly selected chest and breast images was conducted by three independent nonmedical evaluators, using standardized digital images captured with the Vectra 3D body scanner. All examined patients were qualified for breast augmentation surgery.

Results

Among 1000 randomly examined patients, 923 were classified in the coronal plane, 920 in the sagittal plane, and 627 in the horizontal plane. Other patients were excluded from the study due to insufficient quality of the images. A notable 43.2% of women have shoulder height asymmetries. A relationship between shoulder height asymmetry and chest width was confirmed by the chi-square Pearson test (P = 0.04), indicating that a higher shoulder is associated with a greater chest width on the same side. Furthermore, 84.7% of women displayed excessive upper chest projection, whereas 28.4% showed excessive lower chest projection. Additionally, 84.4% of women had chest projection asymmetries.

Conclusions

The vast majority of the women had natural asymmetries of the breast or and chest wall. The CSH classification allows systematizing the chest shape assessment. The chest shape has a significant impact on breast implant selection and the choice of the breast surgery technique.

A Rare Chest Wall Deformity after Usage of a Tissue Expander for Breast Reconstruction

A 2-stage breast reconstruction using a breast tissue expander and prosthesis is a simple method of breast reconstruction with little donor-site morbidity and short surgery time. In this report, we present a rare case of chest wall deformity, which appeared during breast skin expansion with tissue expander. We present a case of a 31-year-old woman who underwent a 2-stage breast reconstruction with a tissue expander and breast prosthesis. She had a former history of autologous microtia reconstruction using costal cartilages to create a framework of the ear at the age of 10. During expansion, the woman developed an abnormal hollowing of the chest wall. Even though it was difficult to select an ideal size for the breast prosthesis, an excellent breast shape was obtained by measuring the actual breast projection that we needed, using ultrasound sonography. The patient was satisfied with the final result. In this case, the patient suffered from a postoperative chest wall deformity due to cartilage harvesting. This unfavorable result highlights the need for careful preoperative evaluation of risk factors that may lead to chest wall deformity when patients will have tissue expansion as a part of breast reconstruction. When thoracic deformity occurs, surgeons should realize that choosing an adequate implant becomes rather difficult. Ultrasound sonography helps surgeons in measuring the actual breast projection preoperatively.

Quantitative assessment and risk factors for chest wall deformity resulting from tissue expansion for breast reconstruction

BACKGROUND

Chest wall deformity after tissue expansion for breast reconstruction is less recognized than complications such as infection, hematoma, skin necrosis and capsular contracture. However, the condition should not be discounted because pain, rib fracture and dyspnea may occur in severe cases. The aim of this study is to evaluate the extent of chest wall deformity quantitatively using computed tomography (CT) and to identify risk factors for this condition after tissue expansion.

METHODS

The subjects were 34 patients who underwent unilateral two-stage reconstruction and were examined by multidetector-row CT before expander surgery and during maximal tissue expansion. Chest wall deformity was assessed quantitatively using the Chest Wall Deformity Index (CWDI), which was measured before expander surgery (pre-CWDI) and during maximal tissue expansion (post-CWDI). Post minus pre (post-pre) CWDI was used as the index of chest wall deformity in the assessment of risk factors.

RESULT

Post-CWDI was significantly higher than pre-CWDI (3.66 ± 3.23% vs. 0.03 ± 2.74%, P < 0.001 by paired t test), showing that chest wall deformity occurred after maximum expansion. In a multiple linear regression model, capsular contracture emerged as a significant predictor of increased post-pre CWDI (P = 0.003). BMI was a significant predictor of decreased post-pre CWDI (P = 0.003), but this result may have been due to the measurement method.

CONCLUSIONS

Our findings suggest that chest wall deformity is common after maximum tissue expansion for breast reconstruction. Awareness of the possibility of chest wall deformity during tissue expansion is important, particularly in cases with capsular contracture.

Substantial chest-wall deformity following tissue expansion after radiotherapy

We present the case of a 54-year-old woman who underwent a two-stage breast reconstruction with a tissue expander after sustaining a lumpectomy and local radiotherapy for breast cancer. During expansion, the woman developed an abnormal concave deformity of the chest wall. Although respiratory or aesthetic consequences were expected, our patient reported only pain and was satisfied with the end result. Osteoporosis or local recurrence was excluded as predisposing factors, and radiotherapy was considered to be the causal factor in our patient. On the basis of this finding, we advise surgeons to take the risk of chest-wall deformity into consideration when planning a reconstruction with tissue expanders, especially in patients with a history of radiotherapy, and we recommend an alternative reconstructive method in this group of patients.

MOC-PSSM CME article: Breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent to different reconstructive breast procedures.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.