Correction of Poland’s syndrome in a male with solid chest wall implants

In the past, breast implantation for men was limited to transsexuals. Recently, more men have requested an adequate chest wall symmetry and an increase of chest size, particularly in the area of the pectoralis major muscle. This has lead to the development of pectoralis implants. This paper describes the surgical technique and possible complications of the correction of the chest wall deformity in Poland’s syndrome with solid silicone implants. These implants can either be custom made, using a moulage technique, or can be obtained as pre-fabricated, manufactured implants, which can be modified on the operating table. This method, with the appropriate indications, gives good predictable long term results. Received: 24 March 1998 / Accepted: 17 November 1998     

Midiabdominoplasty: Indications and Technique

In the treatment of aesthetic deformities of the abdomen there are three points we should analyze: the skin, the fat tissue, and the muscles. Based on these points we can classify it into six groups. Midiabdominoplasty is indicated in the correction of deformities of groups 2, 3, and 4. A small fusiform resection of skin is done in the lower abdomen, undermining of the skin up to the umbilicus (or to the xiphoid appendix if necessary to treat diastasis of the rectus muscles in the supraumbilical region), and desinsertion of the umbilicus, with no external scar, are the main points in this technique. The main complication was the formation of seroma. No necrosis of the flap or unsightly scars were observed. The results were good, with the patients satisfied with their new abdomens.     

Perinipple Round-Block Technique for Correction of Tuberous/Tubular Breast Deformity

A one-stage surgical correction of tuberous and tubular breast deformities is described. An intraareolar donut of pigmented skin is deepithelialized to correct the associated mega areola, allowing, at the same time, a port of entry for insertion of a retroglandular breast implant. The exposed areolar dermis is then telescoped inward and stretch-anchored to an imaginary circular line situated beneath the breast skin areola junction, thus pushing the breast tissue against the implant and the chest wall and correcting the deformity. The round-block technique is then utilized to approximate the skin edges, resulting in a minimal scar, totally inconspicuous, confined to the immediate perinipple area.     

Reconstruction of pectus excavatum with silicone implants.

The pectus excavatum deformity is characterised by a deep depression usually involving the lower one-half to two-thirds of the sternum. The indications for surgery are often aesthetic. Extensive procedures, requiring fracturing and remodelling of the chest wall skeleton are associated with high morbidity and high rate of complications. In this article we describe our renewed experience with reconstruction of mild and moderate pectus excavatum deformities with custom made prefabricated silicone implants. The fabrication of the implant and the surgical technique are described in detail. An excellent aesthetic correction of the deformity was achieved in all of the patients in our series, with high patient satisfaction rate. We conclude that with careful patient selection, artistic implant fabrication and meticulous surgical technique, this approach achieves excellent aesthetic correction with minimal morbidity and a low complication rate and therefore should maintain its place in the armamentarium of surgical techniques for reconstruction of pectus deformities.     

Pectus Excavatum Breast and Chest Deformity: Indications for Aesthetic Plastic Surgery Versus Thoracic Surgery in a Multicenter Experience

Background Breast and chest wall disfiguration attributable to a funnel chest is an aesthetically and sometimes functionally debilitating deformity requiring surgical correction. Whereas extensive and combined deformities of the ventral chest wall are classically corrected using a so-called minimally invasive repair of the pectus excavatum, a modified Ravitch repair, or the minimized Erlangen repair, plastic surgeons are mostly challenged with alloplastic implant corrections of mild funnel chests. The authors have introduced an endoscopic method for placement of customized implants to restore the visible and nonfunctionally disturbing deformation of mild funnel chests when only the sternal plate is involved. This study compared these different plastic surgical and thoracic surgical approaches in a multicenter experience to develop a clinical algorithm and to identify those patients not requiring bony correction but rather alloplastic endoscopic implant correction alone. Methods Patients with deformed rib cages and sternal plates were treated with the Erlangen minimally invasive procedure or a modified Ravitch procedure. For deformities involving the sternal bones only, endoscopically assisted minimally invasive implantation of silastic implants was performed. Results Between 1987 and 2003, 599 patients with a pectus excavatum deformity were treated surgically by the authors’ group. Between 1999 and 2003, 515 patients underwent surgery using the Erlangen minimally invasive repair technique at Friedrich–Alexander University–Erlangen. In addition, 84 patients underwent surgery at the Freiburg University Medical Center. In the current series, 79 patients underwent surgery using the modified Ravitch method. The mean patient age was 20.5 years (range, 3–54 years), and the rate of postoperative relapses was 5%. The findings showed that 73% of the patients judged the aesthetic result as excellent to good, and 20% were satisfied. In contrast, only five patients were suitable for soft tissue augmentation only. Two of these patients in the initial period received custom implants presternally via classical transverse skin incisions, whereas three patients were treated with endoscopic customized implant tissue augmentation. Conclusion Whereas with combined deformity of the sternal plate and the rib cage, a modified Ravitch repair yields good results, the endoscopic soft tissue correction with customized implants helps to avoid unsightly scars, allows for safe hemostasis in the dissection pocket, and leads to enhanced patient satisfaction. In the case of major chest wall deformity with orthopedic and functional relevance, a combination of the minimally invasive procedures (e.g., endoscopic correction and Erlangen repair) seems to show both optimized cosmetic results and maximized functionality.     

An Outer-Table Suspension Technique for Endoscopic Browlift

For the past 2 years, we have sought to develop a stable and reliable technique for soft-tissue suspension in the endoscopic browlift, while eliminating the need for permanent or temporary anchoring screws. To this end, we have developed an outer calvarial table fixation technique. This technique allows direct fixation of the periosteum or galea to the outer table of the frontal bone through the use of an outer table calvarial tunnel. The technique has been used in 34 patients, 21 of which were followed for more than a year. The results have been consistent and reliable. We feel this technique affords precise control of soft tissue suspension during endoscopic browlift, providing long-lasting elevation and lateral advancement of the brow complex.     

Vertical Mammaplasty: A Personal Approach

We have been using the vertical mammaplasty technique with personal adjustments for reduction mammaplasty and glandular resection since 1989. There were 63 cases of aesthetic reduction mammaplasty and mastopexy and 38 cases of reduction mammaplasty and mastopexy contralateral to breast reconstruction with implants and/or autologous tissues performed during the period from 1989 to 1993. The aim of this work is to discuss the complications, long-term results, and limitations to this technique.     

Endoscopic repair of anterior table: frontal sinus fractures with a Medpor implant.

OBJECTIVES: Isolated anterior table frontal sinus fractures are commonly repaired through a coronal incision. Endoscopic repair of these injuries has recently been described. This study evaluates the endoscopic repair of isolated anterior table frontal sinus fractures with a Medpor implant. METHODS: Preinjury photographs of 10 cadaveric heads were obtained. Anterior table frontal sinus fractures were generated in all cadavers. The fractures were documented with postinjury computerized tomography (CT) scans. The fractures were then endoscopically repaired with a Medpor implant. Five cadavers received prefabricated implants generated from the post injury CT data. Five cadavers received a standard implant (0.85 mm sheet) contoured intraoperatively. The success of each repair was documented with post repair CT scans, photographs, and direct transcutaneous visualization. RESULTS: All 10 defects were successfully repaired within 1 to 2 mm. All implants were palpable, but no objective asymmetry could be appreciated photographically or on CT scan. CONCLUSION: Anterior table frontal sinus fractures can be endoscopically repaired with either a standard 0.85 mm sheet or a prefabricated implant. Clinical application of this technique would be expected to reduce operating time, surgical morbidity, and cost.     

Augmentation Mammaplasty with a New Cohesive Gel Prosthesis

We present our experience with augmentation mammaplasty on 14 patients with a thin chest wall and poor subcutaneous tissue. Thanks to Polytech Silimed code 20675, a new anatomical prosthesis filled with ``soft' cohesive gel, the lodging in a subglandular position was possible without anomalous salience in the upper pole, and a more natural mammary profile was achieved without capsular contracture, dislocation, or misplacement of the mammary implants.     

Evaluation of asymetric implants in breast cancer

Since more than twenty years, methods of breast reconstruction using implants have continued to evolve in order to improve their aesthetic results. Shapes and materials of these implants have also evolved to obtain contours similar to that of the natural opposite breast. Therefore it can be considered that the use of asymmetric implants is the last step in implant technology before using made to measure implants. Asymmetric implants allow obtaining different contours in harmony to the different breast shapes according to the side, left or right, of the reconstructed breast which maximise the naturalness of the result. Such implants have an axis directed towards the exterior and lower part of the chest wall, are wider than high with a thinner part on their inner edge and a concave rear side moulding the curves of the chest wall. In our own experience, we placed more than 500 asymmetric implants. When analysing retrospectively the medical records of 156 patients, no distinctive features were observed when compared to symmetric classic implants in easiness in the surgical procedure or in complications except a slightly higher rate of seroma formation. When compared to usual implants the main benefits of asymmetric implants are: to offer a wider breadth, to slope down gently on their upper and inner sides according to their concave rear side, and therefore to better match subtle curves of a normal breast. Moreover such contours allow a distribution of the volume which fit better to the usual natural breast configuration of patients who underwent surgery for breast carcinoma. At last, such implants are easy to place and a very low rate of secondary rotation has been observed. In summary, for all these reasons, asymmetric implants, can be considered to be the class one in the choice of implants for breast reconstruction after breast surgery.     

Textured Surface Silicone Breast Implants: Histology in the Human

Previous studies on the interaction of textured silicone breast implants has analyzed tissue expanders or used animal models. To date, the data on long-term results of the textured silicone breast implants have not examined permanent implants or in vivo effects in the human. A prospective study was designed to examine the interaction of textured silicone breast implants in a human over several years. A single surgeon, standard surgical technique, and single-type implant design were included. The results revealed 78% had silicone particles in the tissue immediately adjacent to the implant interface. No distant migration, metaplasia, or adverse effects were noted. Our results indicate that silicone fragmentation is common but appears to be confined to the local environment.     

Congenital breast deformity reconstruction using perforator flaps

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved.     

Autologous Breast Reconstruction with the Inchworm Flap in an Obese Woman

Breast cancer may particularly occur in the obese female population. Although mastectomy can be a life-saving procedure, it frequently leaves soft tissue defects and deformities that can be psychologically and esthetically upsetting to the patient. A number of reconstructive methods have been utilized including prosthetic implants, TRAM flaps, and latissimus dorsi myocutaneous flaps. We present an obese woman who underwent a novel method of post-mastectomy breast reconstruction using a staged lateral chest wall fasciocutaneous advancement flap which we term the 'inchworm flap'. The patient had good outcome with no complications. In a select group of obese patients who have redundant lateral chest wall soft tissue following mastectomy, this technique can be a successful means of recreating the breast mound using autologous tissue.     

New Computerized Indices for Quantitative Evaluation of Depression and Asymmetry in Patients With Chest Wall Deformities

An evaluation index that can quantitatively assess the severity of chest wall deformities is essential to prepare and assess corrective surgical operations for patients with these deformities, including funnel chest patients. In previous studies, our group proposed several automatically calculated indices that represent the severity of depression and asymmetry in the chest wall. These indices showed sufficient performance in most cases of deformities, including those involving asymmetric and symmetric depression; however, their linearity declined when assessing complex deformities. The purpose of this study is to propose two automated indices that provide linear evaluation output for all types of chest wall deformities, including complex deformities, and to evaluate their performance and clinical feasibility. Six reference chest wall boundary curves were obtained from 60 computed tomography (CT) images of a normal chest. Next, an active contour model‐based image processing technique was used to extract boundary curves from images of patients with real chest wall deformities. Third, the required parameters were extracted from the boundary curves and the targeted indices were calculated. Finally, the performance of the proposed indices was evaluated using 33 synthetic images and 60 real chest CT images of patients with chest wall deformities. The newly proposed indices can be automatically calculated from the original CT images and showed sufficient performance for all types of chest wall deformities. We believe that the newly proposed indices can facilitate pre‐ and postoperative evaluation of chest wall deformities in clinical practice.     

Repair of Pectus Excavatum by Sternal Eversion

Pectus excavatum was repaired by the sternal eversion (turnover) technique in 26 patients over a 7-year period. Vascular supply to the sternal graft was maintained by preservation of one internal mammary vascular pedicle. Good results were obtained in 21 (81%) patients followed for periods ranging from 2 to 76 months (mean, 32 months) postoperatively. Four patients (15%) had fair results; 2 patients with Marfan's syndrome had partial recurrence, as did 1 patient with skin necrosis and 1 with hypertrophic scar. One patient (4%) had a poor early result due to wound infection and distal sternal necrosis requiring reoperation. Other complications were minor: superficial wound seroma in 2 patients and pneumothorax in 1.The sternal eversion technique for repair of pectus excavatum utilizes the concave shape of the sternum when turned over to create a cosmetically acceptable convex anterior chest wall contour. Judicious tailoring of the costal cartilages and shaping of the anterior sternum corrects asymmetrical deformities. The chest wall is very stable after repair. Since no prosthetic struts or pins are used, a second operation for removal is avoided. Preservation of the vascular supply to the sternum should allow normal growth of the anterior chest wall. The results have been sufficiently encouraging for us to recommend sternal eversion as the primary method for repair of pectus excavatum.     

PVP breast implants after two years: initial results of a prospective study

A prospective study of a new mammary prothesis with PVP-based gel as filling material was carried out. Scheduled follow-ups were planned at 3, 6, 12, and 24 months post-implantation to assess all complications, Baker scores, and the patient's, and the physician's global assessment of each implant. PVP-filled implants were used in 95 breasts for augmentation (60%) or reconstruction (40%). Sixty-nine percent of all patients underwent a primary procedure, 19% had a history of severe capsular fibrosis. During follow-up, a hematoma was observed in 2% and a seroma in 5%. Leakage occurred in 3% (one iatrogenic and two cases of unknown reason), a Baker 3 in 6% (12 months). No volume increase of the implants occurred. The probability that a patient would be complication-free at 24 months was 0.86. Physician's and patient's satisfaction rating after 12 months remained high without any time effect (physician very good/good 63%, patient 75%). According to our current experiences, the PVP-filled implants are a remarkable alternative with an improved viscosity and enhanced x-ray transmission, compared to saline filled implants.     

Late Intracapsular Seroma in Subfascial Buttock Augmentation: A Case Report

Late intracapsular seroma and hematoma have been described frequently as a complication of breast augmentation surgery. However, there are few reports of late intracapsular seroma in buttock augmentation. Textured and polyurethane implants have been used for subfascial enlargement of the buttocks. In this article, the authors report a large late intracapsular bilateral seroma caused by a retrofascial polyurethane-covered implant used for buttock augmentation: 1,200 ml on one side and 300 ml on the other. This patient’s intracapsular seroma was of sudden onset 2 years and 6 months after surgery, and apparently had no relation to any trauma, use of medication, or physical exercise. Local tissues, including the gluteal fascia, were distended such that the implant was replaced inside the muscle and there was no relapse of the seroma. Late intracapsular hematomas or seromas from implants for buttock and breast augmentation may have the same etiology, and textured implants seem to be involved. All the reports on the matter are associated with textured implants. Any late seroma or hematoma caused by a smooth implant is related to an additional factor that may be considered as the etiologic agent. Further studies aimed at a large-scale assessment of the cause and actual incidence of late seromas and hematomas from textured implants are required.     

Nasal reconstruction using split calvarial grafts.

The reconstruction of nasal deformities after trauma or surgical procedures presents an arduous task for the reconstructive surgeon. The anatomic alteration of supporting cartilage and nasal bones, as well as scar formation, compound the difficult nature of this type of reconstruction. In the past, multiple autogenous and alloplastic implants have been used in nasal reconstruction. Autogenous implants include auricular and septal cartilage as well as rib and iliac crest bone grafts. Alloplastic materials include acrylic, supramid mesh, Gortex, and silicone rubber. Autogenous grafts have been shown to provide excellent long-term reliable results in nasal reconstruction. In our study, autogenous split calvarial bone grafts were used in the nasal reconstruction of 17 patients. Among the corrective procedures were dorsal augmentation for saddle-nose deformities, insertion of columella struts for nasal tip ptosis, and insertion of nasal battens for nasal valve collapse. Patient followup has been from 1 to 5 years, with no significant resorption noted during that time. Complications were limited to one seroma at the donor site before wound drains were routinely used. No major complications, including hematoma formation, CSF leak, or infection, have been observed.     

Treatment of depressed scars with a dissecting cannula and an autologous fat graft

Contemporary options for the improvement of depressed scars include scar revision with an elliptical excision, z-plasty, w-plasty, and geometric broken-line closure. Dermabrasion and laser treatment has been used to obtain a uniform skin surface. When scars are hypertrophic, intralesional steroids and silicone pressure therapy may be useful. Occasionally, scars may be adherent to the underlying fascia. The resulting depression along the length of the scar worsens the aesthetic deformity. Fat injection is an established method for treating depressions and contour deformities. We report encouraging results with the use of this fat injection technique into a pocket made with a sharp cannula in treating 30 patients with postsurgical scars that were depressed and adherent to the underlying fascia. This technique is a useful addition to the surgeon's resources when treating scars.