Article Published By: Nikolas V. Chugay., and Quang Quach, M.D.
Introduction: Pectoral implants have been used to improve chest wall deformities, pectus excavatum, and Poland’s syndrome. We have implants bilateral pectoral prosthesis mainly to augment muscular inadequacy of the chest wall as well as to correct deformities.
Materials and Methods: Since 1995, 16 males patients have receive pectoral implants. Fourteen patients has muscular inadequacy, 1 patient had Poland’s syndrome, and 1 patient had a small right pectoralis major muscle (probably from fuste Poland’s syndrome).
Results: Most patients (14 of 16) developed temporary numbness of the upper inner arms that lasted up to 3 months. There were no other complications. One patient considered having larger implants but has not decided whether to undergo replacement as of yet.
Conclusions: Pectoral implants cab be used to correct muscular or chest wall defects as well as to enhance chest contour with minimal complications.
Pectoral implants were first used to repair deformities in the chest wall caused by muscle tears.1 Rupture of the major muscle is now more often repaired surgically to relieve weakness, pain, and deformity.2 Indications correction of both congenital and acquired chest wall deformities such as pectus excavatum, Poland’s syndrome, pectoral muscle tears, and muscular insufficiency.3 Although it is rare to perform chest wall enhancement in the female, except breast augmentation, pectoral augmentation has been performed for female bodybuilders or powerfully muscled women.3 The implants is placed through a transaxillary approach using a submusclar pocket, as in breast implantation.
This report is a review of our experience with pectoral augmentation cases since 1995, intended to evaluate the effectiveness of the technique.
Materials and Methods
Sixteen patients who underwent pectoral augmentation since 1995 were reviewed. Most of the patients were men (age range 25-45 years), and most were homosexual.
Bilateral augmentation was requested by these men because of concern over chest size deficiency and lack of muscle bulk despite rigorous and regular exercise (Table 1). Pectoral implants were most often placed concomitantly with other cosmetic surgical procedures (Table 2).
The two man types of implants available for pectoral augmentation are the Aiache and Novak implants. The Aiache implant is a solid, lozenge-shape silicone prosthesis mainly used to augment the lower tow thirds of the pectoralis muscles, whereas the Novack implants is square and has a clavicular extension for subclavicular enhancement.3
The implant we use is available in four sizes with differing dimensions and thicknesses (Table 3 and Figure 1). The choice of implants is made on the basis of the patient’s build and the amount of augmentation desired. Size 3 was used most often, and this yielded adequate augmentation.
Patient Selection
A thorough history and physical examination is essential and can be done at the time of initial consultation. The patient should be questioned about cardiovascular, pulmonary, and blood diathesis disorders to avoid surgical complications. Complete blood count, liver panel, electrolytes, and human immunodeficiency virus tests are obtained.
The chest wall is examined for abnormality and asymmetry. Any asymmetry is pointed out to the patient and preoperatively and post operatively in the standing position from the front, left, and right sides.
Appropriate consent is obtained after explanation of any possible complications of the surgical procedure. All questions are answered in detail. Aspirin and nonsteroidal anti inflammatory medication are discontinued at least 1 week before surgery.
Surgical Procedure
The pectoral implant procedure is performed through an auxiliary approach. On the day of surgery, a surgical marker is used ti mark the medial and inferior borders of the pectoralis major muscle as well as the high natural fold in the axilla for the skin incision.
In the operating room, the skin is prepared with povidoneiodine solution and then sterilely draped with the arms abducted from the body. Intravenous sedation with diazepam and ketamine is used to augment the local anesthesia of 1% lidocaine with epinephrine 1:100,000. Approximately 40mL of local anesthetic is injected into the axillary skin and subcutaneous tissue and medial, lateral and inferior boarders of the pectoralis muscle on both sides. This allows adequate anesthesia and vacoconstriction.
The skin incision is the axilla is 4.5 to 5.0 sm long (Figure 2). The dissection proceeds medially and inferiorly in the subcutaneous tissues to the lateral border of the pectoralis major muscle. A submusclar plane is created with blunt dissection, and the pocket os extended from the anterior axillary line to the medial and inferior attachments of the muscle. The surgeon must be cognizant of chest wall anatomy in order to avoid unnecessary injury to veurovascular structures, especially the fourth intercostal nerve. Hemostatic should be meticulous with the use of a cautery.
With an adequate pocket dissection, the implant (Figure 3) is introduced by folding it in half along the long axis, which allows easy placement through the incision. The subcutaneous tissues are closed with 3-0 Vicryl sutures with subcutaneous 4-0 Vicryl sutures. A pressure dressing is applied around the chest wall to keep the implants in place and to prevent bleeding and the accumulation of serous fluid. The dressings are removed in 24 hours.
Postoperative Care
All patients are given prescriptions for an oral antibiotic (Keflex; Cefakexin; Eli Lilly and Co., Indianapolis, IN) and Darvocet N-100 (propoxyphene and acetaminophen; Eli Lilly and Co.). The patient is seen the day after the surgery for wound examination and dressing change. Activities are increased as tolerated by the patient. Return visits are 1 week and 1 month after surgery. The patient is them monitored on an as-needed basis.
Pain medication is usually required for the first 2-3 days. Light work can be started within 1 week postoperatively.
Results
Fourteen of 16 patients had some temporary numbness of the inner aspect of one or both arms that lasted up to 3 months. There was no permanent numbness, infection, bleeding, asymmetry, or pneumothorax.
One patient expressed a desire for possibly needing a larger implant but elected to retain the size implanted for the present time.
*INDIVIDUAL RESULTS WILL VARY.
Discussion
Pectoral implants are used to correct chest wall deformities of different causes as well as for muscle deficiency. This is a simple procedure to perform with minimal complications. The auxiliary approach is recommended because there is no visible chest wall scar. Possible complications include hematoma, seroma, infection, neurovascular injury, pneumothorax, and hemothorax. Meticulous dissection and control of bleeding is essential. A chest tube should be available in the event of inadvertent pneumothorax or hemothorax.
Uneven swelling with disproportionate pain probably indicates hematoma formation. The implant should be immediately removed, the clots evacuated, and bleeding controlled. The pocket can them be irrigated and the implant replaced. Compression dressings should be applied for 24 hours. Prophylactic antibiotics are used to prevent postoperative infection.
Choosing the implant size is individualized and based on the patient’s body habitus. Obviously, a small chest will not accommodate a large implant.
Conclusions
Pectoral augmentation can improve chest size and physique as well as correct defects. Placement of a preformed solid silicone implant in a submuscular pocket gives good results and patient satisfaction. (Figure 4).
References
1. Aiache A. Male chest correction, pectoral implants and gynecomastia. Clin Plast Surg 1991;18:823.
2. Kretzler HH< Richardson AV. Rupture of the pectoralis major muscle. Am J Sport Med 1989;17:453-458.
3. Hodgkinson DJ. Chest wall implants: Their use for pectus excavatum. Pectoralis muscle tears, Poland’s syndrome, and muscular insuffucuency. Aesth Plast Surg 1977;21:7-15.
Commentary:
Pectoral augmentation in men is not a common procedure in many cosmetic practices. As Dr. Chugay and Quach point out, it is straightforward to perform with minimum postoperative morbidity. They correctly point out that transaxillary placement is preferred. One must be careful not to dissect below the lower insertions of the muscle, or the implant may be too low. There may be occasions when, out of technical necessity, revisions require another approach. In such cases, it is possible to enter the pocket through a periareolar incision. Scarring is minimal and barely visible if meticulous technique is used. The authors’ experience with no complications is admirable and speaks well of their technique. Other issues such as patient selection, a preponderance of homosexuals, and postoperative morbidity are confirmed by me experience. These implants are solid silicone with a soft fell and can be ordered with varying degrees of firmness (durometer). There are several companies who supply these implants as customs implants, because they are not approved by the Food and Drug Administration specifically as pectoral implants. In addition to Allied Biomedical (Paso Robles, CA 93446), “Hanson Medical, Inc. (Kingston, WA 98346) and Spectrum Designs, Inc. (Carpenteria, CA 93013) also supply these implants.
Excessive bleeding, while rare, is the most common complication of this procedure. It can be difficult to visualize a vessel in the depths of the pocket from the superior transaxillary incision. Endoscopic instruments can be helpful in this instance but are bot required. In most cases, excessive bleeding is not a problem because the dissection of vascular branching is from superior to inferior (the same direction as dissection), so the vessels tend to be separated cleanly by the blunt dissection, with retraction and spontaneous hemostatic.
Late displacement of the implant to a more inferior or lateral position probably reflects weakened muscle insertions inferiorly or laterally, but may occur without obvious cause and may bot be evident for several months after surgery. Late implant displacement is a known problem with all submusclar implants. Correction requires open approach with partial capsulectomy and re positioning of the implant. Re displacement can occur.
A simple approach to minor pneumothorax is to place a suction drain in the pocket. This will usually control minimum air leaks sue to the thin chest wall. If the surgeon finds himself in the pleural cavity, then it would be wise to review one’s anatomy prior to the next procedure.
It is clear that the authors have used more than local anesthesia. It might be more appropriate to term the anesthesia as either “conscious sedation: or “heavy sedation.” It has been my experience that the subpectoral space is difficult to completely anesthetize without extensive rib blocks, and even this is not always totally effective. For this reason, it is a good idea to have the patient heavily sedated and restrained during the dissection. When using this type of sedation, expert patient movement and response at lighter planes of sedation, even though there will be amnesia of the event.
The surgeon would be wise to assign to the patient a trained individual whose only responsibility is for the monitoring and administration of drugs. For those who have limited experience with these techniques, I have listed a technique, along with a few examples of various agents in each category. In my practice, we have stopped using ketamine in adults because of the regular number if patients who complain of flashbacks and hallucinations as long as several months after the procedure. However, it is considered a very good agent if used in combination with benzodiazepines and analgesics and is used successfully by a large number of surgeons.
Harry Galoob, M.D.
Ardmore, Oklahoma
References
1. Ellis DA, Gage CE. Evaluation of conscious sedation in facial plastic surgery. J Otolaryngol 1991;20:267-273.
2. Fruedberg BL. Hypnotic doese of Propofol block ketamine-induced hallucinations [letter]. Plast Reconstr Surg 1993;91:196-197.
3. Friedberg BL. Propofol-ketamine technique. Aesthetuc Plast Surg 1993;17:297-300.
4. Holzman RS, Cullen DJ, Eichhorn JH, Philip JH. Guidelines for sedation by nonanestheiologists during diagnostic and therapeutic procedures. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School. J Clin Anesth 1994;6:265-276.
5. Moscona RA, Ramon I, Ben-David B, Isserles S. A comparison of sedation techniques for outpatient rhinoplasty: midazolam versus midazolam plus ketamine. Plast Reconstr Surg 1995;96:1066-1074.
6. White PF, Vasconez LO, Mathes SA, Way WL, Wender LA. Comparison of midazolam and diazepam for sedation during plastic surgery. Plast Recondtr Surg 1988;81:703-712.
7. Yamashiro M. Effectiveness of conscious sedation with a single benzodiazepine compared with a combination of drugs. Anesth Prog 1995;42:103-106.
Response:
I agree with Dr. Galoob that excessive bleeding with this procedure can be a difficult problem and that endoscopic visualization of the pocket would be the best way to approach, find a bleeder, and them coagulate the vessel with a Colorado needle or long bipolar cautery forceps.
Regarding late displacement of the implant to a more inferior or lateral position, to avoid that particular problem I do not dissect the pocket very widely laterally (thus avoiding lateral displacement of the prosthesis) or inferiorly, using the anatomy of the pectoralis muscle as a guide to position the prosthesis primarily under the pectoralis major muscle. I try to make the pocket as small and narrow as I can to comfortably fit the prosthesis, which helps to avid lateral or inferior displacement of the implants. The sedation we use is a diazepam as sedatives helps to keep the patient comfortable and asleep during the procedure. It is feasible to perform this procedure with the patient under only local anesthesia in select patients by injecting some of the tumescent type of anesthesia widely under the pectoralis muscle as well as in the axillary region. We have a registered nurse who monitors the patient throughout the entire procedure, and she is the one who administers the medication under my supervision on an as-needed basis.
Nikolas V. Chugay, D.O.
Long Beach, California
