We read with great interest the manuscript of Kim et al. entitled “Risk factors for chest wall depression after implant insertion for breast reconstruction: a retrospective quantitative study” (1). This is a retrospective study aimed at measuring the chest wall deformity (CWD) after implant insertion and identifying associated risk factors. The authors’ results suggest that implant reconstruction causes CWD, which is associated with capsular contracture and patient age.
In 2015, Cherubino et al. reported that CWD were caused by the use of tissue expanders but found no specific risk factors to predict it (2). However, the study of Kim et al. did find the features mentioned that increase CWD.
Like any other solid, living tissues are subject to the fundamentals of the mechanics of materials. Vegas et al. shown how the long-term results in breast augmentation and augmentation-mastopexy could be explained by the resistance of the tissue material (3).
They focused on the resistance of each anatomical tissue, putting the most important point on the superficial fascia of the breast, which is the second strongest anatomical structure after the skin on breast surface (4,5). In this sense, these studies lay the groundwork for capsular contracture to cause CWD, as confirmed by Kim et al. (1).
This has taught us that the stiffness properties of the surrounding tissues are of utmost importance when planning our surgery and the final aesthetic and functional result (6). In this way Kuramoto et al. reported a case of a large CWD after the insertion of an expander in a patient with the sole history of rib harvesting for microtia treatment (7). In this rare case, lack of mechanical support did cause the chest wall deformity and the deficiency in breast expansion.
CWD is an important clinical consequence of heterologous breast reconstruction which must be taken into account because it alters the preoperative reconstructive measures, modifying the cosmetic result. Autologous fat grafting is also an important tool to improve the tissue characteristics and implant coverage, but it is not a risk-free surgery (8,9). This also serves as a complementary procedure to improve capsular contracture and underexpansion expected on CWD.
Currently, there is no clinical evidence that this CWD has negative effects on respiratory physiology. Since the grade of deformity is minor (a difference of 1–2 cms maximum) and the total volume of depression should not exceed 100 cc, it seems reasonable that this deformity has no relevant consequences in dynamic mechanics. Increased chest wall stiffness and changes in vital capacity only occur when large defects take place in the thorax, such as sternal or multiple ribs resections (10,11). For this reason, it lead us to think that the CWD of breast reconstruction may not have a functional impairment.
We think that CWD implies a cosmetic relevant alteration that must be taken into account for future surgeries, thinking of oversizing the implants or changing the initial reconstructive plan. A proper evaluation of the learned risk factors, would help surgeons predict the final outcome.
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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-22-525/coif). The authors have no conflicts of interest to declare.
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- Kim JH, Lee S, Najmiddinov B, et al. Risk factors for chest wall depression after implant insertion for breast reconstruction: a retrospective quantitative study. Gland Surg 2022;11:1333-40. [Crossref] [PubMed]
- Cherubino M, Scamoni S, Maggiulli F, et al. Breast reconstruction by tissue expansion: What is the integrity of the chest wall? J Plast Reconstr Aesthet Surg 2016;69:e48-54. [Crossref] [PubMed]
- Vegas MR, Martin del Yerro JL. Stiffness, compliance, resilience, and creep deformation: understanding implant-soft tissue dynamics in the augmented breast: fundamentals based on materials science. Aesthetic Plast Surg 2013;37:922-30. [Crossref] [PubMed]
- Gefen A, Dilmoney B. Mechanics of the normal woman's breast. Technol Health Care 2007;15:259-71. [Crossref] [PubMed]
- Briot N, Chagnon G, Burlet L, et al. Experimental characterisation and modelling of breast Cooper's ligaments. Biomech Model Mechanobiol 2022;21:1157-68. [Crossref] [PubMed]
- Rivera A, Gascon D. A Response and Discussion with Respect to Gulcelik’s Study in Oncoplastic Level II Surgical Techniques for Breast Cancer Treatment. Breast Care (Basel) 2022;17:24-30. [Crossref]
- Kuramoto Y, Yano T, Sawaizumi M, et al. A Rare Chest Wall Deformity after Usage of a Tissue Expander for Breast Reconstruction. Plast Reconstr Surg Glob Open 2018;6:e1950. [Crossref] [PubMed]
- Hamidian Jahromi A, Horen SR. Editorial: feasibility, complications, and cosmetic outcomes of immediate autologous fat grafting during breast-conserving surgery for early-stage breast cancer. Gland Surg 2021;10:2885-9. [Crossref] [PubMed]
- Rivera A, González-Pozega C, Ibarra G, et al. Punctual Breast Implant Rupture following Lipofilling: Only a Myth? Breast Care (Basel) 2021;16:544-7. [Crossref] [PubMed]
- Netscher DT, Izaddoost S, Sandvall B. Complications, pitfalls, and outcomes after chest wall reconstruction. Semin Plast Surg 2011;25:86-97. [Crossref] [PubMed]
- Netscher DT, Baumholtz MA. Chest reconstruction: I. Anterior and anterolateral chest wall and wounds affecting respiratory function. Plast Reconstr Surg 2009;124:240e-52e. [Crossref] [PubMed]