Male Pectoral Implants
- SYNONYMS, KEY WORDS, RELATED TERMS
Pectoral implants, male chest enhancement, chest wall implants, pectoralis muscle insufficiency, pectoral muscle implant, silicone implants, silicone prefabricated implants, thorax contouring.
Pectoral implants are used primarily for aesthetic enhancement and improved delineation of the male chest. Other more uncommon uses are for Pectus excavatum, pectoralis muscle tears and Poland’s syndrome. This article will focus on the use of pectoral implants for cosmetic male enhancement.
- HISTORY OF THE PROCEDURE
Initial reports of usage of customized silicone implants for correction of thoracic deformities come from experience in the treatment of pectus excavatum. At that point it became apparent that one of the main problems associated with such implants was due to lack of sufficient tissue coverage because of their subcutaneous/subglandular placement.
Aiache is credited with the first use of silicone implants for cosmetic purpose that were placed under the muscle that provided much more natural looking results. He has also designed one of the most widely used types of silicone elastomer implant for this purpose.
The most common reason for pectoral implants is male chest enhancement for aesthetic reasons. Furthermore some men display and inability to develop their pectoral muscles with exercise in proportion to the rest of their body. For certain men such is a cause of poor low self-esteem. Infrequently pectoral implants are used for pectralis muscle insufficiency, Poland’s syndrome and pectus excavatum.
The frequency of pectoral implants is small. Published data from the American Society of Plastic Surgeons report 440 such operations performed by ASPS members for the year of 2007. The ASPS tracks data from its members only. The actual number of such procedures performed is higher due to other physicians- non plastic surgeons – who also perform them.
The patient desire for placement of pectoral implants is mostly for aesthetic enhancement. Very rarely other conditions causing anatomic and structural irregularities of the chest wall may require pectoral implants for improvement.
The indications for pectoral implants are based on patient demand and need in certain reconstructive operations as mentioned earlier.
The pectroralis major muscle has three components. The clavicular, the sternocostal and the abdominal head. The origin of the muscle is from the medial half of the clavicle, the sternum, the upper six costal cartilages and inserts onto the lateral tip of the bicipital groove of the humerous.
The dominant arterial supply to the muscle is the thoracoacromial artery. The thoracoacromial artery gives off four branches; pectoral, armorial, clavicle and deltoid. The pectoral branch of the thoracoacromial artery is the largest. This branch enters both the pectoralis major and minor at the midportion of the clavicle. It courses laterally for about 4cm till it reaches ts “axis” from the acromion to the xiphoid until it turns around and runs across this axis distally. Additional blood supply to this muscle comes from the intercostal perforators, the lateral thoracic artery and the superior thoracic artery. The thoracoacromial artery can be seen running at the undersurface of the pectoralis major muscle in a fibrofatty plane.
The motor innervation comes from the medial and lateral pectoral nerves. Sensory innervation comes from the intercostals nerves.
The pectoralis minor muscle lays underneath or posterior to the pectoralis major muscle. The two muscles are separated by a loose areolar plane. The proper placement of the implant used for pectoral augmentation is between the two pectoral muscles.
The pectoralis minor muscle extends from the coracoids process to the third, fourth and fifth ribs. Its arterial supply is also from the pectoral branch of the thoracoacromial artery and branches of the intercostals arteries. Its nerve supply is from the medial pectoral nerve.
Poor overall health and unrealistic expectations of the patients are contra-indications to the performance of this operation.
The main part of the workup consists of chest wall and skeletal evaluation. Chest wall asymmetries should be assessed and the skeletal and muscular development should be evaluated. Furthermore the fat distribution of the anterior and posterior aspects of the chest wall would be evaluated.
The shoulder, rib cage and sternum should be examined carefully. Asymmetries of the coastal cartilages anteriorly and the xiphiod process are not uncommon.
- LAB STUDIES
Basic laboratory studies that should be standard with pre-operative workup should be ordered.
- CBC (complete blood count)
- Basic metabolic profile (Sodium, potassium, chloride, bicarbonate, glucose, BUN and creatinine)
- PT/PTT/INR (Basic coagulation studies)
Additional laboratory investigations should be taken based on the history and physical examination of the patient.
- IMAGING STUDIES
If asymmetries of the thoracic contour are appreciated during the physical examination the plain thoracic radiograms should be included as part of the pre-operative evaluation.
The pectoralis muscle dimensions need to be carefully measured. The height, the width and the diagonal dimensions of the muscles need to be recorded. These measurements will serve to select the proper implant. The implants are either custom made or prefabricated. A plethora of companies make prefabricated and custom pectoral implants. I find that using pectoral implants with dimensions 1-2 cm less than the pectoralis major muscle allows for improved outcomes.
- SURGICAL THERAPY/INTRAOPERATIVE DETAILS
The operation is begun with the patient in the supine position. The operation may be done under local anesthesia and sedation or with general anesthesia. I find it is more comfortable for the patients to be under general anesthesia.
The patients' arms are abducted at about 80-90 degrees from the torso and comfortably placed upon arm boards under cushioning.
A 5-6 cm curvilinear incision is made at the upper part of the axilla, partly in the hairbearing portion of it. This will ensure to camouflage a segment of the wound when the hair grows. Care is taken not to extend the incision past the posterior sweep of the pectoralis major muscle and the anterior chest wall.
The incision is carried out through lose areolar tissue. At that point I use a long clamp with blunt edges to carefully dissect right under the lateral edge of the pectoralis. Care is taken not to be too close to the undersurface of the pectoralis major in order to avoid injury to the thoracoacromial vessels. After we find ourselves in the lose areolar space between the pectoralis major and minor muscle I use blunt finger dissection to dissect and define the subpectoral space better. This is done carefully because often there are adhesions and intermuscular connections between the pectoralis major and minor muscles. Careful dissection and electrocautery of those fibrous adhesions will ensure a smooth operation with minimal blood loss.
Following that we rely on long dissectors (Mc Collum- Dingman or Aiache) with a smooth spatulated edge in order to dissect beyond the reach of our fingers. The main goal is to dissect an adequate pocket to accommodate the placement of the implant without too much tension.
The lateral dissection ends at the edge of the serratous anterior muscle. No division of the inferior and inferomedial attachments of the pectoralis should be done.
Ideally the procedure is done bluntly. If any bleeding is encountered that may be not controlled easily then the bleeder should be identified with the use of an endoscope and controlled.
The implants are then introduced. Most commercially available implants are made of solid silicone elastomer and a rough textured edge. They are soft enough to bend and this facilitates their introduction to the subpectoral pocket and proper placement.
The long spatulated dissector is then introduced again to ensure the implant sits properly. The patient is then brought in an upright position and final adjustments are made then.
I prefer to place a drain that comes out from the same incision. I keep the drain in for about 5-7 days and remove it when the drainage becomes serous and less that 30cc per 24 hours.
The wounds are then closed with 3-0 and 4-0 monocryl. The final closure is a subcuticular one.
Ace wraps are used to gently wrap the whole chest following surgery.
- POSTOPERATIVE DETAILS
The next follow up should be within the next 24-48 hours. Any evidence of hematoma should be evacuated in the operating room. A hematoma in this operation will cause a lot of pain due to the small space and it is hard to miss.
Then the patient should be followed every week for the next month to make sure the patient heals without any problems.
Patients may return to proper activities of daily living and full range of motion including exercise after six weeks.
Hematomas are possible complications of this surgery. Patients will complain of excessive pain in the side of the hematoma. The possibility of a hematoma in a healthy patient without any co-morbidity is 1-2%. Hematomas should be drained in the OR upon discovery. The subpectoral pocket should be evaluated for any bleeding and the implant re-inserted.
Sarcomas: The series in the literature are small and no data are available for comparison. One author in his earlier experience reported a sarcoma rate of 30%. After asymmetries of placement sarcoma formation would be the most common complication of this operation.
Wound infection is a possible yet uncommon complication with this operation. The presence of a foreign body makes this potential complication much more challenging. For this reason peri-operative and post-operative antibiotics are empirically given during the healing course.
Asymmetries of placement are the most common complication of this operation. Hence careful dissection of the subpectoral pocket is required with the final adjustments made with the patient in the upright position. Often times the pectoralis major muscles are asymmetric and this has to be explained to the patient beforehand because the eventual outcome will then be asymmetric. Overdissection of the inferior aspect of the subpectoral pocket will result in inferior displacement of the implant. Such will necessitate a re-operation with plication of the inferior pocket capsule and re-insertion of the implant.
- OUTCOME AND PROGNOSIS
This is an operation that technically is straight forward to perform especially for the plastic surgeon that has experience with the trans-axillary approach to augmentation mammaplasty.
With proper care it can be done expeditiously and safely.
The demand for this procedure is small yet growing especially among men who exercise a lot such as body builders.
- FUTURE AND CONTROVERSIES
Pectoral muscle etching which is done with careful suction assisted lipectomy (liposuction/liposculpture) around the edges of the muscle has been advocated as an alternative to augmentation and chest contouring with implants. Although excellent outcomes may be achieved with this technique in some patients, other patients desire a considerable amount of additional volume that can be accomplished only with the addition of an implant.
Suction assisted lipectomy for additional pectoral muscle delineation can be used as an alternative or an adjunctive technique based on the individual patient requirements.
Multiple Choice Questions
- The use of pectoral implants may be indicated in all of the following clinical situations except:
- Desire for pectoral muscle augmentation
- Asymmetric pectoral muscle development
- Pectus excavatum
- Poland’s syndrome
- Pectus carinatum
The correct answer is answer e. Pectus carinatum is a rare developmental condition of the thoracic wall in which there is an outward anterior displacement of the whole anterior thoracic rib cage. Placement of subpetoral implants in such case would have no benefit to the patient.
- The dominant blood supply to the pectoralis major muscle comes from:
- Intercostal artery perforators
- Lateral thoracic artery
- Superior thoracic artery
- Thoracoacromial artery
- Superior epigastric artery
The correct answer is d. The pectoral branch of the thoracoacromial artery provides the main and dominant vascular supply to the pectoralis muscle and can be seen proximally on the undersurface of the muscle.
The pectoralis major muscle can e classified as a type V muscle. That means it has a dominant blood supply with additional segmental pedicles. The dominant blood supply is the pectoral branch of the thoracoacromial artery.
- The most common complication of subpectoral implant placement for male chest augmentation is placement asymmetry. (true/false)
TRUE: Asymmetries of placement are the most common complications of this operation. The most common problems arising from placement are due to inferior or lateral displacement and often will require re-operation.
- The proper anatomic placement of the implants during surgery is under the pectoralis major and minor muscles for added coverage. (true/false)
FALSE: The proper and adequate placement of the silicone elastomer implants are under the pectoralis major muscle and over the pectoralis minor muscle. Care is taken not to injure the pectoralis minor muscle during the surgery as such would only result in bleeding and extra post-operative pain.
- The inferior and inferomedial attachments of the pectoralis major muscle should be divided carefully under visualization with the endoscope during surgery because this would ensure a better shape of the chest wall following implant insertion. (true/false)
FALSE: Unlike female breast augmentation procedures no pectoralis muscle should be divided/dettached during subpectoral implant placement for male chest enhancement. This would only result to weaken the muscle and cause inferior displacement and visible show of the implant.
- Fat harvesting and transfer to the pectoralis muscle and suprapectoral space is a safe alternative to male chest augmentation. (true/false)
FALSE: The safety and efficacy of fat transfer for male chest contouring are not known. There are no reported data for such a procedure.