Robert Whitfield MD explains surgical technique for removing implant capsules, focusing on anatomy and careful dissection near the sternum, ribs, and pectoralis minor. He describes approaches from the midline (breastplate) and from the armpit (lateral-to-medial), cautery and freer elevator use (a dull, rounded instrument), and cautions (avoid angling instruments toward the ribs to prevent thoracic injury/pneumothorax).
Think of it like this, towards the sternum or breastplate, however you want to term that. These are areas which repetition matters, technique matters. Using instruments that help you matter, we use something called a freer elevator that gently raises this tissue off of the surface of the cartilage and the ribs. Cartilage is what connects the sternum to the rib. The rib is actually the bony portion. So as you're raising these, there's clear planes between the layers. And so there's some pitfalls and things to avoid, like don't point instruments downward because they'll go towards the ribs. You want to stay level or parallel to the rib surfaces so you're not tipping down. That'll avoid going into the. And injuring the thorax, which contains the lung, of course. And a pneumothorax is what's written about a lot and described as a really bad complication from this. That rarely happens. But actually, anything that's happened in surgery over time, if you've trained enough, done enough, you've seen these complications, you know how to manage them when getting that tissue off, especially in the lower inner quadrants. So towards the breastplate or the sternum, there's, you know, think of the breast as a pie chart, and this is the lower inner portion of the pie chart. So as you come up those rib spaces, you're working your way around Tom, the upper inner. And then when you get about halfway to the. We'll call it the border of it in the midline, you're going to transition and you're going to see muscle on the chest wall next to the ribs. And this is the pectoralis minor. And once you see that, that landmark, you can choose to keep going or you can switch and go from the armpit towards the midline. And so why. Why does it matter? So for me, it's a level of comfort when I see that I know that I'm on muscle. Now, there's absolutely pretty straightforward. From here, we'll take it off the muscle and be done. Now, people get stuck at this position a lot, and this is why people don't like doing this, because it's adherent to the rib surfaces. And so one way to go about it is start the other direction and come from the armpit where there's always muscle, and just roll it from. We call it lateral to medial, but from the armpit towards the sternum, towards the midline, and you're gently dissecting this with your cautery off until you get to the ribs again and then you start using a freer elevator, which looks to me, I always call it like a little butter knife because it's round at the edge and dull and you're just gently nudging it. This is what takes time and patience to do to remove this tissue.
