Bilateral Breast Deformity after Neonatal Tube Thoracostomy in Fraternal Twins

Abstract

Sir: Chest tubes are required in neonates to treat pulmonary problems in infancy. Scarring from chest tube insertion may cause significant deformities, especially if the tube is placed through developing breast tissue. This is more likely to occur when chest tubes are placed anteriorly, toward the midclavicular line. Two female fraternal twins were born at 27 weeks gestation after premature rupture of membranes. Both had difficulty breathing and required emergent intubation. Both further developed bilateral pneumothoraces due to the positive pressure ventilation, which was treated with bilateral tube thoracostomy via a presumed anterior approach. Fifteen years later, they presented to us with complaints of bilateral breast deformity. One twin was noted to have contractures at the lateral aspects of both breasts with adherence of the overlying skin at the level of the midlateral breast (Fig. 1). There appeared to be normal development of the remainder of the breast and nipple-areola complex.Fig. 1.: Anterior preoperative view of twin A.The second twin was noted to have a similar deformity on her left side. However, the right breast was noted to be severely hypoplastic in comparison to the left and had secondary deformity of the nipple-areola complex, which was retracted in the direction of the axilla (Fig. 2).Fig. 2.: Anterior preoperative view of twin B.Two recommendations exist in the neonatal and pediatric surgical literature for placement of chest tubes.1,2 One method favors placing the chest tube in the midclavicular line, while the other recommends placing the tube in the anterior midaxillary line. Although midclavicular line chest tube placement is still considered acceptable by many practitioners, scarring can be significant and cause secondary deformity of the surrounding tissues. This is especially problematic if placement is too low and inhibits normal breast development. While not initially recognizable, the deformity becomes apparent during puberty with rapid breast development. The deformation may have significant psychosocial effects and, in severe cases, interfere with lactation. Most patients will require contracture release with reconstruction to prevent further deformity. Although this is a severe complication, there are very few reports in the literature. A MEDLINE search from 1966 to the present discovered only scant references documenting cases of breast deformity after tube thoracostomy.3 In one publication, Rainer et al.4 reported two female patients with breast scarring after chest tube placement requiring reconstruction. Through anatomical dissections on five newborns, the authors found that breast tissue in this age group extended from the second to the sixth rib in the midclavicular line. Placing a chest tube below the second rib anteriorly could potentially lead to complicated scars. The reported advantages of anteriorly placed chest tubes are that they are more effective at evacuating pneumothoraces versus posterior chest tubes.5 Given the added morbidity of possible breast tissue injury and scarring, and the psychological stresses that are associated with these deformities, it is recommended that such tubes be predominantly placed in the midaxillary line. If anterior tubes are required, they should be judiciously placed above the second rib to avoid injury to the breast tissue. These recommendations should apply not only to the neonatal intensive care unit setting but also to cases of pediatric trauma. Elie Levine, M.D. Henry Lin, M.D. Saul Hoffman, M.D. Peter J. Taub, M.D. Division of Plastic and Reconstructive Surgery Mount Sinai Medical Center New York, N.Y.