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Hi WRM,

We need your help.  A young lady was encountered who had her breast done two years       

ago with textured implants in a subglandular position.

Because of keloid scar a dermatologist  injected some heavy cortisone  medication into the scar on the left side.

Now she has developed a blue window.

Maybe the implants need to be removed, but what then?

Tell me your proposal,  RS

Reply Hi :

From 1976 thru 1986 I used double lumen implants with the silicone gel covered by saline in an outer shell with a ratio of about four to one  - gel to saline volume, so that an implant might have 300cc gel and 60cc saline.

This was to keep the implants soft and routinely I put a little cortisone in the outer lumen with the saline.

It worked and they stayed soft and I hardly ever had a  firm breast in the first 3 years after surgery.

I used some Solumedrol at about 20mg, but it seemed to me we wanted it to last longer, so I also used kenalog

I had a lot of blue windows and found that the dose of 20 mg of kenalog per implant would cause a blue window half the time. So I would use between 2mg and up to 10mg kenalog depending on the patient’s tendency to scar, to keloid, and the thinness or thickness of the tissue inferiorly below the nipple.

If I saw the patient early with a blue window, in the first year, I might take out the implant and wash it out and replace it with plain saline and a blue window as you see it there in your picture, would be gone within a month.

Every time. Without fail simply washing out the steroid and replacing the implant allowed the tissues in the thin blue window area to thicken and become normal very quickly over a period of just a month with more thickening in time. In only a month the blue window was no longer blue and we knew that it was recovering. Never did I have to remove the implant entirely to get it to recover and none ever had extrusion.

So therefore, I would like to know when the kenalog was injected. Probably some oozed or leaked out into the pocket and didn’t stay in the scar where he wanted to put it.

The time is important because the tissues thin out over 6 months and then stop and the thinning of normal tissue dissipates as the tissues thicken back to normal over another six months to a year or two.

Therefore all the thinning and blue window will go away in time. And if it is due to steroid it will eventually correct itself unless there is pressure stretching the thin skin.

She needs support and must not scratch or have an injury to the thin skin, because if she does, it can easily break the skin and then you are faced with bacteria that can cause infection and we might then have to probably remove the implant for 2-3 months and let it heal and the put one back in without the bacteria in the pocket.

So if she had the kenalog 6mo or more ago, I would wait and see her every 2 weeks with photographs just like you sent me and see if it is improving or not. If it is getting better as it does after 6mo, the thickening and returning to normal  will be hard to detect in less than a month. It returns to normal slowly. Sort of watching a tree grow.

As soon as you see it improving and not getting worse, then I would say yippee and not operate.

If she doesn’t wear support all day that breast could begin to droop. It is not necessary at night.

If the thinning gets worse or if the injection was less than 6 mo ago or for a variety of reasons such has her preference, surgery can be done and hasten recovery.

Some surgeons have been unaware of the ability of that blue skin to return to normal,  and thinking it permanent have removed skin. And this should not be done,

I have seen blue windows that bad and  worse caused by my kenalog in the implant and seen the skin return to normal (every time in all cases with more than twenty cases I have had) in 2-4 weeks after I removed the kenalog from the implant. So I know in my heart and soul from my own experience with steroid caused blue windows, that this skin will return to normal. It will do it quickly over a period of a few weeks, if the steroid is removed.  

The surgery I would do to correct or hasten thickening of this blue window,  if it is getting worse and not better,  is to take the pectoral fascia down from off of the muscle above as a large flap including the fascia under the lower part of the breast which is from the serratus and rectus and lift it up as a sheet and fold it down to cover all the blue window area to strengthen it. The ledge of firm fascia where it is left attached to the chest wall can become the new inframammary fold and can be higher than she has now and can repair the drooping that occurs if she is drooping.

I have always done this through an intra-areolar incision because it seems easier that way than inframammary.

I would like for you to send several pictures of her,  in as many positions as you can, because this can happen with the inframammary incision and is heartbreaking to the patient. I have seen many keloids like that from the incision in that location and have never seen one yet under the arm or with the intra-areolar incision, which heals differently and better because it is essentially mucosa covered by epidermis.

So please email me more pictures of her if you can .And let me know what happens.

Thank you,

WRM

William Roy Morgan, M.D., F.A.C.S.

1419 Superior Avenue #2

Newport Beach, CA 92663

phone 949-645-6665

ascbs web site is ascbs.org

web site is  wrmorganmd.com

Hi WRM

Thank you for your excellent essay concerning the treatment of “blue windows” I saw the young lady yesterday and the blue window didn't either look better or worse. Look at the right picture for comparison. The skin looks the same even though the picture came out with more of a blue color.  It looks more blue on the picture than in reality.

She was quite happy when I explained to her that the blue window may vanish in time. The cortisone medication was applied some months ago. I gave her information on how to be protective and careful of the thin skin, to have the breast supported by a bra and to avoid any rubbing or scratches on that fragile skin. In case of any moisture that might be excreted she should return immediately r to show me. In case there is no change or any improvement she should return to let me see her just about every month or more often until we see improvement and thickening of the skin.

If there is any sign of worsening or no improvement in follow up, we will do the surgery dissecting the fascia as a layer of tissue to place down over the thin skin. It is expected that the fascia is probably thinned just like the skin is and yet it should be thick enough to help and get a good repair. If not, we will just need to perhaps remove the implant for a few months and then plan to replace it after the skin has returned to normal. Neither the patient or I want to do that, so we hope it will gradually improve and recover completely as you have seen.

Looking forward to seeing you

Yours  RS

 

Blue window on first visit

 

Same blue window 3-4 weeks later, actually

the same though more blue in the picture.

 

 

 

 

 

 

 

 

 

Next page shows another case of steroid atrophy of a little different type.  Next

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The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017