When teaching breast augmentation, although mastery of the technical aspects of the operation with emphasis on surgical precision is extremely important, achieving a successful outcome is more often the result of excellent preoperative and intraoperative decision making. Thoughtful consideration of the patient’s desired aesthetic result in conjunction with the anatomic characteristics of her breast and chest wall provides insight into the optimal implant and surgical approach. Selection of the appropriate implant, optimal incision, implant pocket, and inframammary fold location contribute to a satisfactory result. Technical aspects of the procedure also contribute to the final aesthetic result while minimizing undesired sequelae.
Key points
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Preoperative assessment should determine choice of implant, breast pocket, incision, and need to lower inframammary fold.
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Surgical approach, implant choice, and operative technique can affect the incidence of capsular contracture.
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Inframammary fold positioning is critical to establishing optimal implant placement in the pocket.
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Creating a controlled pocket minimizes the risk of implant malposition or rotation.
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The dual plane maximizes coverage and support of the breast implant while minimizing the negative attributes of submuscular placement.
Introduction
The operative approach in breast augmentation begins with careful and thoughtful consideration preoperatively to the many variables that ultimately affect the final result. Most decisions are made during preoperative evaluation and require expert operative execution to minimize the risks of unsatisfactory outcomes.
Introduction
The operative approach in breast augmentation begins with careful and thoughtful consideration preoperatively to the many variables that ultimately affect the final result. Most decisions are made during preoperative evaluation and require expert operative execution to minimize the risks of unsatisfactory outcomes.
Preoperative planning
One of the most critical steps in achieving excellence in breast augmentation is the preoperative evaluation. Such an evaluation should identify not only the appropriate implant to achieve optimal results but also the location of the incision, the implant pocket, asymmetries of the breast, chest wall, and nipple-areolar complex, and the potential need to lower and manage the inframammary fold (IMF). The preoperative markings create a roadmap for the planned procedure ( Fig. 1 ). Evaluation of the soft-tissue coverage, including quality of skin and breast tissue, amount of breast parenchyma present, and the level of ptosis, is essential in determining the optimal pocket for implant placement. Precise pocket creation and appropriate implant choice are the best safeguards against postoperative implant malposition issues. Likewise, one of the major drivers of revision surgery after a breast augmentation is capsular contracture. There is significant evidence that contamination with biofilm development is a significant causative component in the development of capsular contracture. Therefore, the surgical approach, implant choice, and operative technique can all affect the development of capsular contracture. At the preoperative planning stage, every effort should be made to minimize this risk. Box 1 summarizes some of the implant and surgical technique options that have been associated with lower capsular contractures.
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No-touch technique
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Nipple shields
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Pocket irrigation with triple antibiotics
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Insertion sleeve
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Submuscular implant pocket
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Textured implants
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Inframammary incision
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Cohesive shaped implants
Patient positioning
Patients are placed on the operating room table in the supine position. The arms are secured to the armboard at 45° to stabilize the patient in the upright position ( Fig. 2 ). This positioning allows access for the surgeon to stand and yet relaxes the pectoralis muscle, providing a more accurate assessment of the implant position and the redraping of the breast tissue overlying it. Placing the arms by the patient’s side is a useful alternative, but assessing the patient with the arms outstretched at 90° should be avoided.
Infiltration of local anesthetic
Before surgical preparation, 50 mL of a local field block of 1/4% lidocaine, 1/8% bupivacaine, and 1:400,000 epinephrine is injected ( Table 1 ). The injection is placed in the dermis along the planned incision line, deep to the dermis along the IMF, the medial pectoral border, the anterior axillary line, and deep to the breast parenchyma, in a fanning fashion throughout the area of planned pocket creation ( Fig. 3 ). These injections provide assistance not only in operative hemostasis but also in the management of postoperative pain.
| 1/2% lidocaine plain | 25 mL |
| 1/2% lidocaine/1:200,000 epinephrine | 25 mL |
| 1/2% bupivacaine/1:200,000 epinephrine | 25 mL |
| Injectable saline | 25 mL |
| 1/4% lidocaine, 1/8% bupivacaine, 1:400,000 epinephrine | 100 mL |
Surgical preparation and sterile draping
After local infiltration, nipple shields (created by placing a small piece of Tegaderm over each nipple-areolar complex) provide a barrier against potential bacterial contamination ( Fig. 4 ). The patient is prepped with chlorhexidine and draped to provide a sterile field with the entire chest and bilateral breasts visible for assessment during the procedure. The sterile dressings must be secured to prevent disruption in the sterile field while placing the patient in the upright position.
Incision
The decision on incision placement is based on a variety of variables, including patient and surgeon preferences, anatomic considerations, and implant type and size. The size of the incision depends on the location, but in general should be as small as possible and yet large enough to safely dissect the pocket and place the implant without distortion or injury to the device. In general, the length of the incision would be smaller with saline than with silicone implants, and longer when placing more cohesive implants, larger implants, or textured implants. Implant fractures of form-stable cohesive implants and rupture or distortion of silicone implants has been associated with attempting to place implants through incisions inadequate to accommodate the implant. In addition, the quality of the scar is often better if a slightly larger scar is created, reducing the stretch and retraction injury placed on the scar. Incision length ranges include 3–4.5 cm for saline implants, 4–6 cm for silicone round implants, and 4.5–7 cm for shaped cohesive silicone implants.
Inframammary Fold Positioning
Predicting the final position of the IMF is critical to determining the placement of all breast incisions, but especially the inframammary incision. This task can be challenging, as so many variables contribute to the final position of the fold. The IMF is formed by the fusion of the anterior and posterior leaves of the superficial fascia, which is intimately associated with the dermis at the lowest aspect of the inferior pole of the breast. Before surgery, the IMF is identified and marked in the sitting position. The true IMF position is actually determined by performing an IMF expansion test. The breast is grasped and autorotated inferiorly to identify the inferior extent of the attachments of the IMF ( Fig. 5 ): this is the best predictor of where the fold will naturally sit after breast augmentation. The amount of lower pole skin required and the ultimate position of the fold is a function of many factors, including the type of implant (saline versus silicone, round versus shaped), size of implant, pocket location, and the strength and stability of the soft tissue of the lower pole. The distance measured from the nipple to the true fold under maximal stretch assesses the amount of lower pole skin available to accommodate the selected implant. An acceptable standard that has been used states that an implant with a base diameter of 11 cm requires 7 cm, a base diameter of 12 cm requires 8 cm, and a base diameter of 13 requires 9 cm. A more comprehensive evaluation has been described using tissue-based planning principles. In the High Five System analysis, variables are analyzed including implant volume, patient’s base width, implant base width, anterior pulled skin stretch, and nipple to fold distance under maximal stretch. Based on the selected implant, a reference chart provides the desired nipple to fold distance, which, if longer than the measured distance, will require IMF lowering. In determining fold position, the author has found an extremely useful alternative method. This calculation takes into consideration implant selections that may fall outside the limits of appropriate tissue-based planning. The required distance from nipple to fold is calculated as a function of implant height and implant projection, which is useful for both round and shaped implants.
If the desired N-IMF distance is equal to or less than the measured N-IMF distance, the fold does not require lowering. The distance can be adjusted based on expectation for lower pole stretch postoperatively. This observation has become increasingly important as more textured round and shaped implants are being used. It is important to recognize that IMF lowering is less often required when placing a smooth silicone implant, especially if higher-profile or larger-sized implants are used secondary to lower pole stretch over time. However, when placing textured implants, IMF lowering may be required more often than smooth implants, owing to less lower pole stretch and inferior implant descent created by the frictional component or adherence of the texture in the implant pocket. Likewise, shaped implants are not only textured but also have a greater volume of a more cohesive gel present in the lower pole of the implant, thus requiring more lower pole skin to accommodate the implant. Box 2 identifies some implant and soft-tissue characteristics that may be associated with a greater need to lower the IMF because of the lesser postoperative stretching of the lower pole.
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Textured implants
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Cohesive implants
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Shaped implants
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Silicone versus saline implants
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Lower profile implants
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Smaller implants
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Tight, firm breast skin
Inframammary Incision
The inframammary incision is the most commonly used, owing to its direct access and visualization of the pocket with the least injury to surrounding structures. After determining the IMF position (either the native true fold position or the planned lowered position), a paramedian line is drawn through the center of the breast and bisects the newly drawn IMF. The incision’s medial extent begins 1 cm medial to the paramedian line and extends laterally for the appropriate distance, as previously described ( Fig. 6 ). The incision is made with a #15 blade through the skin to the mid-dermis. Dissection is then carried out with electrocautery through the skin and subcutaneous tissue, beveling upward while rotating the breast off of the chest wall. Once dissection has been carried superiorly for 1 cm, the dissection is carried through the superficial fascia and toward the lateral pectoral border deep on the chest wall. This beveling maneuver preserves a small cuff of superficial fascia at the incision, which ensures the fold is not inadvertently lowered and also provides a cuff of fascia that will prove useful during closure ( Fig. 7 ).
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