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Before After
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5.7 Case Studies: PA Incisions Used
toCorrect Complications
Case Study: Patient A: High Riding Implant
J. J. Castellano and B. C. Stephan
Fig. 5.21 Patient A presented with bilateral high riding implants. Bilateral PA incisions were made, implants temporarily removed, bilateral
inferior and lateral capsulotomies were performed. Results are shown at 12 weeks postoperatively.
Before After
5 Periareolar Breast Augmentation
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Case Study: Patient B: Bottoming Out
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Fig. 5.22 Patient B presented with severe bilateral bottoming out of
her implants. Bilateral inferior suture capsulorrhaphies (runninglocking 2-0 Ethibond), as well as superior and medial capsulotomies
were performed via PA incisions. Results are shown at 10 weeks postoperatively. Note: The patient has scoliosis.
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J. J. Castellano and B. C. Stephan
References
Peters WA, Fornasier VI. Complications from injectable materials
used for breast augmentation. Can J Plast Surg. 2009;17(3):89–96.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740603/#b1cjps17089. https://doi.org/10.1177/229255030901700305.
Ramachandran K.Breast augmentation. Indian J Plast Surg. 2008 [cited
2020 May 12];41(Suppl):S41–7. http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2825138/#CIT6.
Reece ED, Ghavami AS, Hoxworth RO, Alvarez SE, Hat DA, Brown
SP, et al. Primary breast augmentation today: a survey of current breast augmentation practice patterns. Aesthetic Surg J. 2009
[cited 2020 Apr 1];29(2):116–21. https://academic.oup.com/
asj/article- abstract/29/2/116/270212. https://doi.org/10.1016/j.
asj.2008.12.006
Walden JE.Breast augmentation. In: Aston S, Steinbrech DO, Walden
JE, editors. Aesthetic plastic surgery. 1st ed. NewYork: Elsevier;
2009. p.661–73.
Breast Augmentation: Inframammary
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Approach
JacobHaiavy
6
6.1 Introduction (Teitelbaum 2009)
Breast augmentation through the inframammary approach is
a standard against which all other techniques for breast augmentation are compared. The critical part of the breast augmentation operation is the accuracy and symmetry of the
pocket creation, and the anatomically most critical aspect of
this dissection lies at the inframammary fold. The inframammary approach unquestionably offers the greatest visualization of this area and results in the least damage to normal
tissue. The transaxillary and periareolar approaches create
trauma to tissue that is undisturbed using the inframammary
approach, and does so at the price of less visualization of the
critical aspects of the surgery.
A basic tenet of surgery understood by every surgeon is
that he/she should select the most anatomically direct
approach to the area of concern unless a different approach
avoids critical anatomical structures. The long-term shape of
the breast is dened by the symmetry achieved, the position
of the inframammary fold and overall position of the implant
in relation to the nipple areola complex, and the most critical
aspect of this dissection lies at the inframammary fold.
6.2 Clinical Assessment
As with any technique, a detailed history, physical examination, and measurements should be taken to help guide the
physician and the patient with proper implants selection.
During the physical examination the patient’s general body
shape and relation between upper torso, hips, and existing
breast should be observed. Skin thickness, quality, and elasticity and presence of striae should be noted. Breast size,
Supplementary Information The online version contains supplementary material available at
J. Haiavy (*)
Rancho Cucamonga, CA, USA
https://doi.org/10.1007/978- 981- 99- 3726- 4_6.
shape, proportion, consistency, and symmetry should be
assessed. The position of nipples and inframammary crease
are noted. The presence of any breast lumps, retracted nipple
or abnormal nipple discharge should be noted and investigated. Chest wall musculature is also evaluated and considered in planning the position of the implants. In addition, the
thoracic cage shape and contour can signicantly affect the
position of the implants and symmetry (Bostwick III 2020).
In our practice, we take the following breast measurements
(Figs.6.1 and 6.2) to help plan out the proper implant selection and placement:
1. Patient’s Band size
2. Patient’s Bust size
3. Sternal notch to each nipple
4. Inter-nipple distance
5. Breast width
6. Upper pole thickness
7. Inframammary fold to nipple distance
During the physical examination, asymmetries should be
notied to the patient and documented. In our experience it
is rare to nd a patient who is perfectly symmetrical. Most
patients exhibit some degree of asymmetry but they are
unaware of it prior to surgery but after the placement of
implants these asymmetries may be magnied and bothersome to the patient. Therefore, the consultation and physical
examination are an important educational opportunity for a
successful outcome and a satised patient.
The inframammary fold (IMF) is an important landmark
for surgical planning and it is also an indicator of ptosis
when the nipple is below the fold and in a constricted breast
when the IMF to nipple distance is short.
The inframammary approach to breast augmentation is
one of the most common ways this procedure is performed
worldwide as it provides a direct approach to the breast and
the underlying pectoralis major muscle. The IMF incision is
suitable for any patient that has a well-dened crease and it
is easily camouaged postoperatively. It is also the preferred
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_6
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Fig. 6.1 Implants under the muscle 360–390cc before and after
J. Haiavy
Fig. 6.2 (a) Measurement of band size. (b) Measurment of bust size. (c) Measurement from Sternal notch to each nipple. (d) Nipple to IMF dis-
tance. (e) Measurment of base width. (f) Measurement of upper pole thickness
ef
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c
d
Fig. 6.2 (continued)
incision for younger patients with mammary hypoplasia who
have smaller areolas or are concerned about nipple sensitivity and/or their future ability to breastfeed. The inframam-
mary incision is usually placed in the crease or if the fold
needs to be lowered, at the predicted future crease as marked
preoperatively (Nahai 2010) (Fig.6.3).
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J. Haiavy
Fig. 6.3 Inframammary submuscular silicone implants size 475 on a patient with small areolas
6.3 Procedure
6.3.1 Preop Markings
Prior to the start of operation the patient is marked in a standing position. The clavicles are marked, midline as well as
medial extent of dissection which is 1.5cm to either side of
the midline, is marked rst. Then based on the chosen
implant diameter the approximate dimension of the implant
is drawn on the breasts. In general, we try to choose implants
that t within the patient’s dimension and do not require violation of their normal anatomy. The incision is marked at the
inframammary crease in the midline or just lateral to a line
dropped from the medial areolar margin and it extends laterally 3–5cm. The entire incision needs to be hidden by the
crease. If it extends too laterally it will become visible. In
cases where the inframammary fold needs to be lowered, the
new fold is marked at the new IMF which is created based on
implant diameter (Fig.6.4).
6.3.2 Injection
As with any cosmetic surgery we recommend injection of
tumescent uid or an injection of dilute solution of anesthetic with adrenaline for hemostasis, analgesia, and anesthesia. Our solution usually contains 500 cc of Normal
Saline, 50 cc of 1% Lidocaine, 1 ampule of 1:1000
Epinephrine. About 150–200 cc in total are injected into
each breast along the incision, medial and lateral breast tis-
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Fig. 6.4 Pre op markings for the breast augmentation
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Fig. 6.6 Blunt dissection with an iconoclast
Fig. 6.5 Injection
sue, and underneath the pectoralis muscle. The medial and
lateral injections target the branches of the anteromedial and
anterolateral intercostal nerves that innervate the breast and
nipple areola complex (Bostwick III 2020) (Fig.6.5).
6.3.3 Dissection
6.3.3.1 Dual Plane Technique
A 3–5 cm incision is made in the inframammary crease
based on the pre-op markings. Dissection is carried superiorly with a cautery through the breast tissue toward the lateral inferior border of the pectoralis major muscle.
Tip: Avoid any retraction inferiorly to prevent over dissec-
tion of the lower pocket.
Blunt dissection using an Iconoclast spreader (Fig. 6.6)
and wiping with a Raytec sponge can help with identication
of the muscle border. The lateral border of the muscle is then
Fig. 6.7 Lifting the lateral border of the pectoralis muscle
grasped and elevated carefully at a 45° angle with cautery
(Fig.6.7). It is prudent to start this dissection over a rib for a
novice surgeon to prevent entering the intercostal and pleural
space inadvertently. Once the sub-pectoral space is entered,
majority of the dissection is accomplished bluntly with a nger sweep superiorly, medially, and laterally taking care to
preserve the anterolateral neurovascular bundles and following the pre-op markings. A Deaver retractor is then placed
under the pectoralis muscle and the medial-inferior bers of
the pectoralis are divided under direct vision with the cautery
until the fat under the pre-pectoral fascia is just visible. In
cases of high inframammary folds and dense breast tissue, it
is important to vertically score the fold and the tissue above
the fold, in order to allow the fold to lengthen and avoid a
double bubble deformity.
6.3.3.2 Total Submuscular Technique
In the total submuscular dissection, the dissection is carried
through the breast tissue superiorly toward a more central
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portion of the pectoralis muscle. The muscle edges are then
lifted along the direction of the bers with two Alice clamps.
With blunt or sharp dissection the submuscular plane is
entered. With blunt nger sweep the pectoralis muscle is
then lifted with the serratus anterior muscle laterally in continuity. The pocket is manually stretched prior to placement
of sizers.
6.3.4 Expansion
Expansion of the pocket with sizers allows for checking of
the dissection and symmetry as well as undertaking further
blunt dissection if required. We prefer the saline sizers manufactured by Mentor. These sizers can be lled with air or
saline to the desired implant volume to demonstrate the
accomplished breast shape. Areas that need further dissection can be marked and adjusted. Silicone sizers can be used
for the same purpose as well (Fig.6.8).
6.3.4.1 Hemostasis
Hemostasis is of utmost importance to prevent hematoma
formation and possibly capsular contracture. The edges of
the cut muscle are inspected for bleeding as well as medial
and lateral dissections and breast tissue. Any bleeding vessels are cauterized with the Bovie cautery. We usually do not
use drains for breast augmentation as it is not necessary and
it may increase patient discomfort and risk of infection
(Fig.6.9).
J. Haiavy
Fig. 6.9 Cautery dissection of muscle
6.3.4.2 Irrigation
Once the dissection and hemostasis is complete, the implant
pocket is irrigated with a triple antibiotic solution containing
50,000 units of Bacitracin, 1g of Cefazolin, and 80mg of
Gentamycin in 500cc of normal saline. A 6-year prospective
clinical study by Adams et al (2006). showed signicant
Fig. 6.8 Sizer being placed inside the pocket
Fig. 6.10 Antibiotics used for washing the breast implant pocket
reduction in capsular contracture rate as compared to premarket approval data reported by the implant manufacturers.
About 120–150cc of the antibiotic solution is used for irrigation in the pocket. The implants are also kept in their containers and bathed in the antibiotic solution prior to insertion
into the pockets as well (Fig.6.10).
6.3.5 Second Pocket Inspection
We highly recommend a second pocket inspection after the
irrigation to ensure proper hemostasis. Some of the blood
vessels that are cut during the initial dissection go into spasm
and are not immediately visible to the surgeon or the assistant. Therefore, during the second inspection after some time
has passed those vessels can be identied and cauterized
properly.
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6.3.6 Implant Placement
After further pocket irrigation the implants that were selected
are inserted using a no touch technique with the use of a funnel. Previous studies have shown reduction of bacterial load
on the implant when a funnel was used and therefore less
chance of contamination and subsequent capsular contracture (Flugstad etal. 2016). If a surgeon does not use a funnel,
it is highly recommended that the surgeon and the OR technician change their gloves prior to handling the implants
(Fig.6.11).
6.3.7 Checking forSymmetry
During the dissection the surgeon checks symmetry of the
dissection by placing the index nger of each hand in the
medial pocket and comparing the extent of dissection and
release of muscle (Fig.6.12).
Saline or silicone lled sizers can be used to check symmetry as well. After placement of the implants the patient is
made to sit upright to check for breast symmetry. In my
experience the patients judge their symmetry in order of
importance starting with superior pole fullness, nipple symmetry, and fold symmetry. Pre-op examination and education
is extremely important to having a realistic and happy patient
(Fig.6.13).
6.3.8 Closure
Closure is performed in three layers. First the fascia or deep
fat on the inferior chest wall is grasped and sutured to the
deep fat or fascia on the superior ap with 3-0 Monocryl to
prevent migration of the fold which also creates the new
inframammary fold if it has been moved lower. Next the subcutaneous tissue is approximated. Finally, the skin is closed
with running subcuticular 4-0 Monocryl suture (Fig.6.14).
Fig. 6.11 Placement of implant with no touch technique using a
funnel
Fig. 6.12 Checking the pocket for symmetrical dissection
Fig. 6.13 Patient sitting up on Table while the breast symmetry is
assessed
Fig. 6.14 IMG adhesive being applied around the closure Line
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