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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_611_Библиотеки_им_академика_М_И_Перельмана
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the pectoralis major away from the rib cage,
allowing safe division of the muscle in the direction of the bers. The surgeon can then insert a
nger and sweep the loose tissues between the
muscle and chest wall until the retractor can be
inserted completely, and then the pectoralis major
is divided along the medial lower edge and inferiorly at its origin creating a dual-plane pocket
that permits lower pole expansion by the implant.
The degree of muscle division is according to the
need for lower pole expansion to accommodate
the implant. A larger implant will require more
muscle release. The pockets are inspected for
optimal hemostasis, and once achieved, Betadine
10cc is instilled into the pocket and the opposite
breast is prepared in the same fashion. Once both
breast pockets are completed, the surgeon’s
gloves are changed and an implant is loaded into
a Keller Funnel (or similar device which allows
atraumatic implant insertion) along with tripleantibiotic solution that the implant has been
immersed in (cephalexin, gentamicin, and
clindamycin) and then the implant is instilled
into one side followed by the other and the
implant positional symmetry is assessed by
downward displacement in a caudal direction by
the surgeon’s hand. Both implants should readily
descend to the lower pole area symmetrically
(Fig.16.2). The surgical opening is then closed
with 2-0 Monocryl and temporary staples.
Fig. 16.2 A subpectoral pocket is created. Both implants
should readily descend to the lower pole area
symmetrically. The surgical opening is then closed with
2-0 Monocryl and temporary staples
R. J. Zienowicz and E. Karacaoglu
Fig. 16.3 The NAC is then marked with a cookie cutter
(38–42mm) and the north, south, east, and west meridians
are marked with methylene blue and a 25 G needle to
facilitate correct orientation of the NAC later
The NAC is then marked with a cookie cutter
(38–42mm), and the north, south, east, and west
meridians are marked with methylene blue and a
25G needle to facilitate correct orientation of the
NAC later (Fig. 16.3). Placement of a double
mark at the north (12 o’clock) position will discourage twisting of this structure, which could
compromise circulation to the NAC.The NAC is
incised with a 10 blade, and further freeing of the
edges from the surrounding skin is performed
with a needlepoint cautery. Tailor-tack stapling of
the previously marked edges is performed in a
cephalic to caudal direction, and the new IMF is
secured temporarily with a single Size 0 Maxon
suture (Fig.16.4). This tailor tacking will transform the typically attened breast into a conical
shape. The apex of the cone which has been created will then be attened by the use of a temporary purse-string suture (2-0 Monocryl) that
when tied transforms the cone into a globular
structure resembling the nal desired shape.
Additional staples may be applied until the lower
pole is at rather than curved. This attened
lower pole will round out over the ensuing postop weeks. Small breasts and thick-skinned individuals require less attening because the tissues
will not be as likely to “bottom out” postoperatively due to the smaller volumes and/or less distensible, stronger lower pole tissues. Once the
surgeon is comfortable with the symmetrical
shape of the breasts, the NACs can be marked for
inset. The patient is placed in the fully seated
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Fig. 16.4 The NAC is incised with a 10 blade and further
freeing of the edges from the surrounding skin performed
with a needle-point cautery. Tailor-tack stapling of the
previously marked edges is performed in a cephalad-tocaudad direction, and the new IMF is secured temporarily
with a single 0- Maxon suture. This tailor tacking will
transform the typically attened breast into a conical
shape
upright position. I typically request that several
OR personnel weigh in on the shape, and then the
NAC markings as several sets of eyes will help
achieve more accuracy. The NACs are marked
with a cookie cutter coated with methylene blue.
The size utilized depends on the chosen size of
the NACs previously marked and whether greater
or less skin excision is required in the central
breast area. Once the team agrees that these
markings are ideal in placement, then the patient
is reclined to the mostly supine position. The
base of the NAC marking is incised on the circular and the vertical marking at the apex of the vertical tailor-tacked closure and a single 3-0
Monocryl is subcuticularly placed to secure this
important landmark (Fig.16.5). Next, the pursestring suture is removed and the marked area is
adjusted under tension applied by the assistant in
a circular fashion by pressure applied with both
hands using methylene blue until the area is a
proper circular shape. It is then de-epithelialized,
and optimal hemostasis is achieved with the electrocautery. Extreme care must be taken to assure
that the patient’s NAC that is buried below is
safely remote to the cautery and not injured during this excision. It is then sewn with a deep subcuticular 3-0 Gore-Tex suture, which is tied down
to a smaller cookie cutter, i.e., 34–38mm with
Fig. 16.5 The NACs are marked with a cookie cutter
coated with methylene blue. The size utilized depends on
the chosen size of the NAC previously marked and
whether greater or less skin excision is required in the
central breast area. Once the team agrees that these
markings are ideal in placement, then the patient is
reclined to the mostly supine position. The base of the
NAC marking is incised on the circular and the vertical
marking at the apex of the vertical tailor-tacked closure,
and a single 3-0 Monocryl is subcuticularly placed to
secure this important landmark
Fig. 16.6 Next, the purse-string suture is removed, and
the marked area is adjusted under tension applied by the
assistant in a circular fashion by pressure applied with
both hands using methylene blue until the area is a proper
circular shape
multiple knots (Fig.16.6). The north, south, east,
and west markings are then united between the
areola and the breast skin with 5-0 nylon interrupted sutures. 5-0 Monocryl is placed between
those points and then subcuticular 4-0 Stratax
barbed suture to complete the NAC closure. The
center of the stapled vertical closure is carefully
marked with methylene blue and crosshatch
markings as well to ensure eventual accurate clo-
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R. J. Zienowicz and E. Karacaoglu
Fig. 16.7 The pillars of breast tissue as they are referred
to are then plicated with 0- Maxon buried sutures followed
by 2-0 Monocryl to skin and parenchyma and then 3-0
Monocryl to dermis and running 5-0 nylon to skin
sure. Staples are removed leaving the IMF
securely buttressed by the 0- Maxon, the marked
area is excised by tandem parallel vertical cuts,
and redundant skin is nally excised with pinpoint cautery. The pillars of breast tissue as they
are referred to are then plicated with 0- Maxon
buried sutures followed by 2-0 Monocryl to skin
and parenchyma and then 3-0 Monocryl to dermis and running 5-0 nylon to skin. The IMF is
marked; the 0- Maxon is removed; if necessary, a
short transverse incision is made 3–5cm; and the
redundant soft tissue and skin are excised and
closed with 2-0 and 3-0 Monocryl and nally 5-0
nylon to skin. If indicated, liposuction to the IMF
and lateral axillary areas is performed to rene
the contours in those areas. Tumescent solution
with epinephrine is instilled 10min before anticipated liposculpture (Fig.16.7).
16.5.3.1 Dressings
The NACs are glued with Dermabond, Mastisol,
and Steri-Strips applied to the vertical and small
horizontal incisions. Medipore tape is applied for
support and shaping in lieu of a surgical bra
(Fig.16.8).
Fig. 16.8 The NACs are glued with Dermabond,
Mastisol, and Steri-Strips applied to the vertical and small
horizontal incisions. Medipore tape is applied for support
and shaping in lieu of a surgical bra
16.6 Postoperative Care
Patients are seen at 1 week, and dressings are
changed. At week 2, vertical sutures are removed
unless there is a history of severe hypertrophic
scarring for which sutures are removed after 7days.
Any IMF sutures are removed at 3weeks post-op.
Taping with Medipore is done across all suture
lines for 3months. Medipore tape is used for shaping and support on the lateral breast and fold until
underwire bra wear is initiated after week 3.
16.7 Outcomes andPrognosis
Early scar maturation is seen at 3 months, but
scar coloration may take many months to years to
fully mature in some ethnicities.
Prognosis is typically highly satisfactory
though asymmetries will persist to varying
degrees as in nature. Patient satisfaction is high in
those with realistic expectations. The surgeon
should prepare their patients for the possibility of
revisions if indicated (Figs. 16.9, 16.10, 16.11,
and 16.12).
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Fig. 16.9 A 56-year-old woman with a history of breast
ptosis and two prior pregnancies presenting with lower
abdominal skin laxity. Procedure: This patient underwent
abdominoplasty, and CVM with subpectoral placement of
implants bilaterally. (Left) Preoperative images. (Right)
Postoperative result at a follow-up appointment at 22nd
month
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R. J. Zienowicz and E. Karacaoglu
Fig. 16.10 A 48-year-old woman with a history of breast
ptosis and breast augmentation almost 5 years ago.
Procedure: This patient underwent CVM with subpectoral
placement of implants bilaterally. (Above) Preoperative
images. (Below) Postoperative result at a follow-up
appointment at 18th month
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Fig. 16.11 A 42-year-old woman with a history of grade
3 breast ptosis. Procedure: This patient underwent CVM
with subpectoral placement of implants bilaterally. (Left)
Preoperative images. (Below) Postoperative result at a
follow-up appointment at 12th month
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R. J. Zienowicz and E. Karacaoglu
Fig. 16.12 A 38-year-old woman with a history of breast
ptosis and breast augmentation almost 9 years ago.
Procedure: This patient underwent CVM with subpectoral
16.8 Complications
Asymmetry due to:
(a) Implant malposition
(b) NAC position and size discrepancies
(c) Glandular/implant size discrepancies
16.8.1 Implant Malposition
As in breast augmentation, it is imperative that
the surgeon be certain that implant position be
assessed in the sitting position during mastopexy.
Unlike simple augmentation, the entire premise
of mastopexy is to tighten the accid lower pole
tissues to restore a youthful conguration, and
most surgeons tighten the lower pole tissues
placement of implants bilaterally. (Left) Preoperative
images. (Right) Postoperative result at a follow-up
appointment at ninth month
slightly more than is aesthetically ideal to accommodate the anticipated lower pole stretch that
occurs in the weeks to months postoperatively.
These tissues must heal, and hence the implants
within are concomitantly higher in the pocket
than they will be after a few months of settling.
This settling can unfortunately occur at different
rates resulting in visual asymmetry that can be
unsettling to the patient. Asymmetric bandeau
wear should be employed as soon as this is identied. The application of upper pole force with an
asymmetric bandeau over several weeks can
restore symmetry in most patients. This needs to
be done by the surgeon or trained staff on a
weekly basis to be sure that the process is being
carried out effectively at home. The breasts are
taped with Medipore across the incisions to support the scars and then to support the lower pole
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of the breast with proper implant position including the IMF.The breast with the superior fullness
due to higher pocket position is also taped across
the incisions for scar support. The bandeau will
apply force exclusively to the upper pole of that
breast and will via tissue expansion lead to
descent of the implant if sufcient force is applied
and if the process is initiated prior to the development of unyielding scar tissue in the lower pocket
dissection site (Fig. 16.13). If this intervention
has not resulted in the restoration of symmetry
over a 1–2-month period, then operative release
of the lower pole capsule must be considered. If
this is done, it can typically be accomplished
through a small IMF incision with rapid healing
time and minimal impact on the patient with
respect to discomfort and restriction of activities.
Alternatively, some breasts will require IMF
repositioning with pexy sutures to maintain that
position. In the case of bottoming out, this may
be adequately done in mild cases with strong
suture xation to the chest wall fascia and periosteum while more severe cases may require the
use of an ADM or absorbable devices like
GalaFLEX (Figs.16.14, 16.15, and 16.16).
16.8.2 NAC Position andSize
Discrepancies
Once nal healing has occurred in 3–6months,
any obvious irregularities will be best dealt with
by corrective surgery which may involve simple
NAC elevation maneuvers with crescent excisions to elevate an NAC or more elaborate revisions requiring central lower pole skin excision
to concurrently reshape the lower pole and elevate the NAC.
Fig. 16.13 Unlike simple augmentation, the entire premise of mastopexy is to tighten the accid lower pole tissues to restore a youthful conguration, and most surgeons
tighten the lower pole tissues slightly more than is aesthetically ideal to accommodate the anticipated lower pole
stretch that occurs in the weeks to months postoperatively.
These tissues must heal, and hence the implants within are
concomitantly higher in the pocket than they will be after
a few months of settling. This settling can unfortunately
occur at different rates resulting in visual asymmetry that
can be unsettling to the patient. Asymmetric bandeau
wear should be employed as soon as this is identied
16.8.3 Glandular/Implant Size
Discrepancies
Once postoperative swelling has subsided after
the rst 2–3 months, any persistent size difference will have to be dealt with by either implant
size changes or fat grafting or excision. Those
adjustments may require secondary mastopexy as
well.
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R. J. Zienowicz and E. Karacaoglu
Fig. 16.14 A 46-year-old woman with a history of breast
ptosis and mastopexy augmentation with periareolar
approach 8years ago. Procedure: This patient underwent
CVM with subpectoral placement of implants bilaterally.
(Left) Preoperative images. (Right) Postoperative result at
a follow-up appointment at 24th month
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Fig. 16.15 A 37-year-old woman with a history of tuberous breast deformity that underwent augmentation mastopexy 5years ago. She had her implants removed 6months
ago. Procedure: This patient underwent CVM with sub-
pectoral placement of implants bilaterally. (Left)
Preoperative images. (Right) Postoperative result at a
follow-up appointment at tenth month
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