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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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J. Aso and I. González
Key Points
Dual-plane technique is extremely useful in postmaternity patients, since it combines the advantages of both subglandular (glandular lift) and
submuscular (better coverage in the upper pole).
17.4.2 Composite Fat andImplant
Techniques
It is evident that soft-tissue coverage is a key factor in breast augmentation for long-lasting and
satisfactory results. Moreover, the presence of
adequate subcutaneous fat in a well-developed
breast will allow a safe subglandular implant
placement with its relative advantages.
Unfortunately, the majority of the patients seeking breast augmentation do not meet these criteria since they are very thin.
The composite breast augmentation is a relatively new concept, which combines fat grafting
and implants. Concerns about breast fat grafting
have currently been rejected both by oncological
and radiological long-term studies. Extra parenchymal graft is however recommended. The key
principle is that the prosthesis is used for core
volume augmentation while fat grafting is used
for global reshaping and camouaging of implant
edges (mainly in the medial-upper poles). It is
possible to use fat grafting for potentially any
variant of implant position with benets in terms
of softness and better shaping of the breast and
cleavage area.
However, we believe that the real advantages
are extending the indication of the subglandular
implant placement with less rippling and palpability risk and facilitating round implant use
avoiding malposition. If it is true that fat grafting
is not meant to signicantly increase volume and
projection, it still allows smaller implant selection, which is correlated with fewer long- term
complications.
On the other hand, very skinny patients are not
good candidates (no available donor sites) and
the technique requires adequate surgeon’s condence with fat grafting. The unpredictability of
the result is one of the principal issues; in fact,
part of the adipose graft will be reabsorbed, and
this amount would not generally exceed 50% if
lipolling is properly performed. In addition,
donor-site morbidity has to be adequately discussed with the patient [23, 24].
Fat grafting is extremely useful in revision
surgeries for rippling and palpability correction.
Patients with mild ptotic breast are less likely
to benet from this procedure since the primary
need is to enhance the implant-gland interaction
in a push-up fashion. Adding signicative fat volume (additional soft-tissue weight) in the upper
poles is in our opinion not recommendable. A
partial subpectoral position will allow adequate
implant-gland interface in the lower poles while
covering the upper poles with muscle, which is
not a gravity-susceptible structure.
17.4.3 Surgical Marking
17.4.3.1 Placement oftheIMF
andFootprint
The placement of the IMF is the most important
decision in the surgical marking. Incorrect IMF
placement may lead to bad aesthetic outcomes or
even very visible deformities.
The patient is marked in the standing upward
position with her shoulders in a relaxed position.
First, we mark her actual IMF (if there is one)
and the midline.
Since we have already chosen the implant,
based on the width and shape of it, we know the
exact measurements of it. We rst check the
width of the implant, and we add the measurement of the pinch test. The pinch test is performed
checking the fullness of the upper pole as shown
in the image. This measurement is usually 0.8–
1.2cm in thin patients.
If the implant’s width is, for example, 12cm,
we will measure 12cm+1=13cm. This is the
width we mark on the patient.
Placement ofIMF
First, we check the ARC of the implant. The ARC
is the measurement of the length of the arc
dened between the point of maximum projec-
Inframammary
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Attention
Never try to lower a very-well-dened IMF with
a gland hanging over it, since a double-fold
deformity will be created.
17.4.4 Incision Placement
Multiple surgical approaches have been described
for breast augmentation. The experience with the
inframammary, periareolar, and axillary groove
is the most studied.
7.5
Incision
site
Fig. 17.4 Positioning of the incision site: one hand lifts
the breast, stretching the lower pole to the point where the
IMF starts moving upwards. This is the correct stretching
tension to measure where the incision will be placed
8.0
fold
tion of the implant and the lowest point of it (see
Fig.17.4). Considering that the implant will be
covered by one layer of soft tissue, we add half of
the pinch test. In this example, if the arc of the
implant is 7cm, we will measure 7.5cm.
We then hold the nipple between the index and
thumb ngers and start stretching it upwards until
the previous IMF starts moving. In this point, we
measure the ARC ½ pinch test, from the nipple
down, and check whether we have to lower the
IMF or not.
Never try to lower a very-well-dened IMF
with a gland hanging over it, since a double-fold
deformity will be created. If the measure for the
length of the lower pole exceeds the patient’s
IMF fold and her fold cannot be lowered, a
smaller or more anatomical implant should be
used. In other cases, a mastopexy should be
considered.
Once the new IMF has been marked, the
height is calculated in the same fashion as the
width, and the upper limit of the implant is also
marked.
17.4.4.1 Inframammary Fold
The incision in the inframammary fold should be
placed in the new fold leaving a scar hidden by it.
Its location depends on the patient’s tissues and
the size of the prosthesis.
It allows the visualization of the entire pocket
where the breast implant will be housed and
allows to place all types of implants in a simple
way. The size of the incision is 3–5.5cm depending on the type of breast implant.
As a disadvantage, if the new groove is not
calculated correctly, it may be visible and requires
future renements.
On the other hand, it is the approach that presents a lower incidence of capsular contracture
[25, 26], greater ease of radiological follow-up of
breast cancer since the glandular anatomy is not
altered, and less alteration of the sensitivity of the
nipple-areola complex in most of the studies,
although the presence of hypoesthesia and paresthesia is frequent in the lower pole of the breast.
17.4.4.2 Hemiareolar/Periareolar
Incision
The periareolar approach is also very popular: the
incision is placed at the junction between the
areola and the skin. If the NAC is not to be
changed, an inferior hemiareolar incision is carried out. This approach allows direct access to the
gland, so it is very useful when you have to make
modications of the mammary gland. It also
allows the surgeon to reduce the size of the areola
if necessary. This technique has shown higher
rate of capsular contracture, changes the anatomy
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of the gland, and lengthens the operative time.
We tend to restrict the use of the periareolar incision for the following cases:
1. Tuberous breast.
2. Difcult IMF placement: when the placement
of the future IMF is not a straightforward
decision, the periareolar incision gives the
possibility of deciding that intraoperatively.
3. NACs requiring reduction.
4. Periareolar mastopexy
Possible disadvantages include an alteration
of the anatomy of the mammary gland because of
the need to section it in order to reach the muscular plane, the potential bacterial contamination of
the implant (contact with the glandular ducts),
and a visible scar in case of poor healing. Its use
is not advised in cases of areolas smaller than
4cm in diameter, especially if the implant to be
used is bigger than 300cc.
Most studies on the subject show a greater
incidence of capsular contracture [25, 26] than
the inframammary fold, theoretically due to a
greater contamination of the implant when it
comes into contact with the glandular ducts that
present bacterial colonization.
Also, a higher incidence of loss of sensation in
the nipple-areola complex with respect to the use
of the inframammary fold has been reported.
17.4.4.3 Transaxillary Incision
Transaxillary breast augmentation is frequently
used in the Asian population [27], as they are
prone to hypertrophic and prolonged hyperemic
scarring of the inframammary scar. It can be performed directly or through the use of an endoscope, which allows for greater visibility and
control of the structures. The main disadvantages
of this approach are the difculty for the treatment of glandular alterations and the need for a
different approach in case of postoperative
complications.
The transaxillary approach has shown greater
satisfaction in comparison with other approaches.
The incision is far from the breast and less visible
in patients with no visible IMF prior to surgery.
On the contrary, it is the approach that traditionally presents the highest incidence of capsu-
lar contracture compared to the other two [25].
However, a recent 2019 publication shows that
there are no differences between this approach
and the inframammary fold [27].
Another drawback of this approach is the difculty in correctly positioning the new IMF, which
lies distant to the site of incision. Since the patient
is positioned with her arms abducted in 90° to
access the axilla, it is quite frequent to place the
implants too high (superior malposition), especially if the surgeon is less experienced.
Regarding the alteration of the sensitivity,
there are not many studies that collect the alterations in the sensitivity after the transaxillary
increase. Some authors such as Tebbetts describe
the appearance of paresthesia on the inner side of
the arm during the rst 3–4months and attribute
it to damage during dissection in their rst
patients, but with the modication of the surgical
technique, future injuries were avoided.
17.4.5 Our Preferred Technique
The author’s preferred technique for breast augmentation is through an inframammary fold
(IMF) approach and the placement of the implant
in a dual plane using a technique similar to that
described by Tebbetts [28].
17.4.5.1 Preoperative Care
Prior to surgery, a preoperative study with blood
count, coagulation tests for liver and renal function, as well as an EKG should be performed on
all patients. A pre-anesthetic consultation is also
performed.
17.4.5.2 Technique
General anesthesia was performed in all patients.
The use of muscle relaxants is mandatory, with
the submuscular dissection being more difcult
otherwise.
The patient is placed supine with arms
attached to the body. They place four sterile
cloths having painted the entire thorax of the
patient (including neck and umbilicus) with
povidone-iodine.
In a systematic way, two adherent lms are
placed in the nipple-areola complex to avoid con-
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tamination of the implants with colonizing bacteria of the nipple ducts [29, 30].
An incision is performed in the inframammary fold previously designed, and dissection of
the subpectoral pocket with electrocautery is
done being very careful with hemostasis. The
direction of this dissection is oblique (upwards),
not perpendicular to the skin, in order to minimize the risk of bottoming out (inferior malposition of the implant) (Fig.17.5a and b).
The pectoralis major is sectioned in its lower
and medial portion leaving a small muscle remnant of the caudal insert of approximately 1cm.
This muscle cuff also prevents caudal malposition of the implant.
Depending on the height of the nipple-areola
complex (NAC), prepectoral dissection is carried
out prior to the subpectoral pocket dissection
(Fig.17.3):
– NAC in place: no prepectoral plane dissection
(dual plane I)
– NAC slightly low but clearly in a higher posi-
tion in comparison with the IMF: prepectoral
dissection of the lower pole without reaching
the NAC (dual plane II) (Fig.17.6)
Fig. 17.5 Submammary approach: The dissection is carried out in an oblique fashion, never facing straight down to the
muscular plane, as one risks damaging the IMF ligaments and causing a bottoming out of the implant
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Fig. 17.6
positioned NACs. Note the “lift effect” the implant provides
Breast augmentation with anatomical implants (dual plane II) in a patient with non-ptotic but slightly low-
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Fig. 17.6 (continued)
– NAC positioned at the IMF: prepectoral dis-
section to the level of the upper pole of the
nipple (dual plane III) (Fig.17.7)
The patients presenting a NAC below the IMF
will require an augmentation mastopexy.
The lateral dissection of the pocket is limited
and somehow some millimeters smaller than previously marked. In our experience, the loose lateral tissue is prone to make the pocket larger in
this area, creating lateral malposition in the
implant in the following months, especially when
the patient is in the supine position.
Once the pocket is completed, a very thorough
revision of the hemostasis is carried out and subsequently the pocket is washed with a dilution of
10% povidone-iodine, gentamicin, and cefazolin
[31, 32].
The entire team changes gloves, and the thorax is repainted with povidone-iodine. The main
surgeon is the only one who touches the implant,
and the assistant opens the incision with a leaet
previously washed with povidone-iodine so that
the surgeon places the breast implant.
After implant placement, the subcutaneous
cell tissue is closed with a continuous 2/0 Vicryl
suture and a 4/0 Monocryl intradermal suture.
In cases where the IMF has been lowered
(especially if the implant is larger than 250cc), a
continuous suture with Ethibond 2/0 is carried
out, between the supercial fascia of the caudal
aspect of the wound and the deep fascia of the
chest wall.
The wounds are covered with Steri-Strip, and
an orthopedic bra is placed on the patient in the
operating room. No drains or bandages are used.
Key Points
The pectoralis major is sectioned in its lower and
medial portion leaving a small muscle remnant of
the caudal insert of approximately 1 cm. This
muscle cuff also prevents caudal malposition of
the implant.
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Fig. 17.7
Breast augmentation with round implants. Upper pole is fuller, and the NAC slightly corrects downwards
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Fig. 17.7 (continued)
Key Points
The patients presenting a NAC below the IMF
will require an augmentation mastopexy.
17.5 Postoperative Care
All our patients undergoing augmentation mammoplasty were admitted to the hospital for a minimum period of 6 h of nursing and intravenous
treatment. We prefer to keep them admitted overnight if possible. After the surgery, we instruct
the patient to keep the wounds dry and to use
orthopedic bra for 30days, 24h. Antibiotic prophylactic treatment with amoxicillin- clavulanic
acid 500mg/125mg for 5days [33, 34] and analgesic treatment with paracetamol 1 g and metamizole 575 mg every 8 h for a week are
prescribed.
Only passive movements with the arms are
recommended during the rst week. Abduction
of the shoulder over 90° is not advisable during
the rst days.
If anatomical implants were used, a thoracic
band is prescribed from day 1 for at least 2weeks
to avoid rotation. Most rotation events occur in
the rst 2weeks after surgery.
The rst postoperative visit is scheduled
1week after surgery by performing an ultrasound
scan on all patients to assess the absence of
seroma, hematoma, or rotation of the implants in
the immediate postoperative period. In this consultation, the patient is instructed to take care of
the scar with hydration and taping.
Subsequently, follow-up consultations are carried out in the following fashion: 1 month,
3months, 6months, and 1year after surgery, performing ultrasound control in all of them.
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17.6 Outcomes andPrognosis
The immediate recovery period of a breast augmentation is usually short and well tolerated.
3–5days of breast/chest pain is usually expected.
Bigger implants or very tight soft tissues of the
breast will often generate more pain in the postoperative phase.
Swelling of the breast, lateral aspects of the
chest wall, and abdomen is to be expected in the
rst week.
Patients are advised to halt any physical exercise for a month. After those rst 30days, the
patient is reevaluated in the ofce and an ultrasound exam is carried out. If the ndings are normal, she can start exercising her lower limbs,
without using her upper limbs.
After 3months, more demanding exercise can
be carried out: running, swimming, etc.
The patient is instructed to wear a brassiere day
and night for at least 6months. Failure to do so will
increase the probabilities of implant malposition. A
decubitus position while sleeping should be
advised for the rst month, whenever possible.
17.7 Complications
Breast augmentation with implants is considered
a high-satisfactory surgery. However, the patient
should be carefully informed and educated about
the possible short- and long-term drawbacks and
complications related to the surgical procedure
and the implant of a prosthetic device [35–40].
17.7.1 Surgical Complications
17.7.1.1 Hematoma
Preventive coagulation of intercostal and mammary perforators together with accurate hemostasis is key to reduce the incidence of hematomas,
which should stay under 1%. In case of hematoma, surgical revision is mandatory. Hematomas
likely occur in the rst 48h after surgery, but late
hematomas even after years are possible. Those
are mainly correlated to a traumatic event and
may be clinically evident or not. Many studies
have demonstrated the correlation between persistent hematomas and seromas with capsular
contractures [41].
17.7.1.2 Infection andExposure
Sterility and contamination precautions are
extremely important to prevent both infections
and capsular contracture. Acute infection is
uncommon (<2%) but still represents a dreaded
event for both patient and surgeon. In our practice, mild infections are initially treated conservatively with administration of large-spectrum
antibiotics and echography to discharge suspect
collections (which are eventually aspirated and
analyzed). In cases of no response, more aggressive clinical presentation (fever >38, diffusely
inamed breast), or implant exposure, temporary
implant removal with capsulectomy is performed.
After infection resolution and tissue recovery, a
new implant is inserted.
17.7.1.3 Seroma
Seroma formation is generally a benign event that
occurs as a consequence of an inammatory process resulting from infection, subclinical contamination of implant, mechanical trauma or idiopathic
disease.
Early Seromas
It is dened as a seroma occurring within
12months from the surgery. Despite many different proposed owcharts, the approach we adopt
is based on personal clinical experience. In case
of seroma detection within the rst 6 months
from surgery and >20 cc ultrasound estimated
volume, the uid is aspirated and sent for microscopy and culture. Conservative treatment is
started empirically with large-spectrum antibiotics, NSAID, and corticosteroid. In cases of no
resolution after 1 week or relapse, we recommend capsulectomy and implant exchange. We
consider surgery also in case of positive microbiology with apparent seroma resolution due to the
high risk of secondary capsular contraction.
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Late Seroma
The rising concern about late seromas lies in the
fact that most anaplastic large-cell lymphoma
(ALCL) associated with breast implant will have
a late seroma as its rst clinical sign. However, it
is important to note that most late seromas are not
related in any way to an ALCL. The treatment
protocol in this case requires the additional cytologic study of the aspirate as described in the following section.
Reported late seroma rates range from 0 to 5%
based on the shell characteristics, with the aggressively textured silicon surface being mostly
involved.
17.7.1.4 Capsular Contraction
Capsular contraction is by far the most frequent
complication, reaching rates of over 20% at
10years in some case series. It consists of the
excessive contraction of the brous capsule created physiologically from the body around the
implant with the attempt of isolating it. This
capsule is usually thin and soft; however, for
several reasons, this capsule may contract on the
implant becoming thick and hard. Capsular contraction occurs with different intensities dened
as per the Baker classication: Grade I—normal
soft capsule, Grade II—little hardening of the
capsule detectable only by palpation, Grade
III—visible contracture and palpable hardening
of the capsule, and Grade IV—painful, visible
contraction and palpable hardening of the
capsule.
There is still a partial understanding of the etiology of capsular contraction. Smooth implant
surface has been proved to promote un unfavorable broblast organization with high concentration of collagen bers ending in high risk of
contraction. On the other hand, textured surface
is thought to disrupt the broblast linear organization resulting in irregular vector forces and
ultimately in softer and thinner capsule. Recent
studies demonstrated that textured implant favors
biolm formation due to its higher surface/area
ratio. Consequently, we understood that the bacterial biolm etiology of capsular contraction has
indeed a weaker correlation if compared to tex-
turization itself. Common drawbacks of highly
textured silicone implant are, on the other hand,
the increased incidence of double capsule and
seroma formation. Subglandular implant position
has also been reported to be at higher risk for capsular contraction if compared to partial submuscular and submuscular placement. The question
and relative odds remain somehow controversial
for heterogeneity of the studies and lack of evidence based on fth-generation breast implants
and up-to-date contamination-reducing surgery.
Available studies suggest an overall risk of capsular contraction in textured silicone implant
around 5%.
We recommend surgery in case of Grade III
and IV contraction consisting of complete capsulectomy (whenever possible) and implant
exchange. Polyurethane coating has been proven
to prevent capsular contraction both in primary
augmentation and breast reconstruction. For personal preference, we do not routinely use acellular dermal matrix (ADM), despite good reported
outcomes for capsular contraction as secondary
prevention. We consider the possible risk of
infection and the associated cost as highly inconvenient for a patient who already suffered reoperation for aesthetic purposes.
17.7.1.5 Device Rupture
The fth generation of breast implant has a signicantly increased longevity compared to previous generations. Failure has been reported at
<6-year study.
Nevertheless, the rupture of a silicone gel
implant is a fairly common event, and the patient
should be informed (especially if she is young)
that there is a high degree of probability of this
event over the years. The incidence of this problem depends greatly on the age of the implant,
type of implant, and history of trauma. The diagnosis may be made by physical examination,
ultrasonography, or MRI.MRI is considered the
gold standard when assessing the integrity of an
implant. The treatment of an implant rupture will
require exchange of implant and many times capsulectomy, when the capsule is also affected or an
extracapsular rupture is detected.
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