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J. Haiavy

Fig. 6.26 Before and after 7_45 year old with postpartum atrophy underwent IM subpectoral placement of silicone implants Natrelle Inspira full prole 560cc

6 Breast Augmentation: Inframammary Approach

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Fig. 6.27 Before and after 8_50-year-old woman with postpartum atrophy underwent placement of silicone implants Mentor Moderate Plus Prole Right 375cc, Left 350cc

References

Adams WP Jr. Capsular contracture: what is it? What causes it? How

can it be prevented and managed? Clin Plast Surg. 2009;36:119–26.

Adams WP Jr, etal. Enhancing patient outcomes in aesthetic and recon-

structive breast surgery using triple antibiotic breast irrigation: Six year prospective clinical study. Plast Reconstr Surg J. 2006;118:46S.

Berry MG, Cucchiara V, Davies DM. Breast augmentation: part

II. Adverse capsular contracture. J Plast Reconstr Aesthet Surg. 2010;63(12):2098–107.

Bostwick J III. Plastic and reconstructive breast surgery. 4th ed. St.

Louis: Quality Medical Publishing; 2020.

Flugstad NA, Pozner JN, Baxter RA, Creasman C, Egrari S, Martin S,

Messa CA III, Oliva A, Schlesinger LS, Kortesis BG.Does implant insertion with a funnel decrease capsular contracture? A preliminary report. Aesthet Surg J. 2016;36(5):550.

Haiavy J, Florin W.Management of capsular contracture: non- surgical

and surgical options. In: Duscher D, Shiffman MA, editors. Regenerative medicine and plastic surgery-elements, research concepts and emerging technologies. Berlin: Springer; 2019.

Karu TI, Kolyakov SF.Exact action spectra for cellular responses rel-

evant to phototherapy. Photomed Laser Surg. 2005;23(4):355–61.

Massiha H.Augmentation in ptotic and densely glandular breasts: pre-

vention, treatment, and classication of double-bubble deformity. Ann Plast Surg. 2000;44(2):143–6.

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J. Haiavy

Nahai F.The art of aestheitc surgery principles and techniques. 2nd ed.

St. Louis: Quality Medical Publishing; 2010.

Omar MT, Shaheen AA, Zafar H.A systematic review of the effect of

low-level laser therapy in the management of breast cancer-related lymphedema. Support Care Cancer. 2012;20:2977–84.

Pastore D, Greco M, petragallo VA, Passarella S. Increase in ←H+/e-

ratio of the cytochrome c oxidase reaction in mitochondria irradiated with helium-neon laser. Biochem Mol Biol Int. 1994;34(4):817–26.

Pereira AN, Eduardo P, Matson E, Marques MM.Effect of low-power

laser irradiation on cell growth and procollagen synthesis of cultured broblasts. Laser Surg Med. 2002;31:263–7.

Silviera PC, Silva LA, Fraga DB, Freitas TP, Streck EL, Pinho

R. Evaluation of mitochondria respiratory chain activity in muscle healing by low-level laser therapy. J Photochem photobiol. 2009;95(2):89–92.

Teitelbaum S. The inframammary approach to breast augmenta-

tion. Clin Plast Surg. 2009;36(1):33–43. https://doi.org/10.1016/j.

cps.2008.08.008.

Wan D, Rohrich RJ. Revisiting the management of capsular contrac-

ture in breast augmentation: a systemic review. Plast Reconstr Surg. 2016;137(3):826–41.

Transaxillary Mammoplasty

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JoeDanMetcalf andGregoryLaurence

7.1 Introduction

• Axillary incision was rst published by Hoehler in 1973

• From 1977 to 1993 all transaxillary procedures were done using blind dissection

• 1991—endoscopic assisted transaxillary breast augmentation was rst described

Breast augmentation surgery involves the placement of

breast implants into the breast pocket in order to achieve a desired enlargement. In the transaxillary breast augmentation procedure, the breast implants are placed in such a way that visible scarring is limited and concealed.

7.2 Conditions toConsider When

Choosing aTransaxillary Approach forBreast Augmentation

• Breast position on the chest wall,

• Breast ptosis,

• Plane chosen for placement of breast implant (submuscular, subfascial, or subglandular),

• Characteristics of areola and inframammary crease,

• Secondary procedures and the desire to not have a scar on the breast.

Supplementary Information The online version contains supplementary material available at

J. D. Metcalf (*) Parkway Medical, Oklahoma City, OK, USA

G. Laurence ( Germantown Aesthetics, Germantown, TN, USA

https://doi.org/10.1007/978- 981- 99- 3726- 4_7.

7.3 Advantages oftheAxillary Incision

• The advantage of the location of this skin incision is that the patients can begin immediate massaging to optimize symmetry without fear of incision separation.

• Incision dehiscence and infections are rare, and if either occurs with a transaxillary incision, it is unlikely to impact the environment of the peri-prosthetic space.

• The transaxillary technique may not be used as a preference for patients with ptotic, asymmetric, or tubular breasts.

7.4 Transaxillary Breast Augmentation

Procedure

The patient presented here has a mild chest malformation called pectus carinatum—the bony chest projects forward more than normal. This causes the implant to fall toward the side. This “lateral ow” will minimize the cleavage. A placement of the implant above the pectoralis muscle will preserve some of the cleavage, since an under-the-muscle placement can add an inuence of additional lateral ow. Another advantage of subfascial location is that the implant will not likely move with muscle contraction (animation defect).

In the video you can see the surgeon move from each side

of the surgical table to the other undertaking both the sides together. The implant sizer is repeatedly removed and replaced. This allows precise location of the nal pocket. This incremental pocket expansion prevents over-dissection. After the pocket is formed a saline or silicone gel implant is placed in the pocket.

The rst step of any breast augmentation surgery includes

taking pre-operative photographs in the standing position so that an assessment is made with regard to the breast symmetry, position of the nipple areola complex as well as the position of the inframammary fold.

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This procedure is undertaken using general anesthesia usually with quick-acting muscle relaxation or with local tumescent anesthesia and sedation. The patient is positioned in such a way that the arms are kept at 90°, with adequate space above and below the shoulders so that the surgeon can maneuver himself if he is using endoscopic assistance. All equipment (including the cautery, suction, and endoscopic tower) are placed at the foot of the bed to allow for simple transition from the rst side to the second during the procedure

J. D. Metcalf and G. Laurence

7.5 Steps oftheProcedure

7.5.1 Skin Preparation andMarking

oftheIncision

Preparation of skin with alcohol in all areas to receive skin markings will reduce the chance that marking will be removed with the surgeon’s choice of skin preparation.

Midline marking is undertaken using sternal notch, xiphoid, umbilicus, and labial commissure as reference (Fig.7.1).

Marking of the anticipated new inframammary fold (IMF) location is undertaken based on the size of the Implant. For a 400cc implant this will be approximately 7 1/2cm from the nipple in a non-ptotic breast. This will be measured and marked with a patient in sitting position.

Anatomical location of the clavicle and 2-ngerbreadths cephalad from the clavicle provides invaluable intraoperative reference markings for the incision (Fig.7.2).

The incision for the axillary implant placement is initiated by rst placing a mark in the axillary apex. A 4–6cm straight or serpentine proposed incision is marked along lines of tension (RSTL’s—Resting Skin Tension Lines) in the axillary dome. This mark is extended anteriorly, usually in an existing skin crease, toward the lateral and posterior aspects of the pectoralis major muscle (PMM), but terminating just short of this anatomic landmark. Extending the inci-

Fig. 7.2 Marking the position of the clavicle and the incision in relation to the clavicle

Fig. 7.3 A serpentine incision line has been marked at the axillary apex with the anterior incision mark ending at the lateral border of the pectoralis major muscle

sion line beyond the lateral border of PMM will result in visibility of scar with the patients’ hands by her side which is exactly what this procedure is designed to avoid. From the initial mark in the axillary apex, the incision is then continued in a posterior direction, angled superiorly to avoid visibility when the patient places her hands on her waist (Fig.7.3).

Final skin surgical prep should be alcohol-free so as to not

remove markings.

Fig. 7.1 Marking of the midline being undertaken

7.5.2 Surgical Draping withStrict Aseptic Technique andInltration ofTumescent Fluid

Inltration of tumescent uid was done using a cannula. 200–500cc saline with 0.1% lidocaine and 1cc Epinephrine/ liter was injected in each breast into the subdermal and prepectoral planes using the tumescent technique. Figure 7.4 demonstrates the inltration site used to anesthetize the dome of the axilla and the lateral/cephalad breast area. Inltration using a long infusion cannula from a caudal (umbilical) entry site can also be considered.

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Fig. 7.4 Inltration of the incision site as well as the breast pocket being undertaken using the tumescent uid

Fig. 7.6 A heavy monolament or silk suture is placed at the anterior end of the incision line to minimize any tears in the incision

Fig. 7.5 Zig zag incision being made along the marked incision line

7.5.3 Making theAxillary Skin Incision

The incision can be made using a No. 15 blade or a radio cautery. It is important that the incision extends to just the subcutaneous tissue (Fig.7.5).

Next a wide (loose), supercial 0 or 2 gure-of-eight monolament or silk suture is placed at the anterior end of axillary incision (lateral border of Pectoralis major) to minimize anterior skin extension (tear) during skin retraction and placement of Implant (Fig.7.6).

7.5.4 Dissection andExposure oftheLateral

Border ofthePectoralis Major Muscle

Dissection is then performed anteriorly in an immediate subcutaneous plane, toward the lateral edge of the Pectoralis major muscle. Traction of anterior ap along with retraction using a Cat’s paw retractor or a four-prong skin hook is undertaken to facilitate dissection in the immediate subdermal plane using a Metzenbaum scissors (Fig.7.7). The thick-

Fig. 7.7 Metzenbaum scissors being used to bluntly dissect the soft tissue

ness of the skin ap should be continually checked using a non-dominant hand to avoid both dissection into the axillary contents and buttonholing and damaging the skin itself.

The lateral edge of the pectoralis muscle is exposed by using a combination of army/navy retraction, nger palpation of muscle, and sponge stick dissection (Fig.7.8). This step of the dissection has to be done carefully so as to prevent injury to the Intercostobrachial nerve which lies in the oor of the dissection area.

7.5.5 Fasciotomy oftheDeep Layer

ofthePectoral Fascia

At this stage lighted retractor if present is placed and an incision into the deep fascia covering the pectoralis major is per-

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J. D. Metcalf and G. Laurence

Fig. 7.10 Finger sweep technique being used to create a plane between the Pectoralis major and minor muscle

Fig. 7.8 Soft tissue dissection has exposed the fascia covering the pectoralis major muscle

Fig. 7.9 Fasciotomy being undertaken at the posterior lateral border of the pectoralis major muscle to expose the interpectoral space

formed under direct vision. This can be undertaken using a cautery or a dissecting scissor into the subpectoral space on the posterior aspect of the lateral edge of the muscle. This will help the surgeon gain access into the interpectoral plane between the PMM (above) and the pectoralis minor muscle (Fig.7.9).

7.5.6 Dissection ofthePlane Between thePectoral Muscles

Conservative nger dissection of the plane between the fascia on the anterior surface of the pectoralis minor muscle and that on the posterior surface of the pectoralis major muscle is carried out. A nger sweep technique is performed to widen the entry point into the subpectoral space if desired (Fig.7.10), but this can also be accomplished under direct

vision with a sharp technique using a cautery and an endoscope.

Conrmation of correct plane of dissection is undertaken by using a Deaver retraction and/ or Endoscope. Extension of plane of dissection in undertaken using a nger dissection followed by placement of the paddle dissector (Fig.7.11a–c).

Conservative extension of breast pocket is now undertaken using the Agris Dingman dissector, dissecting rst from medial to lateral, and then from lateral to medial. Care should be taken to avoid the supercial dermal plexus in order to fully preserve the viability of the subcutaneous tissue. The tip of theAgris Dingman dissector should be deected slightly deep being very careful about not allowing the tip to enter the intercostal space. The relatively sharp cutting edge of the dissector help is breaking any adhesions that may be present between the muscle and the ribs as well as stripping the inferior origins of the pectoralis major muscle (Fig.7.12).

7.5.7 Placement ofSizer andSizer Dissection

The breast sizer is placed in the pocket created (Fig.7.13) and is inated to the planned breast implant volume. During air insufation and lling of the sizer, care should be given to protect the medial and inferior expansion of the pocket using the surgeon’s hands to direct the sizer dissection superiorly and laterally. The sizer itself will extend the pocket into the desired direction if the surgeon’s hands forcibly preserve and prevent expansion of the sizer in the appropriate quadrant(s). Additional volume can be added to the sizer in order to address distensible soft tissue attachments. The sizer when left in place for a period of time will also cause hemostasis due to compression of the vessels (Fig.7.14).

Care should be given to minimize instrumentation of the lateral pocket. Anything lateral to the 4 o’clock (left breast) and 8 o’ clock on right breast will risk neurologic sensory compromise of the nipple areola complex.

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Fig. 7.11 (a) Placement of a Deaver retractor helps visualize the dissection plane. (b) Finger dissection helps in an atraumatic blunt dissection of the pocket which is created in a submuscular plane. (c) The Paddle dissector is used to strip the muscle over its costal origins

Fig. 7.13 Inatable sizer being placed in the pocket to complete the

Fig. 7.12 The Agris Dingman dissector being used to create a pocket

and strip the origin of the Pectoralis major muscle inferiorly

Over-dissection of the medial aspect of the pocket has to be minimized so as to prevent herniation of the implant on the medial aspect causing rippling (saline implant) or feeling of the implant edge. In rare cases the two pockets may communicate in the midline causing symmastia.

The differences in the two breasts due to bony or soft tis-

dissection, check for adequacy of the pocket, control bleeding as well as check for any restriction in expansion

breast implants which have volume differences from side to side.

Intraoperative breast-shaping specially when a sizer or an implant is in place should be done using blunt instruments or nger dissection, sharp dissection using scissors or cautery should be avoided (Fig.7.15).

sue chest wall asymmetries may be minimized with use of

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J. D. Metcalf and G. Laurence

Fig. 7.14 Breast sizer being over inated to check for adequacy of pocket dissection as well as hemostasis

Fig. 7.15 Blunt dissection using Fingers or blunt instruments is undertaken with the sizer in place

7.5.8 Checking forSymmetry ofthePocket

Once both pockets have been dissected, sizers are placed and symmetry of the breasts is checked. Make certain that each breast has a similar ratio of upper pole to lower pole and/or each upper pole has a similar relationship to the sub-clavicle markings which has to be the most important consideration. Also check for the centering of the NAC (nipple areola complex) on the dome of the implant (Fig.7.16).

The shape of each breast is a lesser consideration, because the skin and other soft tissue components are likely to normalize as the tissue is susceptible to stretch.

7.5.9 Replacement ofSizers

withtheImplants

The sizer is now removed by deation and the pocket irrigated with saline, betadine, and/or triple antibiotic solution. If endoscope is available, then an endoscopy is done and pocket is checked for any active bleeding and/or any tissue tags preventing complete pocket dissection.

Fig. 7.16 Checking for breast symmetry following placement of sizers

Fig. 7.17 Placement of Silicon implant by the “Funnel” technique

Strict hemostasis is critical. Chest wall cautery is

contraindicated.

Insertion of saline or gel implant using digital-assist or “funnel” technique is now undertaken. If the digital-assist technique is used, then do not forget to change the gloves into a powder free variety (Fig.7.17).

7.5.10 Closure ofIncision

The incision is closed with appropriate intracuticular, interrupted, running horizontal mattress, or surgical clips depending on the surgeon’s choice. Even a single layer of sutures are adequate to hold the suture line but to prevent any scar widening it is suggested to close the skin incisions in two layers with a longer lasting absorbable suture as the rst layer.

Appropriate post-surgical garment include:

Comfortable adjustable strap athletic bra Surgical garment Lateral breast-shaper

7 Transaxillary Mammoplasty

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Fig. 7.18 An adjustable bra with a circumferential strap to reduce axillary hematoma

Always use a strap circumferentially-placed over the upper pole, 4″ compression band to minimize axillary hematoma and minimize cephalad implant displacement (Fig.7.18).

Pearls and Pitfalls Transaxillary

Pearls

1. A post-op 4-in. soft band across the upper pole may pre-

vent post-operative hematoma and cephalad displacement of the implant.

2. The need for a lighted retractor to visualize the surgical

pocket will be needed in less than 1% of cases.

3. Massage technique of choice may be employed on the

rst post-operative day since an associated skin incision separation is not a risk.

4. If a previous subpectoral case is being revised to subfascial, the axillary incision and pocket creation should be made before the explantation.

5. Bleeding rarely requires electrocautery or ligation. Placement of an over-expanded sizer for 8–10min normally provides excellent hemostasis.

6. The deep pectoralis fascia is variable in thickness, but always thins as it transitions to more caudad.

Pitfalls

1. The initial blunt dissection should include the tips of the metzenbaum scissors in a supercial plane pointed up to avoid disruption of aberrant long thoracic artery.

2. The pocket will initially be developed with nger dissection. The use of a deaver retractor, headlight, and early visual inspection will insure against the creation of a false subglandular pocket.

3. Subfascial placements may result in a more obvious degree of cleavage, and might be highly considered for patients with pectus carinatum. The risk of symmastia might be the same as subpectoral. An appropriate postoperative garment should be available. The KMI Metcalf garment or “ThongBra” are recommended options.

4. Consider getting written consent that an added incision might be necessary. It is difcult to access the pocket in order to suture a rare arterial bleed, and the correction of over-dissection may also require an IMF or areolar access.