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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
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N. Bhorkar
a
for negative aspiration of blood, the drug is injected.
Conrmation of correct placement of the drug can be
ascertained by observation of back ow of drug through
the needle on disconnecting the syringe from it.
3. Open technique: In this technique the surgeon can inltrate the drug directly when abdominal ap has been
raised. The drug should be inltrated as laterally as possible on both sides by passing the needle through already
exposed EO (external oblique muscle) and a giveaway is
felt after needle enters TA (transversus abdominis) plane.
3.2.5 Posterior Approach forTAP Block
More recently it has been advocated to deposit the drug as
b
posterior as possible in the TAP plane close to the point
where transverse abdominus muscle tapers off to end on top
of the quadratus lumborum muscle (QL). Recent studies
have shown that this approach gives superior analgesia for
the lower abdomen as compared to the classic lateral
approach. This block is very similar to quadratus lumborum
block type 1 (QL 1).
c
Fig. 3.8 (a) Showing the various muscle planes as seen on ultrasound.
(b) The shadow of the needle as marked by arrows as it approaches the
plane of injection. (c) Local anaesthesia (LA) being injected in the
plane between the Internal oblique as well as the Transversalis
Abdominis muscles
and then second loss of resistance as it passes through
internal oblique muscle. At this point the needle point is
resting in the transverse abdominal plane and after testing
3.2.5.1 Technique forPosterior Approach forTAP
block or QL 1 Block
This block can be given only with the help of ultrasound.
First the probe is placed in the same position as for lateral
approach for the TAP block and the three abdominal muscles
are identied. Then the probe is moved more posterior following the TA muscle till it tapers off posteriorly on top of
the QL muscle. A needle is passed in this plane targeting the
junction of TA and QL and 15–20ml of drug is deposited in
this plane (Fig.3.9).
3.2.6 Subcostal TAP Block
This block is meant to cover the supra umbilical area of the
abdomen innervated by the T6 to T10 segments. This
involves injection of drug in the TAP plane in the subcostal
area just lateral to the rectus abdominis muscle (RA). This is
most ideal for midline incisions of the upper abdomen and
gives relatively poor coverage in the lateral aspect of the
upper abdomen.
USG Technique: The USG probe is rst placed over the
midline and linea alba is identied and then the probe is
moved laterally over the RA muscle and then further laterally till the EO, IO, and TA muscles are identied. EO and IO
join together to form anterior rectus sheath while the TA
muscles continues medially to form posterior rectus sheath
which is seen as a double line structure and the moving
abdominal contents can be identied below it. The probe is
positioned at the junction of TA and the RA and the needle is
3 Regional Blocks forPeri andPost-operative Analgesia
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Fig. 3.9 The target point for the posterior approach of TAP block is
shown by the red arrow
a
b
31
Blind technique: In this technique a slightly blunt needle
is introduced in the subcostal area just medial to the anterior
axillary line perpendicular to the skin and drug is injected
after a second giveaway is felt as the needle passes through
the TA muscle.
By performing TAP block in four quadrants gives very
satisfactory pain relief for all surgeries on the anterior
abdominal wall. One may choose quadrants to be blocked
depending on the surgical incision and dissection area.
3.2.7 Erector Spinae Block (ES Block)
This newest entrant to the group of tissue plane blocks was
rst described in 2017 and has fast become very popular
among the Anaesthesiologists. The Erector spinae (ES) are a
group of muscles that lie over the vertebrae of the spine all
the way from the neck to the sacrum. Hence it can be performed at any level of the spine as desired. This block is
performed by injecting the local anaesthetic solution in the
plane between the transverse process of the vertebra and the
erector spinae muscle overlying it. The drug injected in this
space has been found to spread towards paravertebral space.
This effectively blocks anterior as well as lateral branches of
the intercostal nerves giving sensory blockade in the front as
well as on the back. For this reason it has also been called a
“surrogate” para vertebral block. Thirty milliliter of injected
drug in the upper thoracic level at T5 tends to cover four segments above and below while in lower thoracic level at T10
covers three segments above and below and in the lumber
level at L3 it covers two segments in either direction. This is
best suited in cases which involve either surgery on the back
or in a procedure involving surgery on the back as well as
front of the abdomen like circumferential liposuction or lift.
Major advantages of this block are
Fig. 3.10 (a) The target point for the subcostal TAP block is shown in
red. (b) Inltration of the local anaesthesia visible along the solid and
dashed arrows
introduced in this plane from medial to lateral direction slitting open the TA plane. About 15–20ml of local anaesthetic
drug is injected (Fig.3.10).
1. It can be given potentially at any level from cervical to
lumber vertebrae.
2. Single injection gives excellent sensory blockade several
segments above as well as below on the injected side.
3. It is relatively far easier than epidural or paravertebral
block.
4. It is far safer as the end point for the needle insertion is
transverse process of the vertebra.
5. It can be given in sitting, lateral or even prone position.
Technique: This block can be performed using USG guidance or by a blind technique.
While undertaking this procedure under USG guidance
one can use either linear or curvilinear probe for the purpose.
The probe is positioned in the para sagittal orientation about
3 cm from the desired vertebral spinous process and the
transverse process is identied as a at bony structure. In the
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N. Bhorkar
to manage acute and chronic pain in the Thoraco-abdominal
and Mammary area specially after surgery and trauma. These
techniques are used as part of multimodal approach to relieving pain after surgery. Moreover, with more cosmetic surgeries being performed under local anaesthesia and sedation,
ability to use these blocks will go a long way in providing a
pain free intra and postoperative period with the added benet of early discharge. Not all techniques are risk free and
benecial specially when done blind but the efcacy of these
ultrasound-guided truncal blocks are surely benecial and
would become the standard of care.
Fig. 3.11 Local anaesthesia uid being injected and shown to raise the
erector spinae muscle off the transverse process
upper chest there are three muscles, namely trapezius, rhomboid major, and ES overlying the transverse process where as
below T7 only Rhomboid and ES are seen. Needle is introduced either in plane or out of plane technique till it reaches
the edge of the surface of the transverse process and 30ml of
drug is deposited in this plane to lift the ES muscle away
from it. One can even place a catheter in this space for continued pain management (Fig.3.11).
In the blind technique the desired vertebral level is identied. Spinous process of the desired vertebral level is felt and
marked. Two markings are made at 2.5 cm lateral to this
mark on either side and the needle is inserted perpendicular
to the skin at these lateral marks and advanced till it hits the
transverse process. The drug is deposited on the surface of
the transverse process on either side to achieve bilateral
block.
3.3 Conclusion
With the increased use of guided procedures specially the
ultrasound for various regional procedures including anaesthesia, the treating physicians had received additional tools
Further Reading
Araco A, Pooney J, Memmo L, Gravante G.The transversus abdominis
plane block for body contouring abdominoplasty with ank liposuction. Plast Reconstr Surg. 2010;125(4):181e–2e. https://doi.
org/10.1097/PRS.0b013e3181d45ec8.
Blanco R.The ‘pecs block’: a novel technique for providing analge-
sia after breast surgery. Anaesthesia. 2011;66(9):847–8. https://doi.
org/10.1111/j.1365- 2044.2011.06838.x.
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound descrip-
tion of Pecs II (modied Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59(9):470–5. https://doi.
org/10.1016/j.redar.2012.07.003.
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane
block: a novel ultrasound-guided thoracic wall nerve block.
Anaesthesia. 2013;68(11):1107–13. https://doi.org/10.1111/
anae.12344. Epub 2013 Aug 7.
Forero M, Adhikary SD, Lopez H, etal. The erector spinae plane block:
a novel analgesic technique in thoracic neuropathic pain. Reg
Anesth Pain Med. 2016;41:621–7.
Kot P, etal. The erector spinae plane block: a narrative review. Korean
J Anesthesiol. 2019;72(3):209–20. Published online 2019 Mar 19.
https://doi.org/10.4097/kja.d.19.00012.
Nag DS, Sahu S, Samaddar DP.Adjuvants to local anesthetics: current
understanding and future trends Amlan Swain. World J Clin Cases.
2017;5(8):307–23.
Tran DQ, Bravo D, Leurcharusmee P, Neal JM.Transversus abdominis
plane block: a narrative review. Anesthesiology. 2019;131:1166–90.
Part II
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Breast Augmentation
The Science ofChoosing aBreast
https://t.me/medicina_free
Implant
AnupDhir andNoopurBansal
4.1 Evolution ofBreast Implants
A breast implant is a prosthesis used to change the size,
shape, and contour of a person’s breast. In reconstructive
plastic surgery, breast implants can be placed to restore a
natural look of breast following a mastectomy, to correct
congenital defects and deformities of the chest wall or cosmetically, to enlarge the appearance of the breast through
breast augmentation surgery.
Surgeons have been trying to enlarge breasts since the
1890s. At that time, doctors injected parafn wax into the
breasts to enlarge them. This practice resulted in infections,
migration of the wax to other parts of the body, and hard
lumps in the breasts. Still, parafn wax injections for breast
augmentation were used for almost 30 years.
In the 1940s, women started having liquid silicone oil injected
into their breasts. This was another trial that ended in grave error.
The liquid silicone migrated all over the body, causing granulomas (small areas of inammation in tissue due to injury). Some
A. Dhir (*) · N. Bansal
Indraprastha Apollo Hospital, New Delhi, India
e-mail: dr@anupdhir.com
women also developed chronic inammation and organ damage
as a result of these injections. The side effects were so bad that
the FDA had to ban all liquid silicone injections.
The rst silicone-lled implants were developed in 1961,
and were marketed in 1963. These breast implants consisted
of a shell made of silicone elastomer or other material and
were lled with silicone liquid. The shell kept the silicone in
one place and helped create a breast like shape, something
the injections were not always able to do. Saline-lled breast
implants soon followed.
However, the results of breast implants often looked
unnatural and many women developed capsular contracture
(scar tissue around the implant), a side effect still prevalent
today. The next generation of implants were made with polyurethane foam shells, in an effort to reduce the risk of capsular contracture, but these were later found to break down into
known carcinogens in animals.
Breast implants were originally categorized as Class II
(Devices for which additional measures such as performance
standards, post-market surveillance studies, and/or consumer
education are needed to control risks) devices, but were recategorized as Class III (Devices with poorly established or
questionable safety proles. The manufacturer of a Class III
device has to conduct additional studies to show it is safe and
effective before it can be marketed) in 1988 after reports
about adverse reactions.
In the 1970s and 1980s, implant makers came up with
silicone-lled implants that had thinner shells. These
implants looked more natural but were more likely to rupture
and leak. It was discovered in 1980s that the silicone gel was
leaking out of the implant shells. The gel migrated into the
pocket containing the implant and, occasionally, into other
areas of the body. Many women with these implants seemed
to develop autoimmune diseases and connective tissue diseases such as lupus and arthritis.
The controversy went on for years with different groups
and different studies voicing different opinions and coming
down on different sides. In 1991, FDA opted not to approve
4
© 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_4
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A. Dhir and N. Bansal
the implants after manufacturers failed to provide information on its safety and effectiveness.
Instead, in January 1992, the FDA called for a voluntary
moratorium on the sale and use of silicone breast implants.
Later that year, the agency lifted the moratorium, but stated
that silicone gel-lled breast implants should be available only
for women seeking breast reconstruction after breast cancer
treatment or revision of an existing breast implant. Access to
silicone gel-lled breast implants was restricted for 14 years.
During this time, saline-lled breast implants were marketed with no interruption. They were not widely used until
the FDA cracked down on silicone implants. In 1999, FDA
approved saline-lled implants from Mentor Corporation
and McGhan Medical.
Also, in 1999, the Institute of Medicine concluded that silicone breast implants may be responsible for localized problems
such as hardening or scarring of breast tissue, but they do not
cause systemic diseases such as lupus or rheumatoid arthritis.
In November 2006, the FDA approved the sale of two
brands of silicone-lled breast implants; Inamed
®
SiliconeFilled Breast Implants by Allergan and Mentor MemoryGel™
Silicone Gel Filled Breast Implants by Mentor Corporation.
In 2011, 5 years after the re-approval of silicone gel-lled
breast implants, the FDA released an interim safety report
that said these implants remain relatively safe, but were not
meant to last a lifetime.
In 2012, the FDA gave its nod to Sientra’s portfolio of
Silimed-brand silicone gel breast implants. Three form- stable,
highly cohesive silicone-gel lled breast implants are now
approved for use in the USA.These implants have been nicknamed “gummy bear” implants because their thickness comes
close to that of the gel candies. The main benet of gummy bear
implants is that the gel does not migrate if the implant ruptures.
Today, there are three types of breast implants commonly
used
1. saline implant lled with sterile saline solution.
2. silicone implant lled with viscous silicone gel.
3. structured implants using nested elastomer silicone shells
and two saline lled lumen.
4.2 Saline Implants
Saline breast implants are lled with sterile saline during
the augmentation procedure. Should the implant shell leak,
a saline implant will collapse and the saline will be
absorbed and naturally expelled by the body. The technical
goal of saline implant technology is a physically less invasive surgical technique for emplacing an empty breast
implant device through a smaller surgical incision (Arion
1965).
When compared to the results achieved with a silicone-
gel breast implant, the saline implant can yield acceptable
results, of increased breast-size, smoother hemispherecontour, and realistic texture; yet, it is likelier to cause cosmetic problems, such as the rippling and the wrinkling of the
breast-envelope skin, accelerated lower breast pole stretch,
and technical problems, such as the presence of the implant
being noticeable to the eye and to the touch. The occurrence
of such cosmetic problems is likelier in the case of the
woman with very little breast tissue, and in the case of the
woman who requires post-mastectomy breast reconstruction; thus, the silicone gel implant is the technically superior
prosthetic device for breast augmentation, and for breast
reconstruction. In the case of the woman with much breast
tissue, for whom submuscular emplacement is the recommended surgical approach, saline breast implants can produce an esthetic result much like that afforded by silicone
breast implants, albeit with greater implant palpability
(Eisenberg 2009).
4.2.1 Placement ofaSaline Breast Implant
Saline breast implant can be placed in the subglandular, subfacial or submuscular pocket through any of the known
access incisions namely inframammary, peri-areolar, trans
axillary or trans umbilical (Fig.4.1).
4.2.2 Indications forSaline Breast Implant
A fourth type of implant, composite (or alternativecomposite) implants, have largely been discontinued. These
types featured llers such as soy oil and polypropylene
string. Other discontinued materials include ox cartilage,
Terylene wool, ground rubber, silastic rubber, and teonsilicone prostheses (Zannis 2017).
1. Patients having atleast B cup volume of breast tissue with
minimal or no ptosis.
2. When previously placed saline implants have to be
replaced.
3. Patients who have strong antipathy to use of silicone gel
implants.
ab
cd
4 The Science ofChoosing aBreast Implant
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37
ef
Fig. 4.1 (a) Saline breast implant seen before placement in the implant
pocket. (b, c) The Implant is folded in the form of a tube taking care that
it has to easily unfurl when inated with saline. (d) The folded implant
being placed in the pocket through a very small incision. (e) The
implant being hyperinated to achieve hemostasis by tamponade. (f)
The tube used for the ination of the implant is pulled and the selfsealing valve is checked for any leakage followed by closure of the
pocket in layers
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4.3 Silicone Gel Implants
As a medical device technology, there are ve generations of
silicone breast implant, each dened by common modelmanufacturing techniques.
4.3.1 First Generation
The Cronin–Gerow Implant, prosthesis model 1963, was a
silicone rubber envelope-sac, shaped like a teardrop, which
was lled with viscous silicone-gel. To reduce the rotation of
the emplaced breast implant upon the chest wall, the model
1963 prosthesis was afxed to the implant pocket with a
fastener-patch, made of Dacron material (Polyethylene terephthalate), which was attached to the rear of the breast
implant shell (Cronin and Gerow 1963).
4.3.2 Second Generation
In the 1970s, manufacturers presented the second generation
of breast implant prostheses that featured functional developments and esthetic improvements to the technology:
• the rst technological developments were a thinner-gauge
device shell, and a ller gel of low-cohesion silicone,
which improved the functionality and the verisimilitude
(size, appearance, and texture) of the silicone-gel breast
implant. Yet, in clinical practice, second-generation breast
implants proved fragile, and suffered greater incidences
of shell rupture, and of ller leakage (“silicone gel bleed”)
through the intact device shell.
• the second technological development was a polyurethane foam coating for the shell of the breast implant
(Fig.4.2); the coating reduced the incidence of capsular
A. Dhir and N. Bansal
Fig. 4.3 Image showing the double lumen implant usually used for
breast reconstruction as a single stage
contracture, by causing an inammatory reaction that
impeded the formation of a capsule of brous collagen
tissue around the breast implant. Nevertheless, despite
that prophylactic measure, the medical use of
polyurethane- coated breast implants was briey discontinued, because of the potential health-risk posed by
2,4-toluenediamine (TDA), a carcinogenic by-product of
the chemical breakdown of the polyurethane foam coating of the breast implant (Luu etal. 1998).
• The third technological development was the double
lumen breast implant device (Fig.4.3), a double-cavity
prosthesis composed of a silicone breast implant contained within a saline breast implant. The two-fold, technical goal was:
– the cosmetic benets of silicone gel (the inner lumen)
enclosed in saline solution (the outer lumen);
– a breast implant device the volume of which is post-
operatively adjustable. Nevertheless, the more complex design of the double lumen breast implant suffered
a device-failure rate greater than that of single-lumen
breast implants.
Fig. 4.2 Second generation breast implant having the polyurethane
foam shell
4.3.3 Third andFourth Generations
In the 1980s, the models of the Third and of the Fourth generations of breast implant devices were sequential advances
in manufacturing technology, such as elastomer coated shells
that decreased gel bleed (ller leakage), and a thicker
(increased-cohesion) ller gel. The tapered models of breast
implant have a uniformly textured surface, which reduces the
rotation of the prosthesis within the implant pocket; the
round models of breast implant are available in smoothsurface- and textured-surface types.
4 The Science ofChoosing aBreast Implant
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Fig. 4.4 Fifth generation implants in various shapes and textures
4.3.4 Fifth Generation
Since the mid-1990s, the fth generation of silicone-gel
breast implant is made of a high strength, highly cohesive
silicone gel that mostly eliminates the occurrences of ller
leakage (“silicone gel bleed”) and of the migration of the
silicone ller from the implant pocket to elsewhere in the
woman’s body. These implants are commonly referred to as
“gummy bear breast implants” for their rm, pliant consistency, which is similar to gummy candies (Fig.4.4).
39
4.4 Structured Implants
Structured implants were approved by the FDA and Health
Canada in 2014 as a third form of breast implant (Nichter
etal. 2018). Structured implants incorporate both saline and
silicone gel implant technology. The ller is only saline solution in case of rupture and has a natural feel like silicone gel
implants (American Society of Plastic Surgeons n.d.). The
implant uses an internal structure which consists of a series
of nested shells that support the upper pole with the two
lumen being lled with only saline. The implant is inserted
empty and then lled once in place which requires less of an
incision than pre-lled implants. If one of the lumens of the
structured implant ruptures, it leaks and empties. The other
lumen remains intact and the implant only partially deates,
allowing for ease of explant and replacement (Fig.4.5).
Fig. 4.5 Shows the difference in projection of the three types of
implants
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4.5 Breast Tissue Expanders
Breast reconstruction may be performed after mastectomy,
to rebuild injured or congenitally deformed breasts, or as part
of gender reassignment surgery. As part of the reconstruction
process, a breast tissue expander may be used to stretch the
patient’s tissue for the insertion of an implant or the patient’s
own tissue. Tissue expanders are like thick-walled silicone
balloons, come in different sizes and shapes, and may have a
smooth or textured outer surface. They are implanted under
the breast skin, tissue, or chest muscle, and are regulated by
the FDA as medical devices. In immediate reconstruction,
the expander is inserted immediately following mastectomy.
For patients who choose delayed reconstruction, the expander
is implanted in a separate surgery months or years later.
Once the surgical incision is healed, the tissue expander
is “inated” during the course of weeks to months. Ination
may be through a series of saline solution injections at the
health care provider’s ofce, or through a patient-controlled
device that releases carbon dioxide gas into the expander.
Because expanders are temporary medical devices, an
expander is not intended to remain in place for more than 6
months. When expansion is complete, a new surgical procedure is performed to remove the expander and insert a breast
implant or the patient’s own tissue.
There are some risks in using tissue expanders. The use of
tissue expanders may result in breast tissue injury and skin
thinning, pain, especially during saline lling, and infection.
The expander may rupture, and the site or port for saline
injection may become infected.
A. Dhir and N. Bansal
Fig. 4.6 Measuring the base of the breast to assess its width medially
from where the breast slope begins to its lateral extent
4.6 Method forImplant Size
Dertermination (Figs.4.6, 4.7, 4.8, 4.9,
and4.10)
Five clinical measurements are required:
(a) Base width of existing breast parenchyma
(b) Anterior pull skin stretch
(c) Soft tissue pinch thickness of upper pole
(d) Soft tissue pinch thickness at inframammary fold
(e) Nipple-to-inframammary fold distance under maximal
stretch
The surgeon also must estimate the existing parenchyma’s
contribution to stretched envelope ll as a percentage of nal
desired volume, and consider implant dimensions and ller
distribution and dynamics for implant selected.
Fig. 4.7 Measuring the anterior pull skin stretch using the calipers
To measure base width (Fig. 4.6), view the breast from
anteriorly and, using calipers, measure the width of the
breast parenchyma from a point medially where the breast
mound begins its upward slope to the lateral border of the
breast. The purpose of this measurement is to estimate
breast parenchyma width available to cover the implant. The
width of the breast parenchyma is slightly less than the
width of visible breast mound viewed anteriorly because of
thickness of subcutaneous tissue overlying the parenchyma
medially and laterally. It is preferable to have the parenchyma base width measurement 0.5 cm too narrow than
0.5cm too wide to best ensure adequate coverage of implant
edges medially and laterally when selecting implant width
or volume.
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