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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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tered, one moderately wide spread of the scissors is made
directly anterior to the muscle. This, combined with proper
retraction, exposes the anterior aspect of the pectoralis major
(Fig.5.6).
The surgeon will then digitally palpate within the area of
dissection and reconrm that dissection will be further carried
down directly over the center aspect of the rib. Cautery is used
to incise through the pectoralis major in the direction of the
muscle bers to create a 2-cm long incision through the pectoralis and down to the periosteum of the rib. Once the white of
the rib periosteum is seen, the surgeon will use a nger to
bluntly clear off the periosteum from any residual tissue. This
ensures that the following step will proceed smoothly.
Once the periosteum is cleared, an Allis clamp is used to
grasp the superior aspect of the incised muscle and is used to
lift the muscle gently in the anterior direction (Fig.5.7). The
Fig. 5.6 Exposure of the pectoralis major muscle
Fig. 5.7 Lifting the superior edge of the pectoralis major
J. J. Castellano and B. C. Stephan
Fig. 5.8 Bluntly dissecting the pocket
surgeon’s fth (smallest) digit is then carefully placed under
the pectoralis major and used to start creating the implant
pocket from a superior-medial direction to laterally. The surgeon will then change to the second or third digit to complete
the blunt dissection. Blunt dissection is gently performed
from just lateral to the sternum (avoiding the perforating vessels), superiorly to the rst rib, then inferiorly and laterally.
Great care must be taken when dissecting inferiorly; this is
the portion of the procedure that requires the most delicacy
and attention to detail (Fig.5.8).
Inferior blunt dissection is carried out from medially to
laterally, releasing the pectoralis major from its inferior
attachments while only carrying the dissection through and
not beyond these attachments (do not bluntly dissect through
connective tissue and adipose beyond the inferior aspect of
the pectoralis major). This technique will preserve connective tissue which helps to dene the inframammary fold and
will keep the implant from bottoming out in the future. If a
totally submuscular implant location is desired, do not fully
dissect the inferior aspect of the pectoralis major from its
inferior attachments. While this may be desirable in certain
patient cases, the surgeon risks a high riding postoperative
implant. Therefore, we often completely separate the inferior
aspect of the pectoralis major from underlying connective
tissue, effectively forming a dual-plane pocket. Dissection is
then carried laterally, freeing major bands; however, care
must be exercised to not over-dissect laterally. If the lateral
aspect of the implant pocket is over dissected, the implant
will move laterally and displace the NAC abnormally medially. When rst starting to perform this procedure, it is
advised to perform only light lateral dissection and complete
the lateral (and possibly inferior) dissection once breast
pocket sizers are placed.
After gentle blunt dissection for creation of the implant
pocket is completed, place a Deaver retractor deeper to the
pectoralis major in a superior orientation and a smaller
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Deaver inferiorly. Inspect the pocket and ensure hemostasis.
Once hemostasis is achieved, breast sizers (Fig. 5.9) are
placed within the pocket, complete evacuation of all residual
air within the sizers is ensured by negative pressure creation
using an attached syringe, and then the sizers are inated to
the desired cubic centimeters (to mimic the nal breast
implant size). Proper size and symmetry are ensured by
examining the patient’s breasts from the side, foot of the
table (Fig. 5.10), and by raising the back of the operating
table (place the patient in “beach chair” position). During
this process, the surgeon can determine exactly which size
breast implants to place and make size adjustments to each
side to ensure nal symmetry for patients with different
bilateral breast volumes preoperatively. After determining
the appearance of bilateral symmetry and size of implants to
be used, the nal implant selection is made. Over-inate the
breast sizers by approximately 150 cc of air for a few
moments while the breast implants are being prepared to
ensure no constrictive inferior, medial, or lateral bands are
left in place. Afterwards, deate to desired breast implant
size and check for symmetry once again. Once symmetry is
achieved, and implant size has been determined, deate, and
remove the sizers.
The created pockets are irrigated with triple antibiotic
solution (40mg gentamycin or tobramycin, 1g cefazolin, and
1gm vancomycin mixed with 500cc normal saline), hemostasis is ensured once again, and a 14-guage Angiocatheter
(Vein-o) is pierced through the skin at the more medial
aspect of the inframammary fold (IMF) with the end of the
catheter placed within the pocket (for later instillation of local
anesthetic) (Fig.5.11). Breast implants are placed within the
pockets via the Keller (or similar) funnel using a no-touch
technique (Fig.5.12), the surgeon’s gloves are then changed
to prevent contamination, and proper implant orientation is
ensured by digital inspection. Symmetry and appropriate
esthetic results are ensured via inspection from the sides, bot-
Fig. 5.9 Breast sizer
Fig. 5.10 Ensuring proper size of the breast with sizers in place
Fig. 5.11 Placement of angiocatheter for infusion of local anesthetic
Fig. 5.12 Placement of the implant via a funnel using a ‘no touch’
technique
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tom of the table, and with the patient in beach chair position
(Fig.5.13). The fascia of the pectoralis major is closed with
interrupted 4-0 Monocryl, the deep subcutaneous tissue is
closed with interrupted 4-0 Monocryl, the deep dermis
approximated with interrupted buried 4-0 Monocryl, and the
skin approximated with a running intradermal 5-0 Monocryl
(entering and exiting through the skin, without knots, to avoid
potential postoperative spitting sutures) (Fig. 5.14). Then
20cc of 0.25% bupivacaine with epinephrine is injected into
each pocket via the Angiocatheters and the Angiocatheters
are removed. A liquid adhesive (Mastisol or AllKare) and
paper tapes (Steri-Strips) are applied (Fig. 5.15). Finally,
gauze pads are placed over the incision sites, a surgical bra is
donned, the patient is reversed from anesthesia and transported to the recovery room.
J. J. Castellano and B. C. Stephan
Fig. 5.14 Closure of the incision
Fig. 5.13 Final inspection of the breasts done in various views after
implant placement
Fig. 5.15 Bupivacaine with epinephrine is instilled; dressings are
placed
apparent.
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5.3 Postoperative Care
Postoperative breast augmentation patients are normally provided 7 days of cephalexin (500mg PO QID), 3–5 days of
cyclobenzaprine (10mg PO q8h to prevent muscle spasms),
a course of tapering methylprednisolone (Medrol Dose pack),
3 days of oxycodone-acetaminophen (5/325mg tablets, 1–2
Tabs PO q4 h for breakthrough pain), a stool softener, and
ondansetron ODT tablets (4mg sublingually q6h for nausea).
Patients are also instructed to take oral arnica to help prevent
bruising. In general, patients are to avoid NSAIDs and other
blood thinners for 14 days after surgery and may use plain
acetaminophen once no longer using the oxycodone-acetaminophen combination. Patients are warned not to take more
than four grams of acetaminophen daily, and potentially less
if the patient has any hepatic comorbidities.
Fig. 5.16 Breast exercises
Patientspress/pinch upwards on the
bottomofthe implant. Patients mayuse
their opposite hand if needed.
Patients are seen back in the clinic on the rst postoperative day and then at 1, 2, 6, and 10 weeks after surgery. The
patient can shower on the second postoperative day and the
surgical bra should be worn nearly consistently for the rst
6 postoperative weeks. Breast “exercises” are started on the
rst postoperative day; these exercises are continued and
tailored to the individual’s needs for at least the rst 10
postoperative weeks (Fig. 5.16). The paper tapes (SteriStrips) are removed 2 weeks after the surgery and the
patient is instructed to place a thin layer of 100% silicone
gel over the incisions twice daily for 10–12 weeks. The
importance of avoiding all sunlight to the incisions for up
to 1 year is stressed. In regard to the incision, generally
excellent results are obtained by 10 weeks postoperatively
(Fig.5.17).
Patientspress their breaststogether.
Patientspress/pinchdownonthe topof
theimplants. Patientsmay usetheir
opposite hand if needed.
Patients place onehandonthe topsideof
theimplant,and theother hand on the
breast tissue (not on thebottomofthe
implant). Patients are to press/pinch
downward on theimplant while the
opposite hand holds the breast tissue
steady. A bulge of theimplant on the
bottomsideofthe breast should be
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Fig. 5.17 PA incisions at 10 weeks postoperatively
J. J. Castellano and B. C. Stephan
5.4 Complications
All surgical procedures carry inherent risk. While the risk is
low overall, the primary risks/complications seen with primary breast augmentation are postoperative hematoma or
seroma, infection, changes in nipple and/or skin sensation,
spitting sutures, asymmetry, scarring, delayed or poor wound
healing, skin rippling, fat necrosis, capsular contracture,
implant rupture/fracture, and implant extrusion. Furthermore,
Anaplastic Large Cell Lymphoma has been linked to the use
of textured implants. All these complications may be minimized by careful patient selection and meticulous surgical
patient care. However, even the most experienced surgeon
will have complications now and then. See Table5.1 for a
summary regarding potential complications as well as preventative and treatment options.
Table 5.1 Surgical complications, prevention, and treatment
Complication Prevention Treatment
Hematoma Meticulous hemostasis Drainage
Seroma Meticulous hemostasis Drainage
Infection Perioperative antibiotics
Changes in
nipple/skin
sensation
Spitting
sutures
Asymmetry Careful attention to
Scarring Pre-OP patient
(IV and PO); using
triple antibiotic solution
for pocket infusion;
changing gloves prior to
palpating the implant in
the pocket; strict
adherence to sterility
Do not over dissect the
pectoralis major,
especially medially;
careful tissue handling
Bury the suture knots
well; limit to 3–4
throws per interrupted
buried deep dermal
sutures
symmetry when using
sizers, selecting the
nal implant, and prior
to nal closure
selection/guidance;
meticulous deep dermal
suture placement;
postop management as
described
Removal of implant;
drainage if necessary;
antibiotics
Sensation normally
returns; In general
“treatment” is watchful
waiting along with use of
steroids
Remove the spitting
sutures; treat as necessary
(normally only with
topical skin treatment)
After a period of watchful
waiting, evaluate for
reimplantation,
capsulotomy,
capsulorrhaphy, etc.
Silicone gel; laser
treatment; microneedling;
scar revision
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Table 5.1 (continued)
Complication Prevention Treatment
Delayed/
poor wound
healing
Skin
rippling
Bottoming
out
Capsular
contracture
Implant
rupture/
fracture
Implant
extrusion
Anaplastic
large cell
lymphoma
Pre-OP patient
selection/guidance;
avoid steroid use for
those at higher risk for
poor wound healing
Appropriate implant
selection (i.e.,
cohesivity); appropriate
inferior tissue coverage
of the implant
Do not over dissect
inferiorly
Infection control and
meticulous hemostasis
Meticulous implant
handling; use a funnel
during placement
Submuscular placement
of breast implant in
higher risk patients
(those with poor tissue
quality)
Use smooth implants
(not textured)
Watchful waiting; topical
treatment; possible scar
revision
Exchange to a more
cohesive implant
Inferior
capsulorrhaphy±superior
capsulotomy; buttress the
IMF with thick external
tape postoperatively,
normally for 1 week
Total capsulectomy with
removal and replacement
of the implants
Remove and replace the
implant(s); carefully
irrigate the pocket(s)
Removal of implant(s);
delayed reimplantation
Implant removal with
total capsulectomy (and
send tissue to pathology)
5.5 Summary
In summary, PABA is an excellent modality to safely create
excellent esthetic results for those seeking breast augmentation.
PABA uses a central point to access and develop the breast pocket,
no extra instruments are needed to develop the pocket, the location of the incision is independent of the IMF (very benecial
with patients with a high IMF), and this incision may be used to
revise nearly any complication inherent to breast augmentation
surgery. In addition, the PA incision heals extremely well.
5.5.1 Summary ofSurgical Steps
1. Measure areola diameter:
Generally, need a 3cm
diameter for PABA
2. Markings: PA (3 o’clock
to 9 o’clock at the
intersection of the areola
and normal skin), midline,
superior, inferior (planned
inferior-most extension of
the implant pocket)
3. Supine; arms abducted to
90°; prep; drapes not
pulling on the breasts
4. PA incision through the
dermis; hemostasis
5. Initially grasp the dermis
and retract with Allis
clamps; switch to
Army-Navy retractors as
dissection is carried deeper
by gently using blunt
Metzenbaum scissors in a
spreading-only fashion
6. Periodically digitally
palpate within the initial
dissection; ensure that
dissection is being carried
out directly on top of a rib
7. Once the pectoralis major
is exposed, ensure that the
next incision will remain
directly on top of the
middle of the chosen rib
8. Use cautery to incise
through the pectoralis
major all the way to the
center of the rib, following
the muscle striations;
bluntly “clean” remaining
attachments to the rib
periosteum with a nger
9. Grasp the superior edge of the
incised pectoralis major; start
blunt dissection between the
pectoralis major and underlying
structures in the medial and
superior direction; then
carefully separate the inferior
and lateral pectoralis major
attachments; switch to Deaver
retractors if necessary
10. Ensure hemostasis
11. Place a breast sizer within the
pocket and inate to the
desired size for nal implant
selection
12. Ensure symmetry and
esthetics (make nal
adjustments to the pockets and
chose the nal size for the
breast implants)
13. Over-inate the sizers by
approximately 150cc and
prepare the breast implant via
a no-touch technique on the
back table, then decrease the
sizer volume to nal desired
size
14. Deate and remove the sizers,
ensure hemostasis once again,
place the Angiocatheters (if
desired) and retract/remove
the needles, then insert the
implants using a funnel via a
no-touch technique
15. Change gloves; ensure the
implants are properly
orientated; close; apply liquid
adhesive and paper tapes;
place bupivacaine with
epinephrine within the pockets
via the Angiocatheters and
remove the Angiocatheters;
nally, place gauze pads and a
surgical bra
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J. J. Castellano and B. C. Stephan
5.5.2 Surgical Tips
• Use of headlights (vs.
lighted retractors) has
improved our operating
time and decreased the
rate of complications (i.e.,
hematomas)
• Avoid grasping the skin
with Allis clamps
• Only use blunt-sided
scissors, in a gentle
spreading fashion during
initial dissection; avoid
sharp/cautery dissection
as much as possible to
preserve any encountered
milk ducts
• Sterile breast sizers are supplied
by the major breast implant
manufacturing companies; these
companies also supply guidelines
regarding which sizer to use when
planning for a particular size and
width of implant
• Consider connecting the inatable
sizer to a three-way Luer-lock
stopcock, with the center port open
to air and the other end connected
to a 60cc Luer-lock syringe
(Fig.5.9). Evacuate all air from the
sizer by moving the stopcock
selector back and forth and pulling
on the syringe twice. Then ll the
syringe with air (stopcock shut off
on the sizer end), switch the
stopcock to shut off the open end,
inate the sizer, and repeat to ll
the sizer with the desired cubic
centimeters of air. This allows for
quick and accurate lling of the
sizer. Also, air may be added or
removed from the individual sizers,
for example, if different sizes of
implants will be needed to assure
nal symmetry
• When preparing the breast
implant, we remove the cover of
the sterile container, wash the
implant with triple antibiotic
solution, wash the internal aspect
of the funnel with triple antibiotic
solution, and place the implant
within the funnel without touching
it. Also, do not let the implant
touch the skin when inserting it
into the pocket (the end of the
funnel should be placed within the
pocket itself)
• Leave approximately
0.5–1cm of tissue
between the initial
dissection and inferior
breast skin; this will
reduce risks of rippling
and extrusion
• If creating a dual-plane
implant placement, release
all major bers between
the inferior aspect of the
pectoralis major and
underlying tissue; dissect
just through the bers and
not beyond
• The inframammary
marking is also used to
help determine the
inferior-most extent of
dissection within the
pocket; carry the inferior
dissection to where the
muscle bers release or to
the inframammary mark
placed preoperatively,
whichever is encountered
rst
• When rst starting to
perform this operation,
perform a modest amount
of inferior and lateral
dissection, place a breast
sizer within the pocket
and inate to the planned
size of the nal implant,
and then complete the
inferior and lateral
dissections; step back
from the table and place
the patient in beach chair
position to ensure
appropriate esthetics and
symmetry
• Using Angiocatheters to instill
bupivacaine with epinephrine after
closure has signicantly reduced
postoperative pain, and therefore,
decreased time in postoperative
care prior to discharge home
Before After
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5.6 Case Studies: Periareolar Breast
Augmentation (Figs.5.18, 5.19, 5.20,
5.21 and5.22)
Case Study: Patient 1
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Fig. 5.18 Patient 1: 24-year-old who underwent PABA with 425cc high prole, moderately cohesive implants placed in the submuscular plane.
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J. J. Castellano and B. C. Stephan
Case Study: Patient 2
Fig. 5.19 Patient 2: 28-year-old who underwent PABA with 325cc moderate projection, moderately cohesive implants placed in dual-plane
pockets.
Before After
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Case Study: Patient 3
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Fig. 5.20 Patient 3: 33-year-old with preoperative asymmetry who
desired breast augmentation. She underwent PABA with 485cc implant
on the left and 445cc implant on the right. Both implants were of mod-
erate projection and moderate cohesivity, placed in a dual-plane pocket.
This illustrates the importance of using breast sizers to aid postoperative symmetry.
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