Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
.pdf
72
ab
https://t.me/medicina_free
Fig. 6.15 (a) Hematoma bruising 2. (b) Hematoma bruising 1
6.3.9 Complications
The risks of IMF breast augmentation are just like any other
method of augmentation:
Bleeding/Hematoma, infection, deation or rupture, capsular contracture, asymmetry, double bubble, bottoming out,
Implant exposure/extrusion. We will discuss a few of those
here.
J. Haiavy
6.3.9.1 Hematoma
Bleeding within the pocket can happen immediately after
surgery or delayed within the rst 2–3 weeks post- operatively.
In either case, the patient usually presents with pain and unilateral swelling (Fig.6.15a, b). The incidence is reported to
be 0.9–3% and it can cause the implant can be displaced
superiorly. With signicant bleeding patients will become
symptomatic with tachycardia and shortness of breath. With
any signicant bleeding we recommend that the patient be
taken back to the OR for evacuation of the hematoma, cleaning of pocket, hemostasis, drain placement and possibly
implant exchange. Hematoma can increase the risk for the
Fig. 6.16 Celluma device on patient
development of capsular contracture. We treat our patients
prophylactically with conservative measures such as Milk
Thistle 1000 mg BID and Celluma light therapy daily for
6–12 weeks posthematoma evacuation (Haiavy and Florin
2019) (Fig.6.16).
than later and also perform a capsulectomy. Cultures and
sensitivity testing needs to be done and patient treated
appropriately. If unusual bacteria are isolated such as
Mycobacterium, or methicillin-resistant Staphylococcus
aureus, an infectious disease doctor needs to be consulted
6.3.9.2 Infection
Best treatment for infection is prevention. In our practice
for proper course and length of antibiotic treatment.
(Fig.6.17a, b).
every patient gets 2g of Ancef (Cefazolin) or 600mg of
Clindamycin intravenous prior to the patient going under
anesthesia. In addition, good sterile technique at the time of
surgery, minimal handling of the implants, use of funnel for
placement of implants and triple antibiotic irrigation has all
shown to reduce the chance of infection (Adams Jr. et al.
2006; Flugstad et al. 2016). If the surgeon suspects an
infection it is better to remove the implant sooner rather
6.3.9.3 Capsular Contracture
Capsular contracture is one of the most common reasons for
dissatisfaction with breast augmentation. The incidence of
capsular contracture can vary from 5 to 15% after primary
augmentation and can rise to 50% after correction of recur-
rent capsular contracture (Adams Jr. 2009; Wan and Rohrich
2016).
ab
6 Breast Augmentation: Inframammary Approach
https://t.me/medicina_free
Fig. 6.17 (a) Infection of breast implant pocket. (b) Grossly infected implant
73
Capsular contracture is a chronic inammatory response
that can be due to bacterial contamination or biolm over the
implant, excessive bleeding in the pocket, silicone gel leakage, and or traumatic technique. As with other complications
prevention is key. Treatment can be conservative or surgical
(Berry etal. 2010).
Our current conservative protocol is initiated at the rst
sign of any contracture and it consists of anti-inammatory
herbal medicine Milk Thistle 1000mg BID or prescription
medicine Montelukast 10mg one tab at night, in combination with Celluma light therapy, which consists of infrared,
red, and blue light. The red and the infrared wavelengths
have been shown to have antioxidative and anti- inammatory
effects (Pereira etal. 2002; Silviera etal. 2009; Pastore etal.
1994; Karu and Kolyakov 2005; Omar et al. 2012). This
combination is used daily for 6–12 weeks. If the patient is
unresponsive or fails conservative management, then surgical management is recommended. Surgical management
consists of total or sub-total capsulectomy, implant exchange
and possibly conversion of pocket (for subglandular implants
only). The patient is placed on the conservative protocol after
the surgery again with Milk Thistle and Celluma light therapy. Our current 1-year follow-up data shows 76% success in
preventing another surgery with conservative management
only and 96% success post capsulectomy and implant
exchange followed by the conservative therapy (Fig.6.18a–c).
6.3.10 Double Bubble Deformity
Double bubble deformity can occur in patients with short
IMF to nipple distance, tuberous breasts, and dense breast
tissue that may not conform to the implant. When lowering
the fold the surgeon has to be careful in scoring the old fold
to allow for proper expansion and settling into the new fold.
There are two types of double bubble deformity as described
by Massiha (2000).
Type I is when implant location is high or correct but the
breast tissue hangs over the implant. Type II is when implant
location is low or correct but breast tissue is sitting separately and superior to the implant.
Treatment depends on the presentation and location of the
deformity in relation to breast tissue and implant. In Type I
the surgeon can either try to score the old fold by performing
vertical releases along the old fold to allow the breast tissue
to spread and conform to the implant. Another option is to
change the implant pocket entirely from retro-pectoral to
pre-pectoral. In Type II it is better to raise the fold by performing a capsulorrhaphy and may even need to perform a
mastopexy. If breast tissue is very dense and resistant the
surgeon may need to excise some breast tissue as well
(Fig.6.19a, b).
74
https://t.me/medicina_free
J. Haiavy
a
b
c
Fig. 6.18 (a) Patient with right breast capsular contracture treated with
non-surgical protocol of 24 LED treatments and milk thistle 1000mg
BID. (b) Patient with right breast capsular contracture treated with cap-
sulectomy implant exchange followed by celluma light therapy and
milk thistle. (c) Encapsulated implants removed with the en bloc
capsulectomy
6 Breast Augmentation: Inframammary Approach
https://t.me/medicina_free
ab
Fig. 6.19 (a) Double Bubble appearance. (b) After Double Bubble correction by making vertical releases along the old inframammary fold and
also excising some breast tissue
75
6.4 Results After Augmentation Through
theInframammary Incision (Before
andAfter Figs.6.20, 6.21, 6.22, 6.23,
6.24, 6.25, 6.26, and6.27)
Pearls and Pitfalls
1. Draw the dimensions of the implant and the intended
pocket with patient standing up prior to surgery
2. Use tumescent injection to minimize bleeding, hydro dis-
sect and provide analgesia.
3. Avoid excessive retraction and dissection inferiorly as it
may result in excessive lowering of the inframammary
fold
4. Start muscle elevation over a rib and elevate muscle at
45° to avoid inadvertent intrapleural penetration
5. Inspect the pocket twice and perform careful hemostasis
6. Use “no touch” technique for placement of implant to
minimize implant contamination
76
https://t.me/medicina_free
J. Haiavy
Fig. 6.20 Before and after 1_29-years-old woman with mammary hypoplasia underwent IM subpectoral placement of silicone implants Natrelle
Inspira full prole 450cc
6 Breast Augmentation: Inframammary Approach
https://t.me/medicina_free
77
Fig. 6.21 Before and after 2_32-year-old woman with postpartum atrophy underwent IM subpectoral placement of silicone implants Mentor
Moderate Plus prole implants 550cc copy
78
https://t.me/medicina_free
J. Haiavy
Fig. 6.22 Before and after 2_34 year old with postpartum atrophy underwent IM Subpectoral placement of silicone implants Natrelle Inspira full
prole 605cc copy
6 Breast Augmentation: Inframammary Approach
https://t.me/medicina_free
79
Fig. 6.23 Before and after 4_36 year old with postpartum atrophy underwent IM subpectoral placement silicone implants Natrelle full prole
400cc copy
80
https://t.me/medicina_free
J. Haiavy
Fig. 6.24 Before and after 5_39-year-old woman with mammary hypoplasia underwent IM subpectoral placement of Natrelle 475cc high prole
silicone implants
6 Breast Augmentation: Inframammary Approach
https://t.me/medicina_free
81
Fig. 6.25 Before and after 6_42-years-old woman with postpartum atrophy underwent Inframammary subpectoral placement of silicone implants
Mentor 400cc High prole
Соседние файлы в папке Библиотека им академика М.И. Перельмана