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Ростовский Государственный Медицинский Университет

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7 Breast Surgery

https://t.me/med1917

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Dressing 296

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Aftercare 296

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7.1.2 Submuscular Access 298

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Submuscular Implan t 298

Incision and Dissection 298

Sizer and Final Implantation 302

Wound Closure 302

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Dual Plane Dissection 305

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Results 306

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7.2 Breast Reduction/Breast Lifting 315

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Preliminary Marking of Incision Lines 316

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Tumescense T ech niq u e 322

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Marking and Incision 324

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Dissection 326

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Trial Clamping/Repositioning of the Nipple 334

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Wound Closure 338

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Dressing 340

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Results 344

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Tips and Tricks 342, 346

The symbol indicates parts of the procedures shown in the video

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7.1 Breast Augmentation

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Introduction

Since the beginning of humanity, the female breast has been synonymous with the idea of femininity. The “ideal” size, however , always depended on whatever was in vogue at the time, and any appropriate changes were made on illustrations. The first references to surgical interventions to increase the size of the female breast date back to the end of the nineteenth century. There are reports of treatments ranging from fat transplants to paraffin injections, from creams and various synthetic materials to silicone injections, and, as one can imagine, these had disastrous consequences. It was not until the 1960s that it became possible to develop usable silicone gel implants. The further development of these has continued until the present day and has given rise to a safe method of breast augmentation. This is due above all to the viscosity of silicone gel, which enables the implant to be as natural as possible. There are also saline-filled implants on the market, but these have inherent disadvantages. The saline can diffuse more easily through the outer silicone layer, which firstly may produce a loss and unevenness in size, and secondly may give rise to noises.

7 Breast Surgery

Breast enlargement is a very frequently desired operation. This book presents the most simple, clear technique in order to ensure that the novicehasabasicideaofhowtointroducebreastimplantsandtoavoid risks. The simplest, safest access is by means of a 4-cm-long incision in the inframammary fold which, if made precisely, if an atraumatic suture technique is used, and if there is good postoperative treatment, is hardly visible after 3 months.

The access described in the manual is very clear and easily understandableandalsoproducesgoodaestheticresults.Ofcourse,abreast implant may also be introduced via the nipple and via the axilla. This requires the person carrying out the operation to have appropriate experience. In some cases it will be indicated. Any breast implant, however, may be introduced without problems by means of the access described in the manual. It is then up to the young aesthetic surgeon to build on this knowledge.

Once the question of access has been resolved, the second-most-impor tant decision is whether the implant is going to be placed above or beneath the pectoralis major. Here, too, the manual gives clear and

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7 Breast Surgery

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easily understood instructions, namely , that, if there is good skin and gland coverage, the implant is positioned above the muscle, between muscle and gland. The operation is carried out macroscopically and the dissected pocket is monitored by means of an endoscope so that any bleeding is seen, all strands of connective tissue are cleanly cut through, and the implant pocket is prepared in an anatomically clean manner.

In a clinical study of 1320 patients followed up at the Bodenseeklinik, the fibrosis rate was not significantly lower with submuscular access than with supramuscular access (<3.2%).

Submuscular access is and must be carried out if, following pregnancy or dramatic weight loss, only a very thin flap of ptotic skin is present, meaningthatthecoveringisveryweak.Otherwise,animpressionof the implant and a rippling phenomenon is unavoidable. In this case, the implant must be placed under the muscle. This intervention is more laborious and causes more bleeding. The pectoralis major must be separatedwhileinview,includingbyendoscope,atitslowermarginupto the midline using an electric scalpel, cutting through its points of attachment on the relevant costal arches, directly from the rib. Subsequently, the muscular pocket can generally be dissected bluntly. A disadvantage of this method may be that the implant slips and that the muscle contracts and changes, which means that when the implant is in the submuscular position, there may be later cosmetic problem s and changes if the submuscular pocket is not dissected completely cleanly.

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When implants are used, these should only be implants that have been licensed by the health authorities. Similarly, to start with, one should notuseimplantsthataretoolarge(notover350g)sincetheseareassociated with significantly more postoperative complications and a significantly greater desire for subsequent operations than is the case with smaller implants.

Breast Implants*

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Every day, women in Germany fulfill their dreams of having wellformed breasts. While the round shapes – which are obviously implants – are still preferred in the USA, German women want their surgically enlarged breasts to have a natural appearance: the ‘tear shape.’ Yet, it is not only important to have a natural appearance; the implanted material should also feel as natural as possible. Tear-shaped implant s are made entirely of silicone – with good reason. Other materials used for breast implants have proved to be extremely disadvantageous for patients. Sodium chloride is certainly safe as regards patients’ health but it has drawbacks: the implants gurgle and the material has nothing in common with the surrounding breast tissue. For this reason, only silicone gel breast implants from PharmAllergan* are used at Professor Mang’s Bodenseeklinik. As the sole manufacturer, PharmAllergan* has experience with these implants stretching back more than 25 years. This is an important point as the quality and safety of the implant play an important role in the result of the breast operation. Publications throughout the world confirm the fact that these implants have the lowest complication rate, which is in line with the high quality and safety requirements at the Bodenseeklinik.

7 Breast Surgery

A standardized quality mark for breast implants has been in existence throughout the entire European Union for three years. This guarantees that the implants will not harm patients’ health. The silicone implants used today are filled with cross-linked (cohesive) silicone and therefore cannot leak. If such an implant is cut open, the contents appear as firm as a wine gum. The surface has also been made rough which ensures that the implant meets completely naturally with the tissue.

* PharmAllergan, Pforzheimerstr. 160, 76275 Ettlingen, Germany

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Anatomical Overview (Fig. 7.1)

1. Infraclavicular lymph nodes

2. Cervical plexus

3. Parasternal lymph nodes

4. M. pect. major

5. Pectoral fascia

6. Inframammary lymph nodes

7. Superior epigastric artery

8. M. ext. obl.

9. Intercostal arteries

10. M. serr. ant.

11. Thoracodorsal artery

12. Areola

13. Nipple

14. Paramammary lymph nodes

15. Breast

16. Lateral thoracic artery

17. Internal mammary artery

18. Axillary lymph nodes

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Instruments (Fig. 7.2–7.5)

1 Pump-syringe 2 Centimeter rule 3 Sterile marking pen 4 Scalpel (blade: size 10) 5 Large needle holder 6 Small needle holder 7 Adson tweezers with plate 8 Coarse surgical tweezers

9 Monopolar electrocoagulation 10 Insulated anatomical tweezers for hemostasis 11 Large Metzenbaum dissecting scissors 12 Cooper scissors 13 Illuminated retractor 14 Langenbeck retractor 15 Sharp 4-pronged retractor 16 Redon introducer 17 Curved forceps 18 Roux retractor 19 Areola ring 42 mm 20 Areola ring 38 mm 21 Scalpel (blade: size 15) 22 Delicate small sissors 23 Delicate long single-pronged wound retractor 24 Backhaus clamps

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