Implant type

A significant consideration when planning augmentation mammaplasty is whether to utilize silicone or saline implants. Both types may be used to produce excellent results, with each possessing its merits and potential drawbacks.

The silicone implant resembles breast tissue to a greater extent, creating a more natural appearance and feel. This is often of primary consideration to the patient, and is reflected in the increased use of silicone since FDA reapproval. However, in view of the fact that the implants are pre-filled, they necessitate a somewhat larger incision. This is generally no more than a 1–2 cm variance, but is of course dependant upon implant size. Additionally, many women are still apprehensive about the perceived health risks associated with silicone. Despite the validation of safety regarding systemic autoimmune disease, the local inflammatory responses to free silicone from extracapsular rupture can produce cosmetic issues that may be challenging to manage. However, this has become much less of an issue in recent years with the additional barrier layer of the third generation silicone implants, and increased cross linking of the silicone for a more cohesive gel.

From 1992 to 2006, saline implants were the only prostheses available for use in the United States except for clinical trials, and operative techniques therefore advanced. Remote incisions such as those used in the transaxillary endoscopic approach have evolved with the use of saline implants, and become more popular during the time period of the silicone moratorium. A demographic of surgeons trained in laparoscopy also naturally contributed to this evolution. Implants can be placed through a relatively small incision, and this option allows the surgeon to intraoperatively adjust fill volumes to more readily correct asymmetries. They are also less costly than their gel counterparts, and are regarded by some to provide for more natural movement with activity. Saline implants are, on the other hand, more prone to rippling as well as spontaneous deflation. Regardless of implant type, proper selection must be a joint process between patient and surgeon. A biodimensional approach using the measurements of at the very least base diameter, tissue pinch, and nipple to inframammary fold discrepancies should be employed and are to be covered in another chapter of this text.

Placement

The breast pocket may be created in either the subglandular or subpectoral space (Fig. 53.1). The subglandular technique is usually reserved for patients who have substantial breast tissue or a mild degree of ptosis, since greater projection may be obtained. Also, women who are avid bodybuilders may prefer subglandular implants for the reason that placing them submuscularly, in some instances, may produce breast animation and distortion when the pectoral muscles are flexed. Increased risks of capsular contracture, rippling and implant palpability are typically issues discouraging the routine use of the subglandular plane.

Fig. 53.1 Subglandular vs. submuscular figure depicting subglandular versus submuscular placement. Note the inferior of the implant is covered by breast gland and fascia, and the top by pectoralis major muscle.

In patients with a paucity of breast tissue and little to no ptosis, the subpectoral technique, in our opinion, produces optimum results. The pectoralis major drapes the superomedial aspect of the prosthesis, softening the transition, and thus creating a more anatomically shaped breast mound (Fig. 53.2). This method also achieves a natural feel, which is especially desirable when using saline implants. The submuscular plane additionally tends to be less vascular, and is associated with fewer sensory alterations of the nipple areolar complex. Also, rates of fibrous capsular contracture are demonstrably lowered with submuscular placement versus subglandular. In addition to improved aesthetic outcomes, there are moreover prospective functional advantages in regard to breast-feeding as well as cancer screening.

Fig. 53.2 Submuscular placement. The author prefers partial submuscular implant placement of implants for improved aesthetic shape, camouflaging of the implant shell, reduced rates of capsular contracture, and improved visualization of mammography. The artist depicts placement through a periareolar incision.

Surgical approach

Although numerous methods have been described in the literature, there are three preferred approaches for breast augmentation: inframammary, periareolar and transaxillary (Fig. 53.3). Dissections may be performed in either plane, with or without the aid of an endoscope.

Fig. 53.3 Incision sites: Examples of periareolar, inframammary crease, and transaxillary incision sites are shown. Note how all heal well with proper placement and patient selection given individual breast anatomy. (This figure incorporates images from Figs 53.5, 53.7 and 53.10.)

The inframammary fold incision (Fig. 53.4) provides excellent results in terms of inconspicuous scars, accessibility for both implant types, and fold modifications (Fig. 53.5). This incision allows for optimal view of the pectoral muscle and breast parenchyma, which permits the surgeon to perform an accurate dissection in either, the submuscular or subglandular plane. The downsides of this approach are the potential increased risk of iatrogenic rupture during wound reapproximation, and implant exposure during the postoperative period given the weight of the implant on the healing incision. Additionally, the access incision must be carefully designed to avoid scar migration to the chest wall or inferior pole of the breast.

Fig. 53.4 Inframammary approach.

Figs 53.5 Inframammary incision.

In patients not requiring fold adjustment, the incision is made at the inframammary fold and is approximately 2.5–3 cm in length, extended laterally from below the nipple, and carried deep until the lateral aspect of the pectoralis major muscle is reached. With the author’s preferred technique, if undertaking a subpectoral placement the inferior muscular attachments are freed by means of a fine mosquito clamp and cautery dissection. The pectoralis major can then be elevated from the chest wall using blunt finger dissection or an Agris–Dingman dissector, which is then replaced by a lighted retractor to allow assessment for hemostasis and the transection of any residual muscular bands via electrocautery. The only medial pectoralis muscle fibers transected are those that appear anomalous and medially displaced. Otherwise, purely inferior muscle fibers are released. In cases of ptosis or tuberous breast deformity, the dual plane technique as described by Tebbetts, may be utilized to aid in redraping the breast tissue over the implant.

An implant sizer may be placed to aid in prosthesis selection, and can also be over filled for intraoperative tissue expansion, as well as its tamponade effect to facilitate hemostasis. Using an antibiotic solution, the selected prostheses are bathed and the pockets are irrigated prior to insertion. The implants are placed, and the patient is raised in an upright seated position to assess contour and symmetry. Once any final adjustments have been made, the patient is then returned to the supine position and the incisions are closed in a layered fashion with 3-0 and 4-0 Monocryl (Ethicon, Somerville, NJ). For additional tissue support in the inframammary approach, we also employ a running, subcuticular 3-0 Prolene (Ethicon, Somerville, NJ), which may be removed later in the postoperative course without sequelae.

The periareolar incision (Fig. 53.6) requires a somewhat higher degree of technical skill, but provides a central point of access for pocket development as well as radial release. This incision is especially suitable for those who have an ill defined fold, constricted breast tissue, or require nipple-areolar resizing. It also allows for conservative excision of redundant lower pole skin. In order to achieve discrete scars, the patient must have a sufficiently sized nipple-areolar complex to accommodate the selected implant, a well-defined areolar edge, and differentiation of pigment (Figs 53.7, 53.8). The approach is generally limited to smaller silicone implants, but this is less of an issue with saline prostheses. Given the proximity of the incision to the lactiferous ducts, it may however, be a less favorable choice for patients who desire to breastfeed. Also, there may be an increased likelihood of nipple dysesthesias due to proximity of the dissection.

Fig. 53.6 Periareolar approach.

Figs 53.7 & 53.8 Periareolar incision.

Figs 53.8 & 53.9 Periareolar incision.

The incision lies on the lower border of the areola, and is approximately 3.0–4.0 cm long from 3 o’clock to 9 o’clock. This length may vary depending upon the individual anatomy, but should generally not extend beyond one half of the areolar circumference. After the initial incision is made, the breast parenchyma is dissected down to the fascia of the pectoralis major muscle in an inferior direction towards the breast base. If subpectoral placement is desired, the muscle is carefully released allowing entry into the subpectoral space. The pectoralis muscle is then elevated, thus creating the breast pocket.

Using a lighted retractor for visualization, electrocautery is employed to detach the muscle edge from the inferior chest wall and provide a hemostatic environment. Once the pockets have been adequately dissected, they are irrigated with antibiotic solution and the implants are placed. The patient is then maneuvered to a sitting position allowing the surgeon to evaluate the aesthetic effect and further fine tune any pocket modifications before closing. Again, we use 3-0 and 4-0 Monocryl for the deeper layers, while 5-0 running nylon is employed on the skin.

The transaxillary endoscopic technique (Fig. 53.9) is ideal for patients with minimal glandular tissue, little or no ptosis and an ill-defined inframammary fold. The incision is best suited for saline implants that can be filled once they have been placed, but silicone implants may be placed with extension of the incision up to 4 cm. The main advantage of this technique is that there are no scars created on the breast (Fig. 53.10). However, as the breast pocket is further away from the incision, it is more difficult to precisely alter the inframammary fold and correct asymmetries. Inadequate muscle release with this technique may lead to persistently high riding implants. This approach is not appropriate for patients with tubular breast deformities, and although possible, is impractical for subglandular placement. Also, revision surgeries may require an alternate counterincision if substantial modifications are to be made.

Fig. 53.9 Transaxillary approach.

Fig. 53.10 Axillary incision (3 months postop).

A 2.5–3 cm transverse incision is made posterior to the anterior axillary fold and inferior to the apex of the axilla, following the lines of Langer in an axillary crease. Blunt dissecting scissors are used to create a subcutaneous plane from the incision to the lateral pectoral fascia. It is important that this dissection is carried out superficially to avoid injury to the intercostobrachial nerve, which traverses this area. Once the lateral edge of the muscle has been raised, the inferior and lateral subpectoral spaces are digitally dissected much as possible. Following this, an Agris–Dingman dissector is utilized to develop the remaining subpectoral pocket. Care must be employed with this maneuver to avoid avulsion of the medial perforators and/or entry into the pleural space. If the use of an endoscopic retractor is desired, it may be introduced into the pocket at this point for precision of muscle release inferiorly along the inframammary fold.

To achieve this, we utilize an angled retractor, which accommodates a 10 mm, 30-degree endoscope, along with a standard breast endoscopic instrumentation set. Snowden Pencer (Cardinal Health, Dublin, OH) has provided us with the most effective instrumentation for this procedure. For optimal results, the dissection should be performed bilaterally prior to implant placement. Once the pockets have been irrigated and the implants inserted, the patient is elevated to a sitting position to assess cosmesis as well as symmetry, and allow the surgeon to make any final adjustments prior to closing. The wound is then sutured in a layered fashion using 3-0 and 4-0 Monocryl, with running 5-0 Nylon for skin.