With the introduction of shaped textured implants surgeons started to think in terms of shape and dimensions rather than volume and cup size.¹ In order to fully exploit the opportunity for creation of a natural breast shape offered by the shaped devices, careful attention must be given to the surgical techniques of pocket dissection and implant placement for shaped devices.²^–⁵

In the last decade much of the discussions in the plastic surgery literature has focused on the difference between shaped and round implants, however, a much greater divergence relates to the use of form stable versus non-form stable implants (Fig. 24.1). Basically most aspects of such breast augmentations are different. The way of selecting implants is different. Patient preoperative markings, surgical techniques and postoperative recommendations and results also differ. These are not just new type implants, they represent a new concept in breast augmentation surgery. Surgeons who believe that form stable implants behave in the same way as non-form stable implants will tend to plan, select implants and perform surgery in traditional ways. Unfortunately, they are bound to encounter significantly more complications and problems.

Fig. 24.1 A form stable (Allergan Style 410) implant on the right and a non-form stable responsive silicone gel on the left. Note that the form stable implant retains its upper pole fullness and shape even in a standing position without pressure.

Patient and Implant Selection

Ever since silicone breast implants were introduced in the early 1960s implant selection has been a relatively arbitrary process where the surgeon has estimated the volume of the implant in relation to patients’ desires and biological prerequisites based on his own experience. As form stable implants cannot be deformed (Fig. 24.2) dimensional planning and implant selection is necessary. Instead of estimating an appropriate volume the ideal dimensions of the implant are calculated.

Fig. 24.2 A A non-form stable breast implant can be deformed even if its base dimension is too wide for the implant pocket. Thus they are simpler to use as planning is less crucial. B A form stable breast implant with a too wide base plate cannot be deformed to fit into a too small implant pocket. Thus these implants necessitate new and fundamentally different implant selection and preoperative planning techniques.

The implant selection can be separated into several distinctly different steps. The first step includes definition of patient’s desires and evaluation of the biological prerequisites. This is followed by determination of ideal implant width, height and projection. Knowledge about ideal implant type and its width will provide information on implant volume.

Several implant manufacturers provide form stable shaped implants, but the Style 410 implant from Allergan was first on the market and it still has the widest range of form stable shaped implants available; twelve basic different cells are available. Three different heights (the vertical length in the direction of the clavicle) are available (low, moderate, and full). Each height of this Matrix system is available with four different projections (low, moderate, full, and extra) and each of these twelve different shapes is available in a large number of different implant widths. Breast augmentation has, by this great variability, become more versatile and customized than ever before.

The typical breast augmentation patient wants a proportionate and natural breast augmentation. Once a patient is deemed to be an appropriate candidate, the ‘selection’ process will depend on evaluating patient characteristics and then selecting the correct implant.

Definition of Patient Desires

Contrary to common beliefs and the stereotypical picture of a typical breast augmentation patient in the mind of the general public and the media, the typical breast augmentation patient wants a proportionate and natural breast augmentation. She is not mainly concerned with the size of the breast, but rather its shape and youthfulness. It is of fundamental importance for success in aesthetic breast augmentation that patients are well informed and have a realistic expectation about the outcome of the procedure. It is more important to recognize the patients that are not suitable for an operation than the ones that are. Patients who anticipate detailed, almost millimetre exact results and not just the general improvement of the procedure are usually not good candidates for aesthetic plastic surgery procedures. Also patients who do not listen and take in information should usually be avoided, as should be patients who describe minor defects as horrible. Another group to beware of are patients who have undergone surgery elsewhere and are extremely dissatisfied and complaining about previous procedures and physicians.

The general information about breast augmentation surgery can be conveyed in many different ways and well educated patient coordinators and/or in the written form and a patient information book have proved extremely useful.²⁸ A full size mirror in the doctor’s office is also an extremely important part of the consultation process as the dimension and proportions of the expected result can be demonstrated for the patient by displacing the breast medially and laterally, showing expected borders of the new breast and showing projection of different implants. To use sizers in a sports bra should not be part of the consultation in the first stages but final testing with suitable sizer in a sports bra can be a good way to create final trust in the implant selection for the patient.

Examination of the Breast Tissue and its Envelope

As breast asymmetries are extremely common but not always noted by patients, these smaller asymmetries should be noted and pointed out to the patient. The characteristics and distribution of the glandular tissue should be examined as it has implications on implant selection. A patient with a dense, relatively constricted gland and short nipple inframammary fold distance has increased risk for a double bubble deformity in the lower pole and they may do better with a more projecting implant and shorter implant heights. The surgeon may also need to modify the gland with scoring or unfolding of a glandular flap.⁶ When selecting implants it is also very important to consider the envelope’s characteristics. A lax envelope may need more implant projection to fill it. A simplified way of estimating envelope laxity is to do an anterior pull stretch test (APSS) according to the TEPID-system.⁷ By grabbing the areola tissue beside the nipple and pulling firmly (warn the patient before doing this procedure as it may be uncomfortable), the extensibility of the envelope can be measured. This will provide information on suitable implant projection. An alternative to this is to measure the nipple–inframammary fold distance on the relaxed tissue and maximum stretch and put this in relation to implant dimension (see LVC and N-ILP measurements below). Obviously the selected implant has to suit the characteristics of the gland and envelope in accordance with all tissue based planning systems.⁷^,⁸ However, it should also be remembered that patient desires must be considered and for a patient with relatively lax tissue who desires a small augmentation, but needs a larger implant to fill the envelope an alternative is to combine a small augmentation with a mastopexy, which both takes patient desires and the envelope characteristics into consideration. Also, patients with very tight tissue could be treated with more projecting implants than the anterior pull test indicates as the tissue will expand over time (Fig. 24.3).

Fig. 24.3 A Patient with tight skin envelope (anterior pull stretch only 2.8 cm), but with a desire for 6 cm extra projecting implants (Style 410 FX 410 g). B Six months later – after an initial period of tightness, the tight tissues are expanded and soft.

Examination of Thoracic Shape and Surrounding Tissue Conditions

It should be remembered that the thoracic shape greatly could influence the shape of the breast after the augmentation. Also excess fat distribution and a thick pectoralis muscle in the upper pole may influence the shape of the upper pole of the breast after the augmentation and this should thus be considered when selecting implant height. Also asymmetries in the thoracic shape should be examined and different shaped implants may be considered to compensate for such asymmetries.

Operative Technique I: Selection of Adequate Implant Dimensions

Selection of ideal implant width

Having communicated with the patient and examined the biological prerequisites, the next step is the definition of the ideal implant dimension. The first and most important part of this is to define the ideal implant width. This is equal to the desired breast width minus the tissue cover on the implant (Fig. 24.4). Thus the medial and lateral thickness of tissue has to be examined. This is done at the height of the nipple–areola complex at the expected inner and lateral border of the implant (Fig. 24.5). Tissue cover is measured with a pinch and as a pinch of tissue is a double fold of skin and subcutaneous tissue, the measurement in the medial and lateral part of the breast should be divided by two when subtracting this number from the desired breast width. The desired breast width usually should leave an intermammary distance between 2 and 3 cm and the lateral protrusion of the breast should respect the anterior axillary line (Fig. 24.6). The distance between these two points can be measured with a caliper and the tissue cover, as mentioned according to the description above, is then subtracted for information about ideal implant width. The existing breast width should also be measured as implant selections that are considerably wider than the existing breast width should be avoided as it increases the risk for complications such as palpability and visibility of the implant.

Fig. 24.4 The desired breast width measured with a caliper minus the tissue cover medially and laterally is equal to the desired implant width.

Fig. 24.5 Tissue cover is measured medially and laterally at the estimated border of the implant. This is done with a pinch test, with a pressure that simulates the implant compression on the glandular tissue. The pinch A medially and B laterally is added together. As these represent double folds of tissue this number is divided by two to provide information on how much distance should be subtracted from desired breast width to provide information on implant width.

Fig. 24.6 A In a proportionate breast augmentation, desired breast width should respect an intramammary distance of between 2 and 3 cm and B the lateral protrusion of the breast should respect the anterior axillary line.

When it comes to selection of the ideal implant width it should be recognized that even form stable devices have a certain amount of plasticity. Usually, increasing the ideally measured implant width or reducing it by 0.5 cm is possible without increased risks in most patients. If the calculated ideal implant width is exceeded by more than one centimeter this can create problems. It can create a too small intermammary distance with implant visibility and palpability. Also narrowing the implant width a centimeter or more produces too large an intermammary distance with a more artificial and operated appearance.

Selection of implant height

Having defined and communicated ideal implant width with the patient, the next step is to recommend a suitable implant height. It should be remembered that preoperative upper and lower pole appearance is of great importance for the implant height selection. For example, bulging upper thoraxes may be exaggerated by selection of full height implants whereas depressions in the upper thorax more favorably could be treated with full height implants. When selecting implant height it is important to measure and localize where the lower and upper pole of different implants will be located and compare this to how the upper pole shape is estimated to appear and how the implant correlates to the existing submammary fold and the lower pole appearance of the breast (Fig. 24.8). To be able to estimate where the upper and lower pole of different implants will be located during the consultation, the patient is asked to put her hands on top of her head. This 45° elevation of the arms above the horizontal plane is an accurate estimation of where the nipples will be positioned after a proportionate breast augmentation (see preoperative markings below). Knowing ideal implant width the height of different implants can easily be looked up in the manufacturers’ charts. Usually half of the implant height should be positioned above the nipple–areola complex after the augmentation and half below. Thus it is easy to measure above and below the nipple with the arms on top of the head to estimate how the upper and lower poles of the breast will appear with different implant heights.

Fig. 24.8 When using round form stable implants the implant height is obviously equal to the implant width. In spite of this it is advisable to check the upper and lower pole implant position and how this correlates to the thoracic shape and existing inframammary fold. By arm elevation 45° above the horizontal plane, an accurate prediction of the new nipple position is achieved and from this position the amount of implant desired proximally and distally can be calculated (for shaped implants usually 50% above and below and for round implants 45% above and 55% below).

Selection of adequate implant projection

This recommendation of the ideal footprint (height and width) or base plate of the implant obviously has no volume as it is only two-dimensional. The projection, the third dimension of the implant, will provide the final volume of the implant. Implant projection is highly dependent on patient desires, but remember to consider the envelope characteristics as loose envelopes may need more projection or a mastopexy. Also, patients with a contracted lower pole may have less risk for double bubble deformity if more projecting implants, for instance Allergan Style 510, are selected (Fig. 24.7). A good way of selecting implant projection is to communicate this with the patient standing in front of the mirror.

Fig. 24.7 Several different shapes of form stable implants are available, both round and anatomical. Shaped implants are also available with combined cohesivity as used in this case (Allergan style 510 implant with higher and firmer gel cohesivity in the ventral part than in the posterior part of the implant). A Preoperative planning with arms hanging. B Preoperative planning with arms elevated 45° above horizontal plane. C Four hours postoperatively. Note the elevation of the NS line. D Six months postoperatively.

Indications

Form stable breast implants are considered more demanding and difficult to use. An obvious question is then why is there a need for them. The answer to this question is that form stable implants control the shape of the breast in a much better way, especially if we consider long-term effects of a breast augmentation. The high cohesive silicone gel breast implant retains its shape even if it is cut into two pieces and even if it is put under pressure (Fig. 24.9). On the other hand, relatively small forces are needed to deform a responsive low cohesive silicone gel implant. The clinical consequence of this is that a low cohesive silicone gel implant easily is deformed into a spherical shape during capsular contraction (Fig. 24.10). Contrary to this, capsular contraction on high cohesive silicone gel implants deforms implants much less. Clinically, this difference has been observed by the author in a number of cases. A textured shaped form stable implant should also be positioned into a snug fitting implant pocket and one implication of this is that it moves less in the cranial direction during capsular contraction compared to a round smooth implant which usually is massaged to retain a large implant pocket and softness. Thus circumferential shrinkage during capsular contracture moves a smooth walled implant in a large pocket more in the cranial direction (Fig. 24.11). Consequently, these benefits of form stable implants have improved the appearance and the control of the breast shape better and long-term follow up (>10 years) indicates good stability of results (Fig. 24.12). The use of shaped form stable implants constitutes a new era in breast augmentation surgery: The era of breast shaping and long-term customized control of breast shape versus the traditional breast volumetric filling or stuffing era. Obviously a prerequisite for controlled shaping of the breast is not only to have a form stable shaped implant, but also a wide variety of different implant shapes.

Fig. 24.9 A A form stable implant cut in two pieces will still retain its shape and the filling material will be confined to the shell. B The same is true even if the implant is put under pressure.

Fig. 24.10 A The same low cohesive implant on the left and right hand side of the picture, but the right one with its contracted capsule. Note considerable narrowing of the base and increased projection. B Comparison to a form stable high cohesive implant with capsular contraction on the right hand side; note much less narrowing of the base compared to A.

Fig. 24.11 A Frontal view of a patient with a smooth round responsive silicone gel implant with capsular contraction Baker grade III. As ‘smooth’ implant pockets frequently are made larger than the implant and implants are massaged to maintain softness, implants shift cranially during circumferential shrinkage of the capsule. B Same patient, side view. C After exchange to form stable textured implant positioned in a new submuscular pocket which is much more snug fitting than the excessively large pocket made for the non-form stable implants. Frontal view after implant exchange. D Same patient, side view after implant exchange. Note that capsular contraction has redeveloped in this case, but as the implant pocket is snug fitting and the implant textured, there is much less cranial displacement of the implant and less deformation compared to smooth walled implants. The degree of capsular firmness is similar before and after implant exchange but the shape is much better.

Fig. 24.12 A Before breast augmentation with form stable implants, oblique view. B Frontal view. C Six months after breast augmentation (Allergan style 410 FM model 350 g subglandular), oblique view. D Frontal view. E Oblique view of the same patient ten years later. F Frontal view of the same patient ten years later.

Other advantages relating to these devices have been reviewed elsewhere.⁹ Among these are that breast augmentation can be more customized than ever before and that the great variability of different implant shapes makes it possible to compensate for breast asymmetries. This is also a great advantage when it comes to breast reconstructive procedures where bilateral treatment with different sized implants (Fig. 24.13) and different shaped implants can provide a long-term stability of the results compared to unilateral implantation of a round, non-form stable device.¹⁰ High cohesive silicone gel also minimizes gel bleeding and leakage after a shell rupture and as the filler is form stable, irregularities such as fold and rippling are significantly less common.¹¹ Capsular contracture rates have also been lower for form stable implants compared to implants filled with saline or regular low cohesive silicone gel.¹² It is also likely that the form stable filler minimizes the envelope movements, and thus the wear of the envelope, giving better chances of low long-term risk for ruptures. This has also been clinically proven in long-term magnetic resonance imaging (MRI) evaluation of these devices.¹³ The rupture frequency has been as low as 0.3% after up to 9 years of implantation, and comparing this to other similar MRI studies on non-form stable breast implants these have shown that the risk for rupture has been considerably (3.5–17%) higher.¹⁴^–¹⁷ Others have also confirmed the low rupture of Allergan form stable implants whereas other manufacturers’ form stable implants have not been confirmed to have this low incidence of ruptures.¹⁸^,¹⁹

Fig. 24.13 The large variability in different breast implant shapes is also suitable for breast reconstructive surgery. A Preoperative situation after a previous reduction mammaplasty on the patient’s right side and secondary mastectomy. B After bilateral breast implants, on the right side (Allergan style 410 FX model) extra projecting and a latissimus dorsi flap and on the left side augmentation with low projecting implant (FL) to create long term symmetry.

In spite of all these advantages several surgeons refrain from use of form stable implants. A common argument against is that patients are happy with the non-form stable devices provided. This is true as patients usually are happy even with inferior result, but this is no reason why we should refrain from doing our best to improve results. It is also claimed that non-form stable implants deform into an ‘anatomical’ shape when a patient is standing,²⁰ which also is true if the device is underfilled with a low cohesive filler and if there is no capsular contraction (Fig. 24.14). However, during capsular contraction the implants become more round and artificial in their appearance (Fig. 24.10) and also the shaped ‘deformity’ of a round implant increase rippling and irregularities in the upper pole which is likely to increase the wear of the envelope. It is sometimes also claimed that form stable implants behave unnaturally on the chest wall giving unnatural appearance when the patient is lying on their back. This has not been our clinical experience as even these implants move laterally when the patient is lying on her back. The firmness and movement of the implant is more related to common and small degrees of capsular contraction not regarded as true Baker II deformities. These small degrees of capsular activity usually regarded as natural softness are relatively common and by the author regarded to be more important for the movement and firmness of the breast than the firmness of the implant itself.

Fig. 24.14 Low cohesive non-form stable or responsive gel implants (here, Allergan style 110) held in vertical position deforms from round to ‘anatomical’ shape.

To compare the results after implantation of shaped and round implants similar conditions have to be present. Thus, it is not possible to compare a patient with a subglandular shaped implant in a small breast to a submuscular round implant in a patient with a large breast and a large amount of tissue cover. Also the degree of capsular activity influences the appearance. However, if similar conditions are present relating to the position in relation to the muscle, the type of breast examined, the degree of capsular activity and the subcutaneous thickness, shaped implants produce more natural appearance in its upper pole compared to round ones. This is even more apparent when comparing round form stable implants to shaped form stable implants. Round form stable implants retain their upper pole shape and fullness more than round non-form stable implants (if no capsular contracture is present). Thus these devices give an extra rounded appearance in the upper pole, especially if they are highly projecting (example Allergan INSPIRA TSX models). There are patients who request this more artificial breast appearance and this is where round highly projecting form stable devices are better suited than shaped ones. Most patients, however, request a natural appearance of the breast and recent market research ²¹ indicates that only 29% of patients have size as a primary request when seeking for a breast augmentation, 71% of patients have desires that relate to the shape of the breast as primary goals with their breast augmentation.

Disadvantages with form stable shaped implants are as discussed above: that they are more technically demanding to use; the learning curve is steeper; the price of these devices is also higher. The form stability of the implants also necessitates a slightly longer incision to implant and a volume between 200 and 300 cc usually necessitates a 5 cm long incision, whereas implant sizes in the range of 300–350 cc usually need an incision of about 5.5 cm. Larger implants may need an implant incision of up to 6–6.5 cm. Form stable implants are also firmer in true Baker I capsular conditions, but in the typical augmentation patient no differences in the firmness related to touch is noted. Form stable implants are neither suitable for non-proportionate augmentations and for patients who want oversized augmentation. In this case it is better to deform a round non-form stable implant, which becomes more projecting. However, patients who request oversized breast augmentations should be advised against it, and properly informed about the negative aspects of this when it comes to tissue stretch and destruction of the normal glandular parenchyma and the skin.

Form stable shaped implants are also more difficult to use in secondary cases, especially after severe unilateral capsular contraction where there may be a central atrophy of the gland underlying the nipple areola complex. It is difficult to fill this empty space with a form stable implant and a simultaneous mastopexy may be needed to address this problem if a form stable implant is selected. Final disadvantages with these devices include the fact that there is a risk for rotational problems (see Pitfalls section below).

Operative technique summary

1. With arms elevated 45° above horizontal plane draw a horizontal nipple to sternum line (NS). At the medial end of this measure distally the length of implant desired distal to the nipple after the augmentation (usually 1/2 height). Mark a horizontal implant lower pole line (ILP).

2. Calculate and mark length of skin between the nipple and the new submammary fold based on the implants lower ventral curvature (LVC) and the amount of covering glandular tissue (= half tissue pinch measurement of the gland or N-ILP distance with arms on top of head minus 1/2 implant height).

3. Select implant position in relation to pectoralis muscle. Use subfascial/subglandular position only in selected cases, usually large breast. All patients with tissue pinch cover at the upper border of the implant <2–3 cm should have muscle cover in the upper medial pole.

4. After scalpel skin incision continue dissection with needle tip electrocautery.

5. Create a subglandular or subfascial pocket to or past the nipple–areola complex (NAC) depending on type of dual plane position decided on.

6. Divide the muscle distal to the subglandular dissection. Start at lateral border, elevating the muscle with a forceps and cutting parallel to the rib cage.

7. Leave loose connective tissue on the ribcage. Dissect with proactive hemostasis, controlling small vessels before cutting them.

8. The medial part of the muscle division along the sternum should always respect the preoperatively marked NS line (usually 2–3 cm distal to this).

9. After implantation ensure that the pocket is snug fitting without buckling and irregularities of the implant border. The implant markers for the vertical axis of the implant should also be checked and the lower border of the implant positioned along the ILP line.

10. Close a submammary incision with sutures between thoracic wall along the ILP line and the supra-Scarpa’s level of the incision.

Preoperative planning

In breast augmentation surgery the vertical height of the implant on the thoracic wall should be adjusted to the nipple position. This is contrary to mastopexy augmentation cases where the nipple position is adjusted to the implant dimensions. Unfortunately, the planning of the implant position has often been relatively arbitrary, based on surgeons’ experience instead of careful analysis and measurements. Throughout the history of breast augmentation surgery many different preoperative markings and planning methods have been described; the majority of these are, however, not mathematical in spite of the fact that a breast implant has certain dimensions and proportions that can be calculated, measured and taken into consideration when performing preoperative markings. In 1994 the first form stable implant and the Biodimensional planning system by the McGhan Co. was introduced. However, this system, that recommended how to adjust the areola–inframammary fold distances in relation to implant base width, was not made on true mathematical calculations. This development initiated the author to develop the Akademikliniken system for mathematical planning in breast augmentation surgery and this is the first truly mathematical breast implant planning system described.²^,²² This new preoperative planning system is especially important in difficult cases to calculate how to position the implant vertically on the chest wall and how to calculate amount of skin in the lower pole of the breast (Fig. 24.15). With this system two important questions should be answered. The first is how to calculate the ideal vertical implant position on the thoracic wall in relation to the nipple–areola complex. In the mid 1990s the author made some fundamental and important observations, not previously focused on in the plastic surgery literature. The first of these observations was that a correctly performed breast augmentation elevates the NAC. The second observation made was that if a line was drawn from the nipple to the fixed tissue along the sternum, this line (NS-line) could be used to illustrate the amount of nipple elevation achieved. Thirdly it was also observed that a preoperative arm elevation could be used to simulate the amount of nipple elevation achieved by the augmentation (Fig. 24.16). The elevation of the NAC is the result of increased projection and outward–upward rotation of the NAC. This elevation necessitated that the implant is placed correctly in the breast (Fig. 24.17). If the implant is placed too high no elevation is achieved and in fact a downward push and rotation of the NAC could be the result instead. In a careful clinical evaluation of several hundred augmentation patients it was found that nipple elevation could be accurately preoperatively simulated by an arm elevation 45° above the horizontal plane. Knowledge of the postoperative nipple position and marking of this with a horizontal NS-line could be used to calculate the ideal vertical implant position on the chest wall based on implant dimensions. According to the Akademikliniken method (or AK method) these so-called NS-ILP measurements are performed by elevation of the arms 45° above the horizontal plane (a simple way to achieve this is to ask the patient to clasp her hands on top of her head). A horizontal line is then drawn from the nipple to the fixed tissues in the midline along the sternum (NS-line). The arms are then lowered again and in the midline as much of the implant as desired to be distal to the nipple position is measured distally. Usually for a shaped form stable implant this is equal to half the height of the implant. At the distal end of this midline measurement a horizontal line is extended laterally. This horizontal line (ILP-line) indicates the implant’s lower pole. The NS-line and ILP-line are extremely valuable guidelines during the surgical procedure as they will guide the surgeon on how to position the lower pole of the implant and also to illustrate where the nipple will be located after the augmentation. Also, the NS-line is a valuable guideline when dividing the inferior origin of the pectoral muscle as the muscle division always should respect the NS-line and stay well distal to this line.

Fig. 24.15 A Preoperative markings of a patient with difficult conditions for a breast augmentation: A narrow base width, tight submammary fold, moderate laxity of the tissue and asymmetric submammary folds and nipple positions. Preoperative planning is crucial for a good outcome. B Oblique view of the same patient preoperatively. C Appearance 6 months postoperatively, selection of different implants on left and right produce a more symmetrical shape. D Oblique view 6 months postoperatively.

Fig. 24.16 In the 1990s the author made two fundamental and important observations for preoperative planning. The first was that a correctly performed breast augmentation elevates the nipple areola complex and that this could be accurately simulated preoperatively with an arm elevation 45° above the horizontal plane. The second observation was that if a line was drawn from the nipple to the fixed tissue of the midline (the NS-line) during this arm elevation this was a useful guide in performing the preoperative planning and also a useful peroperative guideline.

Fig. 24.17 A If the old implants are not placed too high in a secondary breast augmentation, arm elevation is not necessary during the drawing of the NS-line as the NAC is already elevated by the implant. B Preoperative pectoralis muscle tightening.C Worms’ eye view on the operating table with submuscular saline implants and lateral migration. D After insertion of form stable implants (Style 410 FX 450 g) in a new submuscular pocket leaving the old implant capsule behind the new pocket. E Three hours postoperatively. F Six months later. G Six months postoperatively during pectoralis muscle tightening with less widening of the inframammary space thanks to release of the inferior medial origin of the pectoralis muscle and dual plane III lateral muscle release.

It has been noted that the elevation of the NAC only varies slightly in relation to implant projection. Selection of low or extra projecting implants has limited variation in the elevation of the nipple–areola complex (2–5 mm). When it comes to the width of implants the elevation is similar in all proportionate augmentations (an intermammary distance of about 2–3 cm and lateral desired breast respecting the anterior axillary line). However, ptotic breasts have more elevation of the NAC and in these cases the arm elevation is recommended to be slightly above the standard 45° above horizontal plane to illustrate the amount of nipple elevation.

Usually half the implant height is recommended when calculating ideal vertical implant position on the chest wall, but other calculations such as a 60/40 ratio, or half the implant width could also be used with this method provided that the surgeon knows how this influences the appearance of the breast. When using round form stable implants half the implant height could be used but the author sometimes favors a 55% localization of the implant distal to the NS-line.

With the Akademikliniken preoperative planning system the second important question to answer during the preoperative markings is the calculation of ideal length of skin needed between the nipple and the new inframammary fold (Fig. 24.18). This distance is highly influenced by the width and the projection of the implant, but also by the amount of glandular tissue and when marking this distance on the breast the envelope characteristics also must be considered. It is amazing that we have been doing breast augmentation surgery for almost 40 years without considering the obvious fact that a wider based implant needs a longer nipple to inframammary fold distance and more projecting implants also need longer nipple to inframammary fold distance than lower projecting ones. Thus the new nipple to inframammary fold distance in relation to the selected implant is equal to the distance between the ideal nipple projection point on the implant’s ventral surface measured down to the implant’s lower border, the LVC. This distance could be measured on a piece of paper, but the LVC-values for Allergan’s different implants has also been calculated by the author and can be provided by the company or by communicating with the author. If a patient is completely flat this LVC-value is the only distance needed between the nipple and the new inframammary fold, but as most patients have a certain amount of glandular tissue this also has to be considered and additional length provided in relation to the amount of gland. The distance that has to be added to the LVC-value of the implant for the amount of covering tissue can be calculated in three different ways. The first and most accurate way to calculate is to measure the distance between the nipple and the previously marked ILP-line with the arms elevated on top of the head and from this distance subtracting half of the implant height. This means that we measure the difference between the convex side of the breast and the posterior side (equal to half the implant’s height). A second alternative to calculate additional length of skin needed for the amount of covering tissue is to measure a pinch at nipple level with a caliper and divide it by two. This is also relatively accurate, but not as accurate as the first alternative described above. A third way is just to approximate the amount of extra distance needed between the nipple and inframammary fold in relation to the amount of gland and for small breasts to add 0–1 cm, for moderate sized breasts add 1–1.5 cm and for larger sized breasts 1.5–2.5 cm.

Fig. 24.18 The distance of skin needed between the nipple and the new inframammary fold in a breast augmentation with form stable implants is equal to the LVC of the breast implant plus a distance relating to the amount of glandular tissue. The LVC distance of the implant is equal to the distance from the ideal nipple projection point (usually measured at half the height of the implant) on the ventral surface of the implant measured down to the lower border of the implant. This distance can be calculated on a piece of paper but has also been calculated for all Allergan’s form stable implants by the author. If the patient is completely flat the length of skin between the nipple and the inframammary fold is equal to this LVC distance, but as most patients have a small to moderate amount of glandular tissue this also has to be considered when calculating ideal distance between the nipple and new submammary fold. This added distance is equal to the difference between the nipple and the previously marked implant lower pole (ILP-line) measured with arms on top of the head, minus half the implant height.

After adding the LVC-value (the ventral curvature of the implant) as gained from the manufacturers or calculated based on implant dimension, add to this the distance between the nipple and ILP-line, subtracting half the implant height: these three values provide the ideal distance between the nipple and the new inframammary fold. When marking this distance on the chest wall it should be remembered that the skin should be stretched almost maximally. In a standard breast augmentation the ILP-line and the calculated amount of skin between nipple and new inframammary fold falls into the same place. However in tight tissue conditions where a patient selects a relatively large implant, a small amount of skin has to be recruited to the lower pole of the breast and in these cases the ILP-line is usually localized above the ideal position for the incision. At the end of the procedure the incision is elevated to the ILP-line and fixed by sutures between Scarpa’s fascia and thoracic wall. In lax breasts where there is a moderate amount of ptosis in the tissue, it is common that the ILP-line ends up distal to where the ideal amount of skin in lower pole is marked and in this situation an inframammary fold incision is placed above the ILP-line and dissection is done distally to lower the inferior pole of the breast and in the end of the procedure suture the submammary fold incision to the ILP-line by sutures between Scarpa’s fascia and the thoracic wall.

These measuring techniques are sometimes regarded as complicated in spite of the fact that the arithmetic is simple (Figs 24.19 and 24.20). However, these planning systems produce more predictability in the results and surgery also becomes faster. Reoperations related to poor implant positioning etc. can also be reduced.

Fig. 24.19 A Preoperative markings. With arm elevation 45° above horizontal plane a line is drawn from the nipple to the sternum (NS). From the sternal part of this line the length of implant desired distal to the nipple areola complex after the augmentation (for shaped implants usually half the implant height is recommended) is measured distal in the midline. At this distal marking a horizontal line is extended laterally indicating the implants lower pole (the ILP line). B Compare the shift of the NS-line with the arms hanging preoperatively. C Three hours postoperatively. D Two weeks postoperatively.

Fig. 24.20 A Preoperatively before markings AP view. B Oblique view. C Preoperatively markings with arms elevated on top of the head (marking technique description in Fig. 24.19). D Note shift of NS-line with arms hanging. E Six months postoperatively (Style 410 FM 350 g implant). F Oblique view 6 months postoperative.

Operative Technique II: Surgical Technique

The importance of a exact surgical technique when using shaped implants has been stressed in several publications.^2,^3,²²

Implant position in relation to the pectoral muscle

Before commencing the surgical procedure the position of the implant in relation to the pectoral muscle is decided. Of fundamental importance for this decision is to evaluate tissue cover at the upper border of the implant. A tissue pinch and measurements of the cover should be done prior to the procedure. If the tissue pinch is less than 2 cm then submuscular placement is always recommended. With less tissue cover, implant edge visibility, irregularities and rippling are more likely. Implants with more tapered edges such as the Allergan Style 510 implants perform better in the subglandular position than other types of implants if tissue cover is on the borderline of being too thin. A tissue pinch at the upper border of the implant of more than 4 cm usually coincides with large natural breasts and in these cases subfascial or subglandular placement may be recommended.²³ With long-term aging, descent of large breasts is expected. With a subfascial or subglandular placement of the implant, the implant is more prone to descend together with the breast. In young patients with between 2–4 cm of upper border pinch, then submuscular implantation may still be advantageous to avoid problems with the long-term aging process. With the new submuscular dual plane techniques described in recent years, the benefits of subglandular implant positioning have been reduced and today the majority of implants are placed with some type of muscle cover in the décolletage area (the upper medial border of the breast). Dual plane positioning^5,^22,²⁴ is possible with dual plane I–IV techniques (Fig. 24.21). This type of dissection minimizes animation of the breast during pectoralis muscle activity after a breast augmentation (Figs 24.17 and 24.22).

Fig. 24.21 Different type of dual plane dissections.

A Dual plane I; where the pectoralis muscle inferior origin is divided from the lateral border but still respecting the NS-line in the midline. No separation between gland and muscle is done proximal to the muscle division. B Dual plane II; the most common technique in naturally shaped youthful breasts, the subglandular dissection on top of the pectoralis muscle is done to the level of the nipple–areola complex and the muscle is divided distally to this creating a weakened lateral pectoralis flap that retracts and minimizes animation during pectoralis activity. The NS-line in the midline is respected and usually division of the muscle should be kept well below this level (2–3 cm). C Dual plane III dissection has the same type of muscle division as in dual plane II but a more extensive subglandular dissection useful in more ptotic breasts. D Dual plane IV techniques is mostly applicable in patients with severe ptosis or in tuberous breasts. The subglandular dissection in these cases is more extensive and the muscle division is much higher laterally. The division of the pectoralis muscle is more parallel to the muscle fibers but in the midline the NS-line is still respected. This creates a more true subglandular position of the lower pole of the implant especially suitable in severely tuberous breasts.

Fig. 24.22 After dual plane II dissection and implant insertion. The muscle and gland are separated to the NAC (higher in the lateral part of the breast than medially) and the origin of the muscle is divided distally but preserved in the midline along the sternum well distal to the preoperatively marked NS-line. This permits lateral muscle retraction with less flattening, banding and upward shift during animation. Only a widening of the intramammary space is frequently seen. A Relaxed. B From above relaxed. C During pectoralis muscle tightening AP-view. D From above during pectoralis muscle tightening.

Incisional approach

When using form stable implants a submammary fold approach is recommended for several reasons.² This approach is however considerably different compared to the historical and traditionally used submammary fold incision. This new submammary fold incision is an exact calculation (as described above) of the position in relation to the implant’s dimensions and the amount of glandular tissue. Also the reinforcement and/or re-creation of the fold by suturing is an important part of this new way of performing submammary fold incisions (see description below). Historically the submammary fold incision has had a bad reputation as the resulting scar was not always placed exactly in the new fold. A scar located in the submammary fold is considerably less conspicuous than a scar located in the lower pole of the breast. The axillary, periareolar and new submammary fold incisions all have both advantages and disadvantages (Table 24.1). The new submammary fold approach has more advantages and is the incision of choice when using form stable implants.

Table 24.1 Comparison of Different Incisional Approaches

The surgical procedure

Intravenous antibiotic infusion is administered 20 minutes before commencing the procedure. Gram-positive cocci are most important to cover and therefore 2 g of cloxacillin is the method of choice for the author. Also before commencing the surgery, local anesthetic infusion has several advantages, as it minimizes the depth of anesthesia and need for narcotic preparation during the procedure. It also minimizes preoperative bleeding and has a long-lasting pain reducing effect. It is interesting to observe that the pain reduction is longer lasting than the usual duration of the local anesthetics.²⁵ We have found that this regimen speeds up recovery time significantly and the majority of patients leave the clinic within three hours after the procedure. Usually up to 80 ml of local anesthetic is used per breast (1/4% xylocaine with epinephrine 5 µg/ml). Infusion is done along the incision line and the fascia and intramuscularly at the border of where the implant is to be positioned.

The incision is done through the dermis with a 15 blade and continued with electrocautery (Valley Lab Force FX and a Colorado Tungsten tip). Dissection is vertical down to the thoracic fascia, exposing this along the previously marked ILP-line. From this point dissection is proximal past the inferior border of the pectoral muscle in dual plane II–IV dissection. The lateral border of the pectoral muscle is exposed and it should be noted that there is great variation in the width and the length of the origin of the pectoralis major muscle. The dissection is carried on up to the level of the NAC, higher on the lateral border of the subglandular pocket than on the medial one to provide good retraction of the pectoral muscle in dual plane positioning. In dual plane III dissection the subglandular dissection is continued past the NAC to provide more retraction of the muscle and in dual plane IV techniques the dissection is extended even further past the NAC.

Following this subglandular pocket dissection the muscle is divided. The lateral border of the pectoralis muscle is identified and elevated with a forceps off the chest wall. The height of the muscle division depends on which type of dual plane positioning is selected. In the dual plane II (Fig. 24.21A) and III the muscle is divided distally approximately 2 cm above the ILP-line (if the origin of the pectoralis major muscle extends to this level). Leaving 2–3 cm of muscle distally provides good conditions for suturing of Scarpa’s fascia of the incision to the chest wall at the end of the procedure. In the dual plane IV (Fig. 24.21B) technique the muscle is divided higher laterally, usually all the way up to the NAC. This provides a true subglandular placement in the lower pole. This is advantageous in tuberous breasts with poor tissue cover in the upper pole and in more ptotic breasts. Lifting the muscle off the chest wall facilitates the division with the electrocautery needle tip. It is important to divide the muscle parallel to the ribcage. The benefit of this is, first, that the lateral inferior fibers of the pectoralis muscle are weakened and this minimizes later animation during pectoralis muscle activity. Second, it minimizes the risk in entering into the intercostal muscles and causing a pneumothorax. This oblique muscle division is continued until the loose connective tissue below the pectoralis muscle is visualized. A retractor is inserted and the muscle is elevated. Sharp electrocautery dissection is preferred and blunt dissection should be avoided. A proactive hemostasis is used burning all small vessels before producing any bleeding. This type of dissection can usually be done with virtually no blood loss at all. Even small amounts of hematoma may contribute to development of capsular contracture.²⁶

The sequence of dissection is first from the point of entering underneath the pectoral muscle in the direction of the sternal notch until the upper medial border of the pocket is reached.

The benefit of this is that the risk for elevation of the lateral pectoralis minor fibers is minimized. Sweeping from the upper medial part of the pocket laterally enters in the space on top of the pectoralis minor. The only area of the dissection that may be blunt is in the area of the axilla to minimize sensory nerve disturbances in the NAC. The final step of the submuscular dissection is to horizontally divide the inferior medial origin of the pectoralis major muscle. It is easiest to do this from the deep side of the muscle until fat is visualized. Dissection along the sternum in a proximal direction should be minimized. Note that the nipple–sternum (NS) line previously marked always should be respected when doing this dissection. Usually the dissection stays well distal to this position. Dissection above or to the NS line has a high risk for postoperative inferior medial irregularities of the muscle during muscle contraction. During the dissection the loose connective tissue is left intact on the ribcage by dissecting with a Colorado tip deep to the pectoralis muscle (Fig. 24.23). This loose connective tissue contains lymph and blood vessels and is protective minimizing the risk for seroma and postoperative pain. The size of the pocket usually extends the width of the implant with 0.5 cm medially and laterally, but proximally the pocket is 1–2 cm longer than the implant to provide good draping of the upper pole. The lateral subglandular dissection and type of muscle division described provides good retraction of the lateral border of the pectoral muscle and minimizes animation during pectoralis muscle activity. Only a moderate widening of the intermammary space is seen in the majority of cases during muscle tightening. As bleeding or exudation through drains with this technique is negligible, usually drains could be avoided. However, in secondary breast augmentations drains are usually used.

Fig. 24.23 In submuscular implant insertion sharp dissection with electrocautery on the deep side of the muscle and proactive hemostasis without bleeding is recommended. This leaves the loose connective tissue on the ribs preserving innervation and blood vessels minimizing the risk for seroma and pain.

In the subglandular or subfascial dissection it should be emphasized that it is easy to underestimate the height of the pocket dissection. This should be measured with a ruler before implantation and the height of the implant pocket when using form stable implants should exceed the height of the implant by at least 1 cm. The width of the dissection should, however, only exceed the implant width by approximately 0.5 cm on each side. If the height of the pocket is under-dissected there is a risk for buckling of the upper pole of a form stable implant, which can produce visibility and palpability of the implant. If the submammary fold is lowered in patients with contracted lower pole breasts, radial division of the gland is recommended to minimize the risk for double bubble deformity.

Implantation

It is recommended to minimize contamination of the implant during implantation. Contamination of the implant surface may produce a biofilm and contribute to development of capsular contracture.²⁷ To minimize contamination several steps are vital: as previously mentioned prophylactic antibiotics should be administered intravenously before the start of the procedure. The submammary fold incision minimizes contamination of Staphylococcus epidermidis known to exist in the gland of the breast. To further minimize contamination a protective adhesive tape on the nipple during the procedure is recommended (Tegaderm). Irrigation of the implant pocket with Betadine or antibiotic solution has also been recommended.²⁸^,²⁹ During implantation the so-called ‘no-touch technique’ is also another step in minimizing implant contamination. The no-touch technique involves glove change to powder free gloves and placement of a clean drape below the breast. When the package of the implant is opened it is only touched by the surgeon and implanted directly with care in an incision that is large enough to minimize the manipulation of the implant. Too small an incision may also create a fracture and irregularity of the form stable gel. Some type of lubrication such as Betadine or saline solution on the implant surface further facilitates implantation. If a shaped implant is inserted at 90° where the top of the implant first is rotated into the pocket this also facilitates implantation. When the marking dots along the vertical axis of the implant are seen at the lower border of the breast and half of the implant is in place in the implant pocket, pushing the left, right and deep side of the implant usually easily positions the implant in the correct place. Before finalizing the procedure the implant border should be carefully palpated to see that it fits snugly into the implant pocket without irregularities and folds and that the vertical axis of the implant is correctly positioned. Finally, the lower pole of the implant is positioned along the previously marked ILP-line.

Incision closure

An important step of the procedure is the re-creation of the submammary fold. This is especially true when the submammary fold is lowered or other situations where the ILP-line and incisions are not at the same level. A strong grip into the thoracic fascia with a 3-0 or 2-0 Monocryl suture along the ILP-line and the lower border of the implant is taken (Fig. 24.24). A horizontal grip at the supra-Scarpal fascia level of the incision (above and below) is placed. Usually a middle stitch is first inserted and left untied, followed by a lateral and medial closure of the wound in a similar fashion. With these three deep sutures the incision is pulled down to the new submammary fold. This deep closure is followed by deep dermal relaxing stitches in a ridge fashion. These ridging sutures take a good grip of the dermis far away from the wound edges and are positioned deeper in the dermis at the wound edge. When these stitches are tied a very strong relaxation of the deep dermis is achieved and a ridging appearance of the incision is noted. This is finally followed by a subcuticular running stitch, also in a ridged fashion, to provide good long-term relaxation of the scar. Usually Monocryl 3-0 is used in all layers of the closure.

Fig. 24.24 A After implant insertion but before closure. B After suturing between the supra-Scarpa’s fascia level and the thoracic wall. This pulls down the scar to the new submammary fold and provides much better condition for an inconspicuous scar. Compare the position of the incision to A. C Compare left and right side, where the right side has sutures between Scarpa’s fascia and the thoracic wall and the left side only has subcuticular suture closure.

Pitfalls and How to Correct

With the introduction of form stable shaped and round implants breast augmentation surgery has entered into a new era. With this we have been forced to be more analytical and exact in our implant selection and preoperative planning taking not only patient desires but also the biological prerequisites into consideration (Figs 24.25–24.28). The surgical technique is also much more precise. This new era is more demanding and has a steeper learning curve, but on the other hand it has increased the predictability and speed of breast augmentation procedures. The need for preoperative sizers is virtually non-existent because the planning is so precise and much more accurate. This has also resulted in very favorable and long-term stable results with higher patient satisfaction and a reduced risk for rupture and reoperations. Even if this is not the globally predominant technique in breast augmentation today it is the author’s belief that this new era represents the future in breast augmentation surgery.

Fig. 24.25 Form stable implants are well suited to expand the lower pole of the breast A before and B 6 months postoperative (style 410 FM model 350 g subglandular implants).

Fig. 24.26 A Before breast augmentation with a desire for a large, but still proportionate breast augmentation. B After dimensional planning and insertion of form stable extra projectioning implants six months postoperatively (style 410 MX 370 g).

Fig. 24.27 A Having decided the ideal implant width and height during the implant selection process, the last dimension to decide is the projection. This depends on patient desires but also on the tissue condition. A good way to communicate this with the patient is to show projections of different implants in front of the mirror. The patient should then be standing obliquely observing the breast that is furthest away. The implant is compressed on to the chest wall (here an FM 350 g implant). During this procedure the arms should be elevated 45° above the horizontal plane. B Oblique view with arms hanging preoperatively. C Oblique view of the situation six months postoperatively with what the patient perceived as a good prediction of the outcome preoperatively.

Fig. 24.28 Another way to communicate implant projection is to show the projection of different implants for the patient in front of the mirror using a caliper extended equal to the projection of the implant and pushed into the glandular tissue to simulate the compression of the gland by the implant. A Demonstration of the estimated border of low projecting implant. B Demonstration of the estimated border of an extra projecting implant. Most patients can well perceive if they desire to be in the low or extra projecting range of implants.

Between December 1995 and July 2008, 10,120 form stable high cohesive silicone gel implants were inserted at Akademikliniken. Throughout this period the number of form stable shaped implants has increased from 20% to more than 90% of cases performed. Most of the implants inserted were the Allergan Style 410 implants, but in recent years growing numbers of Allergan Style 510 have also been inserted (Fig. 24.30).

Fig. 24.30 A One year after a mastopexy augmentation with suturing between the supra-Scarpal fascia level and thoracic wall in the submammary fold. Note that the submammary fold of this inverted T-incision is the least conspicuous compared to the vertical and periareolar part of the incision. B One year after breast augmentation with hanging arm with incision positioned exactly in the submammary fold. C One year after breast augmentation during arm elevation straight above the head. The scar is still positioned in the fold.

Our earlier results using shaped form stable implants were published in Clinics of Plastic Surgery 2001,² and with these early results the reoperation frequency was 5%. Long term this reoperation frequency has increased to 11% as calculated per patient and most of these were related to inability to control capsular formation (6% capsular contraction and non-adhesion including rotation).

Rotation may be seen in primary augmentation surgery and this may be related to poor surgical technique with overdissection of the implant pocket; thus the surgical technique for use of form stable implants has to differ compared to use of non-form stable implants (see Surgical technique above). Rotation has however in our experience been uncommon and accounts for 0.42%² to 0.7%³⁰ of reoperations. The texturization of the envelope should have a pore size of >300 µm to allow tissue in-growth and fixation.³¹^,³² Without fixation to surrounding tissues the risk for rotational problems increase. Texturization also minimizes capsular contracture.³³^–³⁸

The formation of a so-called pseudo-capsule or double capsule can be another explanation for late rotations of anatomic implants. One reason for this may be a subclinical infection with the formation of a biological film on the implants. Another possible explanation is that seroma is formed around the implant early after implantation. Excessive movements creating a traumatic dissection or rupture between the two layers of the capsule is another possible explanation for rotation of anatomic implants.

To minimize the risk for rotational problems in secondary cases it is recommended that a new implant pocket be made. Smooth-walled implant pockets do not permit tissue ingrowth into the texturing of the implant. The creation of a neosubmuscular pocket was described by the author in the late 1990s and this is a good way to treat complications such as rotation, descent, poor animation during pectoralis activity, etc. (Figs 24.11, 24.17 and 24.29). The capsule is then exposed and followed proximally without removal of the old implant. The dissection is carried on as far as possible until it becomes technically difficult, the implant is then removed and the capsule stretched distally with vessel clamps and the dissection is carried out between the capsule and the muscle until the appropriate pocket is created. The incision in the capsule is closed and the anterior capsule is left behind as the posterior wall in the new implant pocket. Secondary cases should always be drained when using form stable implants.

Fig. 24.29 A Before secondary breast augmentation (submuscular responsive silicone gel implants) during pectoralis muscle activity. B Relaxed pectoralis muscle side view. C During pectoralis muscle tightening after proper inferomedial release of the pectoralis muscle 6 months postoperatively and exchange to form stable shaped implants. Implants positioned in a new submuscular pocket leaving the old implant capsule behind. D Side view of the same patient with relaxed pectoralis muscle. E The submammary fold incision used during the secondary procedure. F The axillary incision used during the primary procedure. Axillary incisions do not permit dual plane II–IV dissection and thus have less favorable pectoralis muscle animation.

Postoperative Care

Modern surgical techniques have dramatically improved the recovery after breast augmentation surgery and it is generally accepted that a 24 hour recovery period is feasible.³⁹ To speed up the recovery the postoperative regimen is also of importance. A sports bra is kept around the abdomen during the procedure and after dressing of the wounds (Micropore tape, 3M Co.), the sports bra is put in place on the breast as the only supportive garment. In the recovery room arm movement is encouraged and the patients are asked to put their hands on top of the head as soon as they wake up. This muscle stretching minimizes postoperative pain according to the experience of the author. This type of muscle stretching and movement is performed once or twice per hour during the first postoperative day. Within 24 hours most patients resume normal activity, but are instructed to minimize too vigorous activity as this may increase seroma formation. Patients are allowed to shower the day after the surgery with surgical tape on the wound. Patients are also instructed to avoid exercise that produces sweating during the first 3 postoperative weeks. After three weeks patients can resume gym activities but should avoid bouncing movements such as trampoline jumping, horseback riding and jogging. Bouncing movement may be negative for tissue ingrowth into the implant surface. Non-adhesion of the implant has been noted in 0.7% of patients.³⁰ It is not known how long tissue ingrowth or fixation of the implant takes to occur, but this process is expected to be finalized at 3 months, possibly sooner. During the first 3 months patients are also instructed to minimize excessive scar tension. Movement that puts perpendicular strain on the wound, for instance the tennis serve movement, may increase scar widening. Patients are also instructed to keep Micropore tape on their scars for 6 months. The tape is changed at the first follow up 1 week after the procedure and the ends of the subcuticular running Monocryl stitches are cut at the skin surface. The surgical tape could be left in place during showers and normal daily activity but usually it starts to peel off after 1–2 weeks and is then changed after washing and drying of the scar followed by reapplying new tape. This regimen minimizes the risk for widening of the scar and also helps it to mature.

With the suture technique and postoperative regimen described it has been noted that 94.5% of the patients have an inconspicuous scar (Figs 24.29 and 24.30) less than 1 mm wide located at the fold both with arms lowered and elevated on top of the head. 3.1% of patients have an atrophic, slightly widened scar and 1.6% of patients have a scar that is wider than 2 mm, but still atrophic, 0.8% had a tendency for hypertrophy.¹³

References

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