The senior author Dr. Randquist has developed an easy and understandable system when calculating the positioning of the implant and IMF incision by controlled lowering of the inframammary fold as illustrated in Figure 23.2. Randquist’s experience is that highly cohesive, textured, form-stable gel implants in a precise pocket work as controlled tissue expanders. As such, depending on how the volume of gel is distributed in the implant, it will apply tissue expansion and skin stretch where most of the gel is distributed. Once the cohesive gel implant has expanded the tissue in accordance to predesigned shape, it does not influence or alter the breast shape or positioning any more with time. The algorithm developed for implant positioning is as follows:

Fig. 23.2 Lowering the IMF. The width of the implant generates a value for the new N-IMF distance and the new position of the IMF.

The width of the implant (IW) generates a value for the new N-IMF distance and the new position of the inframammary fold.

For example, an implant with a 12 cm width would require a lowering of the fold to 8.5 cm (± 0.5 cm). For each 0.5 cm increase in implant width, 0.5 cm is added to the lowering. IW 12.5 cm would therefore require a lowering of the fold to 9 cm (± 0.5 cm) and IW 11.5 cm would therefore require a lowering of the fold to 8 cm (± 0.5 cm). In addition, if the patient has approximately >4 cm of parenchyma in the upper pole, an additional 0.5 cm should be added. Furthermore, if the patient has a tight, firm skin envelope that does not stretch, as often is the case in patients with aplasia mammae or lower constricted pole, 0.5 cm should be added. In patients with loose, overstretched skin, as seen in patients with postpartum striatic breasts, 0.5 cm should be subtracted. The system can also be adjusted according to the surgeon’s or the patient’s aesthetic preference regarding more or less upper and lower pole fullness. However, care should be taken when adding or subtracting more than 0.5 cm even if criteria add up. This minimalistic measuring system has been used and refined over a decade, and aids the surgeon to position the implant.

Changes in positioning or lowering of the inframammary fold are not required even if an implant with the same width might have a different projection.

More projection merely means more gel distributed in the projected area, applying more expanding energy and thereby stretch over that area, elongating the N-IMF distance proportionally over time.

With the level of skin incision decided and marked, the height and width of the implant should be outlined on the patient’s chest wall. It is important to respect the medial attachments of the major pectoral muscle in order to prevent possible implant visibility or synmastia. Adhering to these basic principles should result in a perfect placement of the implants.

After the preoperative planning, including a thorough measuring and marking of the patient’s chest wall, the patient can be taken into the operating room.

Operation Technique

In the authors’ practice, the patient is placed in the supine dorsal position and anesthesia is induced using propofol and maintained by sevoflurane. The patient maintains spontaneous breathing at all times through a laryngeal mask.

Scrubbing and draping

With the patient anesthetized, a rectangular area reaching cranially just above the clavicles, laterally to the dorsal axillary line and caudally to the umbilicus is scrubbed using 10% chlorhexidine solution. The solution is allowed to dry thoroughly for optimal effect. The patient is draped using a specially designed draping set (Victoriakliniken Breast Augmentation Set, Mölnlycke, Sweden), with one large rectangular opening exposing the breasts and some surrounding skin (Fig. 23.3). Besides the drapings, the set contains everything needed for the operation except the instruments, such as needles, syringes, etc.

Fig. 23.3 Draping.

The nipple areola complex and skin incision site are covered with transparent Tegaderm film (3M Healthcare).

Double-check of preoperative markings and local anesthetics

Before proceeding with surgery, the surgeon now double-checks the N-IMF distance under maximum stretch. Checking the N-IMF distance is at times more easily done on the operating table as it requires an upward pull of the nipple which, in some patients, is painful.

To reduce postoperative pain, approximately 5 cc of lidocaine with adrenaline is injected deep into the upper portion of each major pectoral muscle (Fig. 23.4). The authors do not inject local anesthetics in the incision lines as this might cause a subcutaneous hematoma.

Fig. 23.4 Injection of local anesthetic and shields.

Surgical instruments

The number of surgical instruments used should be kept to a minimum in order to make the procedure as efficient as possible, and to minimize the pre- and postoperative work of the surgical staff. The set of instruments used by the authors has been put together by Dr Randquist for Stille instruments (Stille-Randquist Breast Augmentation Set) and comprises the following:

1. Sponge holding forceps Foerster black coated, 24 cm

2. Monopolar forceps with cable, finger controlled, 25 cm

3. Monopolar dissection needle, 120 mm, 2 pcs

4. Golden ruler, 15 cm

5. Scalpel handle no. 3 black coated

6. Stille-Volkmann retractor with 4 sharp prongs black coated, 22 cm

7. Breast retractor double-ended black coated

8. Diathermy forceps insulated, 25 cm

9. Needleholder Olsen-Hegar with scissors, TC-jaws, black coated, 18 cm

10. Mayo-Hegar needleholder, TC-jaws black coated, 14 cm

11. Stille-Rapp knot-holding forceps black coated, 13 cm

12. Mayo-Stille Supercut scissors curved, 15 cm

13. Stille forceps 1×2 teeth black coated, 15 cm

Surgery

The following section first describes the authors’ most common breast augmentation procedure, i.e. the submuscular pocket dissection and implant insertion through an inframammary incision. After this follows a description of the subglandular implant placement and, finally, a description of implant insertion through a periareolar incision. All surgery should preferably be performed from the same side of the operating table, such that the table should be tiltable.

The surgical procedure of breast augmentation can be divided into eight different steps as follows:

1. Skin incision

2. Dissection through the deep dermis and subcutaneous fat

3. Identification of the major pectoral muscle

4. Entrance into the subpectoral space

5. Creation of the subpectoral implant pocket

6. Implant insertion

7. Wound closure

8. Bandaging.

1 Skin Incision

An incision is made according to the preoperative markings using a sharp scalpel (Fig. 23.5). As discussed above, the authors’ preferred placement of the scar is in the inframammary fold where the lowest part of the IMF curve is located. The length of the incision depends on the size of the implant. A 4 cm long incision is sufficient for a 300 g implant and a 4.5 cm long incision is sufficient for a 400 g implant. These relatively short incision lengths are applicable if the surgeon is experienced in the method of inserting the implant. If necessary, the incision should be made wider in order for the implant to be inserted easily without the risk of gel rupture.

Fig. 23.5 Skin incision.

The incision is made through the epidermis and into the superficial dermis. At this point, the surgeon changes to the mono-polar needle electrocautery in order to avoid unnecessary bleeding.

2 Dissection through the deep dermis and subcutaneous fat

Using the monopolar needle electrocautery, the dissection continues down through the dermis (Fig. 23.6). For the best scarring results, care must be taken to create a clean cut perpendicularly to the skin, avoiding burns to the epidermis. The dissection continues down through the subcutaneous fat. Here, the cut should be made directly downward to the musculature without erring cranially or caudally. This part of the dissection should be swift and without hesitation, taking seconds in time. As soon as the musculature has been made visible, the surgeon switches to the monopolar electrocautery dissection forceps and continues with the muscular incision (Fig. 23.7).

Fig. 23.6 Subdermal dissection with colorado needle.

Fig. 23.7 Muscle dissection with monopoles forceps showing elevated pectoralis major.

3 Identification of the major pectoral muscle

When reaching the musculature, it is of utmost importance to identify the visible muscle or muscles and to locate the major pectoral muscle. The muscles that may be encountered at this point are: (1) the major pectoral muscle; (2) the rectus abdominal muscle; (3) the external oblique abdominal muscle; and (4) the serratus anterior muscle (often located more laterally, but at times having very medial insertions). The objective is now to locate the lower lateral insertions of the major pectoral muscle onto the ribcage. This is normally not difficult and, in the standard case, the surgeon, after having gone through the skin and subcutaneous tissue, will end up just below or on top of the lower part of the major pectoral muscle. Using the short end of the double-ended retractor, the surgeon now grasps the subcutaneous tissue and elevates the musculature anteriorly. If it is the major pectoral muscle, it will follow the movement of the retractor easily, thus displaying elevated muscle fibers traversing in direction from the chest wall and anteriorly (Fig. 23.7). The other muscles in the area will, in most cases, not behave in this fashion. The muscle is now incised laterally, perpendicular to the muscle fibers at a point approximately 5 mm above its insertion on the chest wall. Leaving a thin strip of muscle fibers at the insertion prevents blood vessels within the muscle, often intercostal perforators, from retracting into the underlying tissue.

4 Entrance into the subpectoral space

When the major pectoral muscle has been identified and incised laterally, entrance to the space under the muscle is usually not a problem. The correct entrance into the subpectoral space is often facilitated by moving medially from the lateral edge of the muscle insertions. The surgeon will often notice a natural opening, obscured only by a thin, white veil of areolar tissue (Fig. 23.8). At this point, the opening through the major pectoral muscle should be made wide enough for the broader end of the retractor to enter. The retractor should be moved forward and repositioned further and further under the major pectoral muscle as the sharp dissection proceeds cranially. The retractor is at all times kept firmly elevated in order to help continuous identification of the major pectoral muscle, avoiding any contact with the perichondrium.

Fig. 23.8 Entrance to the subpectoral space.

5 Creation of the implant pocket

The retractor is flipped over and the broader end is inserted under the major pectoral muscle. For optimal visibility during pocket dissection, the retractor should, at all times, be pulled in an anterior direction rather than in a cranial direction. Furthermore, the blade of the retractor should be inserted completely into the pocket under the muscle and the muscle should not be folded on top of the blade.

The main objective during the dissection is to create a pocket which is optimal in size with regard to height and width. The width of the pocket is determined by a correct dissection in both the lateral and medial directions.

In order to achieve a precise pocket, the dissection should follow a standard pattern, with which the surgeon must become completely familiar. The dissection described below begins in a cranial direction, continues medially and finishes laterally.

With the correct use of the retractor and maintaining direct vision, the dissection continues cranially into the pocket under the major pectoral muscle. Care must be taken not to deviate under the anterior serratus muscle or the minor pectoral muscle. Once clearly positioned under the major pectoral muscle, the dissection continues medially. The medial dissection is preferably performed using a sweeping motion with the electrocautery forceps in a craniocaudal direction. This facilitates early visualization of blood vessels, including perforators, which then can be cauterized before they are cut. Complete release of the major pectoral muscle’s abdominal and caudal sternocostal insertions are performed to about 4 o’clock on the patient’s right side and to about 8 o’clock on the patient’s left side. Dissection and release of these lower muscle insertions is essential in order for the implant to be positioned properly in a caudomedial direction.

The inside surface of the pocket should be made completely even, as any unevenness could cause visible indentions in the tissue.

It must be emphasized that the bulk of the medial attachments of the muscle, cranial to the above described 4 and 8 o’clock level should not, under any circumstances, be completely divided. This holds true even if the patient has a very wide intermammary space. If these medial aspects of the muscle insertions are divided, the risk of future implant visibility and synmastia increases. However there should be a smooth transition where the muscle is trimmed down to the last centimeter before total release at 4 and 8 o’clock (Figs 23.9 and 23.10).

Fig. 23.9 Smoothing and thinning of the muscle medially.

Fig. 23.10 Release and thinning out of pectoralis major muscle.

The dissection now continues in a cranial direction, releasing the uppermost parts of the pocket. The tissue here is very slack, consisting of loose areolar tissue. It is therefore important to be careful so that the pocket does not become too high, as the implants otherwise could be dislocated cranially. The preoperative markings are enormously helpful here, and should be followed.

At this point, the dissection continues laterally where the tissue is released to create a sufficiently wide pocket for the selected implant. Again, it is preferable to perform the dissection by using sweeping motions in a craniocaudal direction, releasing connective and fatty tissue just above the anterior serratus muscle. It is important not to dissect too wide, as this could cause dislocation of the implant laterally.

After the dissection has been performed on both sides, the surgeon should take time to palpate the pockets simultaneously using the index fingers, ensuring that all surfaces are even, that the pockets are wide enough and that the tissue release in the anterior direction is sufficient (Figs 23.11 and 23.12).

Fig. 23.11 Implant pocket check medially.

Fig. 23.12 Implant pocket check laterally.

6 Implant insertion

A double antibiotic solution of cefuroxin 1.5 g and gentamycin 80 mg is injected into the sterile box containing the implants prior to insertion, thereby soaking them.

Before the implants are inserted, it is also imperative to make sure that absolutely no bleeding is present in either of the implant pockets.

At this point, the surgeon should change to a new pair of surgical gloves and be careful not to touch anything except the implants during insertion.

Insertion of the implant into the pocket should be made in a firm and consistent fashion, with which the surgeon should become thoroughly familiar (Figs 23.13 and 23.14). The authors use a bimanual technique and the implant should be inserted with its narrowest part going through the incision. An implant with a greater height than width should be inserted with the apex first, whereas an implant with a greater width than height should be rotated 45° clockwise before being inserted. The authors use a small amount of sterile lubricating gel to aid the insertion, allowing the textured implant to slide easily on the tegaderm without foreign body contact. During the insertion, the right hand is used to massage the implant into the pocket using a squeezing motion with the palm and the fingers. The left hand is kept more fixed and aids the insertion by maintaining a constant pressure on the implant into the pocket. The movements require some practice and the incision should be sufficiently wide in order for the implant to be inserted easily, as mentioned above. If the implant is inserted using excessive force, this might cause fracturing of the implant’s gel.

Fig. 23.13 Implant insertion.

Fig. 23.14 Control of implant positioning.

Once the implant has been inserted, its correct position should be verified. By palpating the markings on the ventral, caudal surface of the implant, the surgeon can check that the asymmetric implant is not rotated. The implant’s position in the pocket medially, laterally and cranially is also checked. If the pocket seems too tight on either side, or if there are strands of tissue causing indentions in the implant, this is corrected. The surgeon should always strive toward performing perfect primary pocket dissection, which does not require any corrections once the implant has been inserted. No sizers or drains should be used, as these cause untoward traumatization and increase the risk of bacterial contamination.

7 Wound closure

A correctly performed wound closure is crucial, and this step of the procedure should also be performed in a standardized fashion. Wound closure serves several functions. As described below, a multilayer closing technique that adapts a large amount of tissue over the wound minimizes the risk of future implant visibility. Anchoring the wound to the thoracic wall defines the new inframammary fold and places the scar directly in the inframammary fold.

The wound is closed in three layers as follows. First a deep layer with three 2-0 absorbable sutures is made (Fig. 23.15). The needle is first passed through the tissue of the chest wall surface. It is important to get a good grip in the muscle fascia and musculature so that the thread does not cut through the tissue. However, the surgeon must be careful not to go too deep, thus running the risk of causing injury to the pleura. The amount of available tissue depends on the constitution of the patient, and a superficial grip in the periosteum might be needed in a very thin patient. The needle is subsequently passed through the deep layers of fat and Scarpa’s fascia on both sides of the wound before the knot is made. When placed correctly, this first row of sutures will approximate the edges of the wound.