In many respects, quality breast surgery is as much a product of intelligent preoperative preparation and planning as it is sound technical skill. In fact, much of the most useful information that hopefully will come from this book will be contained in this chapter. As I have built my breast practice over the years, a pattern for success has emerged that has improved my personal results in both aesthetic and reconstructive breast surgery. This approach has made these results more consistent and helped tremendously in holding complications to a minimum. This approach can be divided into preoperative and intraoperative considerations.

The specifics of the standard preoperative consultation for each aesthetic breast procedure covered in this book will be addressed in the appropriate chapters. However, for all breast procedures, a preoperative office appointment 1–3 days before the actual procedure is performed is highly recommended. For a Monday surgery, this appointment takes place either Thursday or preferably Friday. At this appointment, the procedure is reviewed in detail and the goals and expectations of the patient are once again confirmed. If there was any question as to the exact nature of the procedure to be performed, these uncertainties are eliminated as much as possible and final decisions concerning breast implant size, bra cup size, incision location or implant position are determined. If there are variables or unknowns related to a specific portion of the procedure, these are once again reviewed and how these unknowns will be handled at the time of surgery are decided upon. One example of this relates to the inframammary fold. After total capsulectomy, the fold sometimes drops, which necessitates suture plication to provide symmetry with the opposite breast. This is notoriously an unpredictable and difficult undertaking and a certain percentage of patients will require a revisionary procedure to obtain the best result. While covered during the initial consult, these limitations are best stressed again at this preoperative visit to remind the patient of what the important considerations are for a specific procedure and how problems will be managed. If, in fact, complications do occur, the patient will be better educated and have a greater understanding of her condition if the case is managed in this proactive fashion. Attempting to explain complications after the fact is tolerated only by the most realistic of patients and can result in great medicolegal risk for the treating physician, even in cases where true malpractice is not even remotely an issue.

In addition to issues which fall into the category of appropriate informed consent, basic procedural matters are efficiently and easily managed at this visit. All required paperwork can be completed at this time, including history and physical completion, writing of the operative note and postoperative orders, reviewing the appropriate procedure-related preprinted discharge instruction sheets and filling out prescriptions for anti­biotics and analgesics as indicated. Arrangements for postoperative follow-up can also be made, understanding that specific times and dates may change. Such an organized approach, while somewhat labor intensive on the front end, pays significant dividends later on. Most importantly, many potential postoperative problems are eliminated because they will have been managed ahead of time. Issues such as antibiotic allergies or analgesic intolerances can be addressed at this time rather than later over the phone with nurses or pharmacists. On-call responsibilities are greatly minimized, which eliminates over-the-phone decision making. Perhaps most importantly, patient confidence in the entire process is greatly facilitated,which creates the best environment for postoperative management. All of the above enhance overall patient safety and reduce the potential for complications.

The second major goal of the preoperative visit is technical and relates to patient marking. As opposed to the often harried environment which is present in the hospital or surgical center, marking in the office allows the surgeon to apply all his or her energies to the task at hand in a quiet, controlled environment without interruption by anesthesia staff or nurses. All marking supplies will be readily available and experienced nursing staff assistance is assured. Marking done in conjunction with the administrative functions described previously assures that all issues will be addressed and greatly minimizes the potential for either significant or insignificant errors. Standard ‘permanent ink’ skin markers are used to identify pertinent landmarks as the patient stands upright in a relaxed position. Various multicolored packs of markers are available, with my personal preference being the ‘Sharpie’ brand, which offers up to 24 different colors (Figure 2.1). Bedsides the standard black and red, various other colors can be used to signify the particular surgical steps to be undertaken. For instance, areas of skin to be resected can be designated one color and areas where undermining is to be performed can be outlined in another. Any color scheme is appropriate and when this scheme is applied uniformly from patient to patient, the accuracy of the preoperative plan becomes enhanced. Essentially, the entire operative sequence is performed in the surgeon’s mind’s eye during the marking procedure with the marks documenting the surgical steps. In my opinion, the more detailed the marking pattern, the better the likelihood the proposed surgical procedure will be successful (Figure 2.2 A,B). One additional device which is quite useful is a standard laser leveler, which is available at most hardware stores. By dimming the lights and using the red laser light to reveal the true horizontal plane across the chest, accurate placement of important breast landmarks such as the top of the areola can be assured. Using this device can be very helpful, particularly in patients with preoperative asymmetries, where landmarks can be sometimes difficult to identify correctly and symmetrically (Figure 2.3 A,B).

Figure 2.1 Multicolored ‘Sharpie’ markers allow versatility and accuracy in designing and documenting a preoperative surgical plan.

Figure 2.2 (A,B) Using the multicolored markers, a detailed and visually descriptive surgical plan can be instantly appreciated. Such detailed markings are helpful not only at the time of surgery, but also later on after full healing has occurred. By referring back to the marking photographs, the accuracy and success of the overall surgical strategy can be assessed. In this way, the maximum amount of information and learning can be obtained from each patient experience.

Figure 2.3 (A) A standard laser leveler which emits a straight line laser beam can assist in evaluating symmetry from side to side in a patient. (B) By turning down the lights, the laser beam can assist in drawing patterns which are symmetric. In this case, the beam is confirming symmetry in the top of the periareolar pattern on each side.

At this point, it is very important to note the patient’s natural shoulder position. Many patients will have an asymmetry in their shoulder level, which affects the position of the breast when the shoulder is artificially raised or lowered (Figure 2.4). This asymmetry must be replicated during surgery when the patient is placed upright on the operative table to allow accurate intraoperative assessment of important landmarks such as the location of the nipple and areola or the level of the inframammary fold. Another important yet subtle maneuver to perform is the ‘arm abduction test’. Here, the patient slowly raises her arms up from the sides to a position extending straight out from the torso at 90 degrees. As this is done, the effect of this position on the shape and position of the breast is noted. In some patients, no significant change in breast shape occurs and it is perfectly acceptable to position the arms at 90 degrees on armboards at the time of surgery. However, in some patients, the breast begins to become distorted in some fashion at about 45 degrees and worsens with continued arm abduction (Figure 2.5 A–C) (DVD clips 1.02, 1.03). In these patients, it is important to position the arms on armboards during surgery at no more than 45 degrees in order to assure the most accurate intraoperative assessment of breast shape that can be obtained (Figure 2.6 A,B). This may necessitate working above the arm in some cases but is well worth the effort to afford the most control over the final result.

Figure 2.4 The preoperative appearance of a patient who is presenting for mastopexy. Failure to recognize the marked asymmetry in shoulder height could potentially lead to inappropriate surgical positioning of the nipple-areola complex (NAC) during the mastopexy procedure.

Figure 2.5 (A–C) The preoperative appearance of a patient presenting for breast augmentation. Note that, as the arms are raised, the breast begins to elevate as the arms extend out 90 degrees from the torso. In this patient, in order to obtain the most accurate information about breast shape during the procedure, the armboards would optimally be extended out only 45 degrees away from the patient to avoid breast distortion when upright.

Figure 2.6 (A,B) After wrapping the arm in preparation for sitting the patient up during surgery, the armboard can be lowered to a 45 degree angle as needed to avoid breast distortion.

Once the marks have been made, it is very important to obtain photographs which clearly document the preoperative plan. One of the greatest teaching tools a plastic surgeon can provide to ensure steady improvement as his or her practice matures is a photograph of the preoperative marks. Not only can these images provide useful medicolegal documentation, but also they can serve as effective visual reminders to support the operative note once the result has matured over a prolonged period of time. When examining the patient after full healing has occurred, often many months to a year may have elapsed. These photographs can be used to correlate decisions made at the time of surgery with their long-term result. Such information is vital to the development of an aesthetic breast surgeon. Photographic standards must also be developed and adhered to for both pre- and postoperative images. Standard views include an AP and lateral image taken from each side with the hands and arms resting comfortably against the sides. The photograph must include the tops of the shoulders and extend down to midway between the inferior pole of the breast and the umbilicus. Centering the patient in front of a crisp colored background completes an artistic image. While various shades of gray or brown are effective, it is my personal preference to use a bright blue as a background color. This tends to provide a pleasing contrast to the patients skin color, which enhances the visual effect of the photograph (Figure 2.7 A–C). Additional views particular to the individual procedure can also be included. These additional views commonly include 3/4 views, both arms overhead, bending forward slightly to visualize implant wrinkling, breast elevation to expose scars and hands pressing in against the sides to show the effect of pectoralis major muscle contraction on breast and implant shape (Figure 2.8 A–G).

Figure 2.7 (A–C) Standard photographic views obtained during preoperative evaluation include an AP and straight lateral of each side.

Figure 2.8 (A–E) Additional views obtained as needed include 3/4 views, arms elevated, bent over position to reveal implant wrinkling and breast elevation to reveal the appearance of scars. (F,G) Also, by placing the hands on the hips and squeezing inward, contraction of the pectoralis major muscle can be initiated and the effect of this contraction on the position and shape of the implant can be documented. In this case, a significant upward displacement with distortion was documented, which was the major source of this patient’s dissatisfaction after her subpectoral breast augmentation.

It is strongly recommended to utilize the tremendous advances which have been made in digital photographic technology when building the photo suite. The ability to view the photos immediately ensures that proper views have been obtained and are of good quality. The images can also be printed immediately and taken to surgery the next day, a practice which is highly recommended to assist in intraoperative decision making. Storage is also easily facilitated and immediate recall of patient-specific images is performed without difficulty, a fact which streamlines subsequent pre- and postoperative comparison of results.

Lighting is a critical variable in the generation of high-quality images. A good basic photographic studio is relatively easy to set up and should include a backdrop with an even contrasting color (blue is recommended) and at least two photographic lights with diffusing umbrellas. The lighting system must be adjustable and synched to the camera for best results. Any camera store or photographic supply business can equip a basic studio, which can be up and running immediately.

I would add a special note about photography. There are clearly inappropriate images and poses, which continue to be presented at major meetings and published in books and journals even today. In any breast image, the patient’s face must not be visible. Uniformity in magnification and framing indicates a careful and considered approach to the entire presentation of the case, which can only enhance the professionalism which is demonstrated. Backgrounds which include light sockets, power cords, doorknobs and windows bespeak a lack of concern for detail and detract from the overall result, no matter how aesthetic. In short, there is not enough emphasis which can be given to proper attention to photographic detail.

Preparing for surgery begins before the patient even enters the operating room (OR). Here, an experienced surgical staff or a dedicated nurse working closely with the surgeon can greatly facilitate the preparation of the room. Perhaps the most important piece of equipment required to successfully complete the case is the operating table. The table must sit up to 90 degrees to allow the patient to be placed upright intraoperatively. This maneuver allows the breast to be evaluated with the patient in the sitting position, a process which facilitates successful intraoperative decision making. Many operating tables do not have this capability or only sit up partially to 45 degrees or less. These tables are of limited utility and ideally would be replaced with a table that sits up a full 90 degrees to allow the best results to be obtained (Figure 2.9 A,B).

Figure 2.9 (A,B) To be most useful, the operative table should have the capability of being raised a full 90 degrees to allow upright evaluation of breast shape.

Once in the room and after the successful induction of anesthesia, the patient is positioned so the head is directly at the top of the table and is well supported by a foam headrest (Figure 2.10). This assures that the tops of the shoulders can be incorporated into the surgical prep without risk of contamination by pillows, towels or other types of head wraps commonly placed by the anesthesia staff. The arms must then be secured to allow the patient to be placed upright safely during surgery. Armboards are placed at shoulder level and foam pads are placed under the arms. The arm is then secured to the board and the foam pads with a soft gauze towel followed by a gentle circumferential wrap of gauze which runs from the axilla to the hand. This even application of pressure gently secures the arm to the armboard without risk of nerve compression during what can be long operative procedures (Figure 2.11 A–C). It is imperative that a single constricting band not be used to secure the arm to the armboard as this can lead to a troublesome pressure point and possible nerve compression. The armboard is then adjusted to an angle which will not distort the breast once the patient is placed upright. To relieve pressure on the back while upright, a pillow is placed under the knees and foam pads positioned under the heels to prevent pressure necrosis (Figure 2.12). It can also be very helpful to position the patiently preliminarily into a mild beach chair position before the surgical prep. By elevating the back of the OR table 20 to 30 degrees and flexing at the hips slightly, a head start on the upright position which will be used during the operative procedure can be obtained. This will make placing the patient upright during the procedure easier and may reduce anxiety on the part of the OR staff who may be unfamiliar with the upright position. Also, any tethering points which may have been created during patient positioning can be appropriately and easily identified and corrected (Figure 2.13). It has been our practice to utilize a heated air-warming device for all cases, no matter how long or short the planned procedure is, and this warming blanket is applied to the lower body as a final maneuver in preparation for applying the surgical prep (DVD clip 1.04).

Figure 2.10 After the induction of anesthesia, a foam headrest is positioned under the head to prevent unwanted movement or twisting of the head and neck when the patient is placed upright during the procedure.

Figure 2.11 (A–C) To prepare for the upright position, the arm is first placed on a foam pad. A towel is then gently wrapped around the arm to secure it to the armboard over a wide area of contact; this is then secured with a soft gauze wrap. This prevents any pressure points from developing, which could possibly result in nerve compression.

Figure 2.12 A pillow is placed under the knees to relieve stress on the lower back and foam supports are placed under the heels to prevent any possibility of pressure-induced localized ischemia.

Figure 2.13 Before prepping the patient, it is sometimes helpful to place the OR bed in a mild preliminary beach chair position. This allows any tethering points to be identified and makes it easier for the patient to be raised into the upright position during surgery. In selected cases where patients may present with limited mobility due to previous injury or surgery, this maneuver can be performed with the patient awake to ensure that the position is comfortable for the patient.

During the surgical prep, it is mandatory that the tops of the shoulders be included and then appropriately draped to allow assessment of the shoulder position when upright (Figure 2.14). Here, it may be necessary to adjust the shoulder position to recreate any preoperative asymmetries which were noted during the preoperative evaluation. Finally, it must be stressed to the nursing staff that the previously applied marks not be completely washed off for obvious reasons.

Figure 2.14 In order for the shoulder level to be visualized during surgery, the prep must extend over the top of the shoulders to allow the drapes to be placed high enough for the shoulder level to be assessed with the patient upright.

The preoperative photos are taped to IV stands at the head of the table so they can be readily consulted as needed during the procedure. It is very helpful to run all cords and tubing related to electrical equipment and suction downward toward the foot of the bed as these tend to interfere with the process of placing the patient upright.

When the decision is made to sit the patient up, it is very important to bring the back of the bed up to at least 80 degrees. It is in these last few degrees that the breast can be seen to settle significantly under the influence of gravity. Only then and with proper attention to shoulder level and the angle of the armboard can the most accurate assessment of the breast be made (Figures 2.15 A–D and 2.16 A–D).

Figure 2.15 (A–D) When observing from the side, as the patient is elevated from supine (A) to first 30 degrees (B), then 60 (C) and finally 90 degrees (D), the shape of the breast can be seen to change dramatically. Under the influence of gravity, the lower pole of the breast fills out and a concavity in the upper pole becomes apparent. Significantly, a continuing change in the shape of the breast is noted even as the patient moves from 60 (C) to 90 (D) degrees. This observation underscores the importance of placing the patient as upright as possible during the procedure to obtain the most accurate assessment that can be made of the shape of the breast during the procedure.

Figure 2.16 (A–D) When observed from the front, the same observation can be made. As the patient is elevated from supine (A) to first 30 degrees (B), then 60 (C) and finally 90 degrees (D), the shape of the breast becomes progressively more ptotic. In moving from 60 to 90 degrees, the position of the nipple–areola complex (NAC) relative to the position of the breast mound changes in a slight but significant way. Failure to recognize these relationships can lead to a host of postoperative shape and position problems in both the breast and the NAC, which can detract from the overall result.

Finally, after careful preparation at each step along the way, every possible variable that can interfere with the performance of a smooth and controlled operative procedure will have been accounted for. With all of these details properly attended to, the full attention of the surgeon can be focused on the procedure at hand and the best environment for success will have been created. All that remains is for the surgeon to apply his or her own technical expertise in a fashion that will provide the best result possible.

The importance of a detailed approach to preoperative preparation and planning cannot be overemphasized as it relates to delivering consistent results in aesthetic breast surgery. By incorporating the preoperative principles of management and preparation described in this chapter, the environment for surgical success is optimized and the best chance for an optimal result is created. Incorporation of these principles and practices is strongly recommended as a means to provide quality results in a consistent fashion.