WP Chung O T in in Breast Surgery, Trunk Reconstruction and

1

Section I: Augmentation Mammoplasty

Transaxillary Breast Augmentation

C H A P T E R

Louis L. Strock

DEFINITION

moderate plus profile silicone gel device. Other options considered included the same device type in moderate and high profile versions, and a moderate height, moderate projection shaped highly cohesive gel device. She stated preference of a partial subpectoral plane of placement over a subfascial approach. Incision choices offered to this patient included inframammary and transaxillary, with the latter preferred by the patient to attempt to avoid incisions visible on her breasts. Nipple reduction was requested by the patient, to be performed following completion of the breast augmentation procedure and access incision closure. Equipment ■ A standard HD endoscopic tower and camera are used in this procedure. This equipment is identical to that used for any subspecialty that utilizes an endoscopic tower and cam- era. The endoscope that is preferred is a 10-mm 30-degree angled scope, that is intended to fit correctly into the Emory Endoscopic retractor ( FIG 3 ). A cautery handle with a suc- tion end is used, and holds a cautery tube with a spatu- lated end. This is the basis for the dissection at the heart of this procedure. Additionally, 4-prong Freeman skin hooks, 2 mirror image Agris-Dingman dissectors, a 1-in fiberoptic retractor with suction port, facelift scissors, and two 1-in short Deaver retractors make up the instrument set for the procedure. 1 ■ The patient is positioned with the arms out ninety degrees and straightened on armboards. All equipment, cords, and tubing are directed toward the feet of the patient in the midline. This allows for ease of transition during the proce- dure for device placement on either side. There is adequate Positioning

■■ Hypomastia. This patient requested that she have a proce- dure to enlarge her breasts in a conservative way. She also stated that she preferred to have her breast implants placed in a way that would allow her to avoid incisions on her breasts ( FIG 1A,B ). ANATOMY ■■ To manage the request of this patient, the level and shape of the inframammary fold (IMF) will be lowered with the aid of endoscopic assistance. The pectoralis major muscle and overlying fascia will be divided according to external mark- ings and correlated with internal muscle anatomy. PATIENT HISTORY AND PHYSICAL FINDINGS ■■ This patient is a 34-year-old woman who presented for breast augmentation after having had three children. She requested that her breasts be enlarged to a small C cup, with as soft a feel as possible. Her examination was remarkable for mild asymmetry, thin tissue, and large nipple size. Her breast base width measurement was 11 cm, and pinch thick- ness measurements were 1.5 cm laterally, superiorly, and medially. She was also noted to have extremely large nipples that she requested to have reduced at the time her breast implants were placed ( FIG 2 ).

SURGICAL MANAGEMENT Preoperative Planning

■ Preoperative planning centered on the choice of breast implant type in the context of her aesthetic goals and tissue type. She preferred the feel and intermediate pro- jection of a Mentor MemoryGel smooth wall, round,

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FIG 1  • A,B. Preoperative photos showing thin tissue patient. She has minimal breast volume, poor inframammary fold definition, and distinctly large nipples.

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