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

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Chapter 1 Transaxillary Breast Augmentation

FIG 2  • Frontal markings show plan to lower the inframammary fold to accommodate dimensions of device to be used.

separation of the anesthesia equipment from the head and shoulders of the patient to allow the surgeon to stand above the shoulder on each side during the endoscopic tissue release portion of the procedure on each side ( FIG 4 ). Approach ■■ The procedure can be performed adequately in this patient with use of inframammary or transaxillary approaches for incision access. The periareolar approach is more difficult given the relatively small size of the areola in this patient. Her thin tissue makes a partial subpectoral, or dual plane, approach preferred to maximize soft tissue cover over the implants. FIG 4  • All equipment is positioned at the foot of the bed, including the endoscopic tower. All cords are kept in a central position to prevent hav- ing to move them during the procedure, regardless of which side is being augmented. The patient is positioned with the arms out at 90 degrees. The endoscopic portion of the procedure is performed with the surgeon above the shoulder.

FIG 3  • Instrument tray used for the procedure. The Emory Endoscopic retractor is with paired 10-mm 30-degree-angled endoscope. The cau- tery handle has a suction port in back, and a hub for hollow cautery rods with spatulated ends. The author prefers mirror image J-shaped rods, but other variants are available. Four-prong skin hooks, two mirror image Agris-Dingman dissectors, two 1-in. Deaver retractors, facelift scissors, and Adson-Brown forceps complete the set.

T E C H N I Q U E S

■■ Incision and Initial Dissection

■■ An S-shaped incision was planned, centered in the axil- lary apex ( TECH FIG 1 ). This incision pattern was selected because it allows for a long functional length in a patient with a narrow area of hair-bearing skin in the axilla. The long portion of the incision was marked within the lon- gest existing skin crease. The anterior extension is placed to stay behind the posterior aspect of the pectoralis major muscle. This is critical to keep the incision hid- den during recovery. A cross-hatch is made centrally to facilitate skin closure. The incision is made through the hair-bearing skin to the subcutaneous tissue. The ante- rior skin flap is raised in an anterior direction toward the lateral edge of the pectoralis major muscle. The skin flap is kept thin to avoid entry into the axillary contents. This helps to avoid damage to the intercostobrachial nerve. Once the lateral border of the pectoralis major muscle is identified, its fascia is incised, and the subpectoral space is entered under direct vision. A finger sweep technique is used to further develop the separation between the pec- toralis major and pectoralis minor muscles.

TECH FIG 1  • In this patient, an S-shaped incision was planned. This incision design was used due to the narrow width of the seg- ment of hair-bearing skin. This design permits a longer functional length to attempt to minimize potential damage to the device during placement, and minimize ultimate incision visibility during recovery.

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