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

T E C H N I Q U E S 4 Breast Reconstruction for Partial Mastectomy Defects, Trunk Reconstruction and Body Contouring ■■ Optical Cavity

to not be a problem. This is performed in a uniform fash- ion to create optimal visualization of the pectoralis major muscle in preparation for the muscle release. The author feels that using the cautery to create the optical cavity is critical to avoid significant blood staining of tissues that can otherwise make endoscopic tissue dissection difficult. The key to this procedure is to avoid bleeding in the tissue pocket! ( TECH FIG 2B–D ). Though the initial descriptions of this procedure advocated use of the Agris-Dingman dis- sectors, the author has found that the occasional bloody outcome from that approach can be avoided with use of the cautery to create the optical cavity. 2

■■ Once the entry between the incision and the space between the pectoralis major and minor muscles has been defined, the endoscopic retractor is introduced. Once correctly positioned, the 10-mm 30-degree-angled endoscope is brought into the operative field and placed into the retrac- tor sheath. The camera head on the endoscope is checked for proper orientation, a critical step to ensure safety with the technique. The suction cautery is then used to create an optical cavity from the undersurface of the pectoralis major muscle ( TECH FIG 2A ). Staying on the undersurface of the muscle allows for variations in rib cage anatomy

TECH FIG 2  • A. The endoscopic equipment is used in a way that ensures proper orientation of the endoscopic tower. The camera head is checked to confirm correct alignment and orientation for the endoscopic dissection. The suction cautery allows for successful smoke evacuation, vital to correct endoscopic visualization. B–D. Endoscopic view of the entry into the subpectoral space. Note areolar plane and lack of anatomic markings. Orientation on this right sided dissection is as follows: left is medial, right is lateral, the rib cage is inferior, and the pectoralis major muscle is superior. The optical cavity is created using the cautery off the undersurface of the pectoralis major muscle. The entire base of the pectoralis major muscle is dissected to complete creation of the optical cavity.

■■ Pectoralis Major Muscle Release

to dissect in a very controlled and limited fashion in a plane superficial to the lower muscle cuff. Because of the magnification of the endoscope, limited tissue cuts make powerful and significant changes in the area of the IMF. Transillumination can again be used to confirm that the release is to the desired level of the new IMF. The muscle edges of the upper and lower cuffs are inspected and con- tacted with the cautery if any bleeding points are noted. It is of critical importance that overdissection be avoided! ( TECH FIG 3E–G ) Additionally, it is critical to understand that when planning to lower the IMF, the actual release of the pectoralis major muscle should never be below the existing IMF , as such a release will consistently result in a double bubble deformity. If the goal is to maintain the IMF at the same level without change, then the pectora- lis major should be divided at a level 1.5 to 2 cm above the existing IMF. When properly performed, visual clarity afforded by the endoscope allows for the prepectoral fas- cia to be divided or maintained as needed.

■■ Successful creation of an optical cavity facilitates release of the pectoralis major muscle. The first step to release of the pectoral muscle is to correlate internal anatomy with exter- nal landmarks. This is the key step to the technical control needed to control the level and shape of the IMF ( TECH FIG 3A–D ). An advantage of the axillary approach is that, when performed as described, the surgeon has a direct and clear view of the pectoralis major muscle and fascial layers that cannot be matched with an inframammary approach. Additionally, the incision itself has no bearing on the IMF or the level it is placed. ■■ In the patient shown, the plan was to lower the IMF. The initial muscle release is performed to divide the muscle at a level several millimeters above the existing IMF, medial to lateral, again carefully correlating external landmarks to internal anatomy. Transillumination can be very helpful in confirming that the muscle has been divided at the desired level. Once this has been confirmed, the cautery is used

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