Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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Part 4 Plastic Surgery of the Breast

PEARLS AND PITFALLS Live by the pinch

■■ A pinch test of less than 2 cm should guide the surgeon away from subglandular and subfascial pocket creation. ■■ Implants that are more prone to rippling (eg, textured implants, saline implants) or poor quality soft tissue might require an even thicker soft tissue coverage and a pinch test of more than 3 cm may be warranted. ■■ No muscle sternal attachments encountered in subglandular or subfascial plane. Symmastia prevention is important. ■■ If IMF is mobile, disrupted or lowered, the closure must incorporate the deep fascia to secure the fold. ■■ Textured implants in the subglandular/subfascial pocket, no-touch technique, nipple shields, pocket ir- rigation with triple antibiotics, insertion sleeve, submuscular implant pocket, inframammary incision, and cohesive-shaped implants. ■■ Precise pocket dissection to minimize malposition, rotation, lateral drift. ■■ Avoid undermining the NAC to minimize disruption of the blood supply to the nipple. ■■ Use the cut current to facilitate elevation of the thin fascia. Fascia thickens as you move superiorly. ■■ Divide pectoralis muscle 1 cm above the fold to the transition point, thin along the transition zone, and release only accessory muscle slips along sternum to prevent wrinkling and window shading of muscle. ■■ Place implants submuscular and create a subglandular pocket in the lower pole with a dual plane to optimize breast tissue-implant relationship. ■■ If you cannot lift the muscle (pectoralis major) off the chest wall, do not cut it.

Avoid midline overdissection

Control the fold

Reduce capsular contracture risk

Pocket control

Periareolar incision

Subfascial pocket entry Submuscular pocket entry Respect the transition point and zone Optimize submuscular dual plane

POSTOPERATIVE CARE

■■ Whereas smooth implants often seem high initially and often require downward massage and the use of breast bands or bandeaus, textured devices that are appropri- ately seated in the base of the breast pocket should only occasionally require such maneuvers. ■■ Whereas smooth implants will seem more mobile and softer in the first few weeks after surgery in comparison with textured devices, the textured implants will soften with modest movement often present after 4 to 6 weeks. OUTCOMES ■■ Preoperative and postoperative photos of bilateral subglan- dular breast augmentation are shown in FIG 14 . COMPLICATIONS ■■ Capsular contracture ■■ Infection ■■ Malposition (symmastia, double-bubble, lateral drift, supe- rior malposition with waterfall) ( FIG 15 )

■■ Incisions are covered with Steri-strips. ■■ Contour tape is placed along the fold and lateral breast. ■■ Breasts are wrapped with a Kerlix and Ace wrap for 24 hours. ■■ For textured implants, a breast band is worn for 1 week. ■■ Early range of motion, beginning in the recovery room, is initiated for all patients, which includes shoulder rolls in both directions in addition to elevation of the arms outward to the sides and over the head. ■■ With smooth devices, implant massage begins postopera- tively on day 4 and includes displacing the implant upward and downward in the pocket, crossing the arms and pulling the implants inward to create cleavage, and downward pres- sure on the implants to stretch the lower pole. ■■ With textured implants, both round and shaped, limited arm movement other than range of motion is recommended for the first week. ■■ Implant massage with textured implants is contraindicated, because the textured surface can irritate the pocket and potentially create serous fluid around the implant. Likewise, the implants are placed in a controlled pocket with the implant positioned appropriately at the base of the pocket; displacement could lead to implant malposition or, in the case of shaped devices, rotation of the implant. ■■ Patients are allowed to resume wearing regular bras after 4 weeks but should continue with sports bras during bedtime for an additional 2 to 4 weeks to limit lateral implant move- ment during pocket formation. ■■ Normal activity resumes within a few days after surgery, but exercise and high-impact activity should be delayed for 3 to 4 weeks for subfascial and subglandular implants and 4 to 6 weeks for submuscular implants. ■■ If a variety of smooth and textured (round or shaped) breast implants are being used within a practice, it is extremely important to communicate to ancillary staff the type of device placed with each patient to initiate the appropriate postoperative protocol, as inappropriate instructions can lead to postoperative problems such as seromas, malposi- tion, and rotational deformities.

FIG 14  • Preoperative and postoperative photos of a 31-year-old woman who underwent bilateral subglandular breast augmentation through an IMF incision, with 355 cc moderate profile textured implants.

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