Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

T E C H N I Q U E S 1306 Part 4 Plastic Surgery of the Breast

Pocket dissection

■■ The dissection should be directed in an inferior direc- tion to ensure that the nipple-areolar complex (NAC) is not inadvertently undermined during dissection and the blood supply compromised. ■■ Dissection proceeds either directly through the breast tis- sue (transparenchymal) to the pectoralis fascia or infe- riorly under the skin (subcutaneous) until the fascia is reached at the fold. The authors prefer the transparen- chymal approach ( TECH FIG 2D,E ). ■■ With the subcutaneous periareolar approach (like the IMF approach), the breast elevation and pocket creation begins at the fold and proceeds superiorly in the subglan- dular plane. ■■ The IMF is a fusion of the deep fascia attached to the pectoralis and the superficial fascia of the breast. ■■ Care is taken to prevent disruption of the IMF as the breast is elevated off the pectoralis fascia. ■■ If the transparenchymal periareolar approach is used, the dissection is directed through the breast down to the pectoralis fascia. ■■ The subglandular pocket is then developed as an infe- rior flap and superior flap with its overlying breast tissue, creating a continuous pocket superficial to the pectoralis muscle fascia. TECH FIG 2  • A. Periareolar incision noted with dark purple line . B. Periareolar incision along inferior border of NAC. Solid black line is the IMF. C. Periareolar incision along inferior border of NAC with counter tension. Be careful not to aggressively undermine the NAC. Solid black line is the IMF. D. Schematic of the transparenchymal and subcuta- neous approach. E.  Periareolar transparenchymal approach with electrocautery. Solid black line is the IMF.

Periareolar incision

D

Transparenchymal dissection

Subcutaneous dissection

Periareolar Incision

■■ Development of the periareolar incision differs slightly based on either subglandular or subfascial implant placement is intended. The differences are distinguished below. ■■ The planned incision location is marked directly on the border of the inferior areolar and breast skin with a series of dots. ■■ The dots are used instead of a line for more accurate visualization of the exact areolar border. ■■ It is most important to follow the exact outline of the areolar border even if irregular because any deviation off the border to smooth the incision outline leads to a more visible scar ( TECH FIG 2A ). ■■ The planned incision should extend equidistance medial and lateral from the midline but not to exceed half of the circumference of the areola. ■■ With the skin placed under tension by the assistant, the incision is made precisely on the areolar border with a no. 15 blade through the skin to the mid-dermis ( TECH FIG 2B ). ■■ Dissection then proceeds through the deep dermis and breast parenchyma with electrocautery. ■■ The skin edges are retracted inferiorly and superiorly, and dissection is carried down through the parenchyma toward the pectoralis fascia ( TECH FIG 2C ).

Subglandular Pocket