Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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Chapter 2 Breast Augmentation: Subglandular, Subfascial, and Submuscular Implant Placement

T E C H N I Q U E S

Breast tissue

Deep pec fascia

Pectoralis fascia

Pectoralis major

A

TECH FIG 3 • A. Elevation of the overlying breast tissue with under- lying pectoralis muscle and fascia. B. Subglandular pocket with pecto- ralis muscle/fascia visible posterior to the pocket.

the lateral action of the forceful pectoralis muscle contraction. ■■ As one carries the subglandular dissection medially, the midline can quickly be violated due to the lack of sternal muscle attachments that usually limit the dis- section in the submuscular plane. ■■ The fascia is adherent to the underlying pectoralis muscle as the sternum is approached in the subfas- cial dissection and will provide some limitation to medial overdissection compared to the subglandular pocket. ■■ Overdissection can lead to implant medialization and the potential for postoperative symmastia. This is especially true when the chest wall is concave or slant- ing medially. Special caution with limited medial dis- section is warranted in these cases. ■■ Remember if IMF lowering is needed, the dissection is in the subglandular pocket, as the attachments creating the fold are superficial to the deep pectoral fascia. 20 Implant Placement ■■ Once dissection is complete, the pocket is irrigated with triple antibiotic solution (1 g cefazolin sodium, 80 mg gentamicin, 50 000 units bacitracin mixed in 500 mL of normal saline) and hemostasis is assessed ( TECH FIG 5A ). ■■ The authors as a personal preference generally remove bacitracin and add betadine solution (50 cc) to the irri- gation mixture if no allergy exists. 14 ■■ The implants are soaked in the irrigation solution before insertion. Gloves are changed and rinsed with the irriga- tion solution to remove any residue. ■■ In the authors’ practice, the implant is placed into the pocket with the assistance of an insertion sleeve such as the Keller funnel ( TECH FIG 5B ). ■■ The opening of the funnel should be cut large enough to allow easy egress of the implant through the funnel. This is confirmed by passing the implant with irrigation solution through the funnel before insertion. ■■ The implant orientation is confirmed in the funnel, and a maneuver of squeezing the implant through the funnel with pressure exerted on the back of the funnel slips the implant into the breast pocket. ■■ These maneuvers provide a “no-touch” technique, which has been associated with lower capsular con- tracture rates. 13 TECH FIG 4  • Creation of the subfascial plane. The deep pectoralis fascia is elevated with the breast tissue exposing the underlying pec- toralis major muscle.

■■ If the fold is inadvertently disrupted and the IMF lower- ing is not planned, the fold must be controlled with deep fascial sutures at the time of incision closure. ■■ Continued upward retraction of the breast will elevate the breast and its underlying superficial fascia as a single unit, leaving the deep pectoralis fascia attached to the muscle. ■■ The dissection is carried superiorly, medial and lateral to create the desired pocket ( TECH FIG 3 ). Subfascial Pocket ■■ With the subcutaneous periareolar approach (like the IMF approach), the breast elevation and pocket creation begins at the fold and proceeds superiorly in the subfas- cial 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 and underlying pectoralis fascia are elevated off the underlying pectoralis muscle. ■■ If the transparenchymal periareolar approach is used, then dissection is directed through the breast down to the pectoralis fascia. ■■ The subfascial pocket is then developed as an inferior flap and superior flap of fascia with its overlying breast tissue, creating a continuous pocket superficial to the pectoralis muscle but beneath the fascia. ■■ If the fold is inadvertently disrupted and the IMF lower- ing is not planned, the fold must be controlled with deep fascial sutures at the time of incision closure. ■■ The inferior extent of the pectoralis fascia is thin and elevation is best carried out with the cut current of the electrocautery. The superior fascia is thicker and more developed providing more easily dissected plane. ■■ Continued upward retraction of the breast will elevate the fascial plane. ■■ The fascia is left attached to the overlying breast tissue and elevated as a single unit. ■■ The dissection is carried superiorly, medial and lateral to create the desired pocket ( TECH FIG 4 ). Pocket Control ■■ As with any breast augmentation, pocket control is key. ■■ Avoid overdissection of the pocket laterally to optimize medial projection of the implant and minimize lateraliza- tion of the implant. ■■ Subglandular implants have less lateral drift com- pared with submuscular implants because they lack