Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

T E C H N I Q U E S 1308 Part 4 Plastic Surgery of the Breast

TECH FIG 5 • A. Irrigation of breast pocket prior to implant placement. B. Insertion of breast implant into subglandular pocket with Keller funnel. C. Hand-assisted implant pocket assessment and breast tissue redraping. D. Note the pocket control and the medial projection of the implant in the supine position.

■■ Once the implant is in the pocket, a finger-assisted assess- ment and manipulation of the implant within the pocket is necessary to confirm its proper placement and assure appropriate redraping of the breast parenchyma over the implant ( TECH FIG 5C ). ■■ This maneuver is especially important with textured devices, as these implants are less mobile and less likely to stretch the pocket and, thus, a distortion or wrinkling of the implant in a tight pocket may be per- manent if not resolved before closure. ■■ Repeated removal and insertions of the implant should be avoided to minimize implant or incision damage, potential contamination, and pocket over- dissection. This is especially important with shaped implants, as a stretched pocket from over manipula- tion could lead to implant rotation postoperatively ( TECH FIG 5D ). Pocket Closure ■■ Before incision closure, the patient should be placed in the upright position to assess implant position, fold posi- tion, and symmetry ( TECH FIG 6A ). ■■ The inframammary approach is useful to control the fold position during the final closure.

■■ The cuff of superficial Scarpa fascia that was preserved during the initial incision is used to secure the fold dur- ing closure. ■■ If the IMF structure is stable, and was not violated or lowered during the pocket formation, reapproximation of the superficial fascia during closure is usually adequate. ■■ If the fold is mobile from inherent weakness or was dis- rupted with fold lowering, the pocket closure should include stabilization of the fold. ■■ Fold stabilization is accomplished by incorporating the deep fascia in the closure. ■■ The Scarpa fascia cuff is sutured to the deep fascia in the lower incisional edge during the closure of the IMF ( TECH FIG 6B ). ■■ Both the periareolar and inframammary incision are closed in three layers: deep fascia/parenchyma (2-0 Vicryl running), deep dermis (4-0 PDS interrupted), and subcuticular (4-0 PDS running) ( TECH FIG 6C ). ■■ Periareolar incisional closures do not stabilize the fold structure as it does with an IMF incision closure. ■■ If using a textured device, the implant must be seated at the desired position at the base of the breast pocket because it is less likely to settle in the pocket postop- eratively as can be seen with smooth breast implants ( TECH FIG 6D ).

TECH FIG 6  • A. Patient sitting upright prior to final closure to assess for symmetry and final aesthetic result. B. Fold stabiliza- tion with a 2-0 Vicryl incorporating the deep fascia in the Scarpa fascial closure.