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

TECH FIG 6 (Continued) • C. Image of the final closure incor- porating superficial Scarpa fascia and deep fascia as one con- sistent layer without the presence of an incisional step off. D. Downward pressure on the implant/breast demonstrates a locked and stable IMF.

■■ Submuscular (Subpectoral) Implants Inframammary Fold Incision ■■ Although the submuscular pocket can be accessed by any incision (periareolar, inframammary, transaxillary, tran- sumbilical), the most common approach is through the inframammary incision. ■■ After determining the IMF position (either the native true fold position or the planned lowered position), a para- median line is drawn through the center of the breast and bisects the newly drawn IMF. ■■ The incision’s medial extent begins 1 cm medial to the paramedian line and extends laterally for the appropriate distance, as previously described based on the implant type (see TECH FIG 1A ). ■■ The incision is made with a no. 15 blade through the skin to the mid-dermis (see TECH FIG 1B ). ■■ Dissection is then carried out with electrocautery through the skin and subcutaneous tissue, beveling superiorly while rotating the breast off of the chest wall. ■■ Once dissection has been carried superiorly for 1 cm, the dissection is carried through the superficial fascia and toward the lateral pectoral border deep on the chest wall. ■■ The beveling preserves a small cuff of superficial fascia at the incision, which ensures that the fold is not inadver- tently lowered and also provides a cuff of fascia that will prove useful during closure (see TECH FIG 1C ). ■■ Dissection is carried down toward the chest wall while maintaining a constant upward retraction of the breast tissue, ultimately exposing the lateral edge of the pecto- ralis muscle. ■■ The upward retraction of the breast tissue is key as the suspensory ligaments of the breast will concomitantly elevate the muscle (see TECH FIG 1D ). ■■ It is imperative to not cut the muscle unless you can ele- vate the muscle off the chest wall. ■■ Inability to elevate the muscle most likely indicates that the identified muscle is actually not the pectora- lis, but rather the serratus, rectus, or an intercostal muscle. ■■ Dissection through an intercostal could lead to pen- etration of the pleural space and pneumothorax. ■■ Once the lateral border of the pectoralis is identified, the fascia is incised to expose the underlying muscle. Continued upward retraction of the breast will elevate the lateral border, allowing further dissection and place- ment of the retractor beneath the overlying pectoralis muscle.

Periareolar Incision

■■ 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 to allow more accurate visualization of the exact areolar border. ■■ It is most important to follow the exact outline of the areolar border even if irregular as any deviation off the border in order to smooth the incision outline leads to a more visible scar. ■■ The planned incision should extend equidistance medial and lateral from the midline but not to exceed half of the circumference of the areola (see TECH FIG 2A ). ■■ With the skin placed under tension by the assistant, the incision is made precisely on the areolar border with a 15 blade through the skin to the mid-dermis. ■■ Dissection then proceeds through the deep dermis and breast parenchyma with electrocautery (see TECH FIG 2B,C ). ■■ The skin edges are retracted inferiorly and superiorly, and dissection is carried down through the parenchyma toward the pectoralis fascia. ■■ The dissection should be directed in an inferior direction to insure that the NAC is not inadvertently undermined during dissection and 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 (see TECH FIG 2D ). ■■ With the subcutaneous periareolar approach (like the IMF approach), the breast elevation and pocket creation begins at the fold and proceeds superiorly in the subpec- toral pocket. ■■ The IMF is a fusion of the deep fascia attached to the pectoralis and the superficial fascia of the breast (see FIG 6 ). Take care to prevent disruption of the IMF as the breast and pectoral fascia are elevated. ■■ If creating a subpectoral dual plane pocket, dissection proceeds subcutaneously or transparenchymal down to the lateral border of the pectoralis muscle. ■■ If accessing the submuscular pocket, the lateral border of the pectoralis is identified and the fascia is incised to expose the underlying muscle. Continued upward retrac- tion of the breast will elevate the lateral border, allowing further dissection and placement of the retractor beneath the overlying pectoralis muscle