Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

T E C H N I Q U E S 1310 Part 4 Plastic Surgery of the Breast ■■

When creating the submuscular pocket, it is impera- tive to not cut the muscle unless it can be elevated off the chest wall. ■■ Inability to elevate the muscle most likely indicates that the identified muscle is actually not the pectoralis, but rather the serratus, rectus, or an intercostal muscle. ■■ Dissection through an intercostal could lead to pen- etration of the pleural space and pneumothorax. Pocket Dissection ■■ After the subpectoral space is entered, dissection is car- ried upward centrally to the superior extent of the pocket. ■■ Dissection is then carried laterally just superficial to the pectoralis minor until the lateral border of the pocket is reached. ■■ Keep lateral dissection of the pocket to a minimum with the cautery because the breast/nipple neural supply from the lateral cutaneous nerves can be inadvertently cut. ■■ Blunt dissection of the lateral edge of the pocket decreases the chance of nerve transection. ■■ Carry the dissection inferiorly along the lateral border of the pocket, identifying and staying superficial to the serratus muscle until the inferior extent of the pocket at the IMF is reached.

■■ Avoid overdissection of your pocket laterally to facili- tate optimal medial projection of the implant. ■■ The pectoralis is then released along the planned IMF, staying 1 cm superior to the fold to account for caudal muscle descent. ■■ Dissection directly at the fold will often lead to a fold that is lower than planned as the muscle retracts inferi- orly ( TECH FIG 7A ). ■■ As the dissection is carried medially along the IMF, it is critically important to stop it at the most medial extent along the sternum ( TECH FIG 7B ). ■■ Preservation of the most caudal attachment of the pecto- ralis muscle at the transition point (TP) along the sternum is critical to minimize the chance of window shading of the pectoralis with subsequent medial implant exposure and animation deformities ( TECH FIG 7C,D ). ■■ A transition zone (TZ) of tapered muscle release con- nects the transition point to the main body of medial pectoral muscle along the sternum. ■■ The extent of the pocket is completed by defining the medial pectoral border and dividing all of the accessory slips of pectoralis muscle that insert along the ribs, pre- serving only the main body of the muscle as it inserts along the sternum.

Muscle release

TZ

TP

IMF

C

TECH FIG 7  • A. Inferior/lateral border of the pectoralis major after it was released along the IMF. B.  Inferior release of the pectoralis major heading medially toward the sternum. C. Transition zone ( TZ ) and transition point ( TP ). Dashed line reveals pectoralis muscle release medially up to the TP. Solid line represents the inframammary fold ( IMF ). D. Schematic demonstrating the release of the pectoralis off of the chest wall to the transition point ( TP ). Notice the transition zone ( TZ ) which is a zone of thinning of the muscle at the caudal end of the ster- num just medial to the TP.

TZ

TP

D