Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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

■■ Dividing these muscle slips with electrocautery instead of blunt dissection improves postoperative cleavage and maintains hemostasis. Although completely divid- ing all accessory slips is required to achieve maximal cleavage, division of the main body of medial pectora- lis muscle should be preserved, other than conservative thinning at the transition zone, to minimize the risk of postoperative wrinkling or implant show. ■■ This division of the inferior pectoralis muscle just above the IMF during initial pocket dissection creates a level 1 dual plane. Thus, all subpectoral pockets where the muscle is released inferiorly are actually dual-plane pockets, as the segment between the caudal edge of the divided muscle and the IMF is subglandular. 21 ■■ The level of dual plane required varies, and each sur- gery can be tailored to provide the optimal level based on soft tissue requirements and implant selection. ■■ The greater the amount of breast parenchyma or breast laxity, the greater the level of dual plane. ■■ It is this creation of a lower pole subglandular pocket that allows for an optimal breast-implant interface and soft tissue redraping. ■■ Failure to optimize the breast-implant interface can lead to a waterfall deformity, with the breast sliding off of the implant. ■■ When submuscular, IMF lowering can be more chal- lenging as it is tempting to carry the dissection under the muscle inferiorly to lower the fold. ■■ The dissection along the chest wall at the level of the fold is deep to the suspensory ligament structures that create the IMF. ■■ IMF lowering in the subpectoral pocket requires transi- tioning into a more superficial plane above the pectoralis fascia to lower the IMF. 20 ■■ Dissection deep to the pectoral fascia will likely result in a lowered fold with persistence of the fold structure, resulting in a double-bubble deformity. ■■ This is more likely when dissection begins from above, such as a periareolar or transaxillary approach. ■■ When using an IMF incision, the dissection below the native fold begins in the subcutaneous plane until the pectoralis muscle is reached, resulting in appropriate obliteration of the native fold at the correct level. Implant Placement ■■ The implants are bathed in the irrigation solution before insertion. Gloves are changed and rinsed with the irriga- tion solution to remove any residue (see TECH FIG 5A ). ■■ In the authors’ practice, the implant is placed into the pocket with the assistance of an insertion sleeve such as the Keller funnel (see 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 easily confirmed by passing the implant with irrigation solution through the funnel prior to pocket insertion.

■■ The implant orientation is then confirmed in the fun- nel, and a maneuver of squeezing the implant through the funnel with gentle pressure exerted on the back of the funnel allows the implant to slip effortlessly into the breast pocket. ■■ These maneuvers provide a “no-touch” technique, which has been associated with lower capsular con- tracture rates. 12,13 ■■ Once the implant is in the pocket (see FIG 3A ), a finger- assisted assessment and manipulation of the implant within the pocket is necessary to confirm its proper placement and ensure appropriate redraping of the breast parenchyma over the implant (see 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 overdissection. ■■ This approach is especially important with shaped implants, as a stretched pocket from overmanipulation could lead to implant rotation postoperatively. Pocket Closure ■■ Before incision closure, the patient should be placed in the upright position to assess implant position, fold posi- tion, and symmetry, and the adequacy of the dual plane (see TECH FIG 6A ). ■■ The IMF approach for submuscular implant placement is useful to control the fold position during the final clo- sure. The cuff of superficial Scarpa fascia that was pre- served during the initial incision is used to secure the fold during closure. ■■ If the IMF structure is stable and has not been vio- lated or lowered during the procedure, reapproxima- tion of the superficial fascia during closure is usually adequate. ■■ If the fold is mobile and unstable from either inherent weakness or from disruption during 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 (see TECH FIG 6B,C ). ■■ 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). ■■ 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 postopera- tively as can be seen with smooth breast implants (see TECH FIG 6D ).

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