Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

1301

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

■■ If the soft tissue coverage is lax and poor quality or if the implant selected is deemed at risk for wrinkling, a pinch test greater than 3 cm is more reliable in providing ade- quate coverage and minimizing the risk of rippling. ■■ Adequate soft tissue coverage in the upper pole in a sub- glandular augmentation will camouflage the transition between the breast and implant, aiding to a smooth natu- ral upper pole. ■■ The deep fascia overlying the implant in the subfascial pocket will provide additional support and coverage in the upper pole and minimize the implant edge visibility, which can be seen if implants are placed in the subglandu- lar pocket with limited upper pole coverage. ■■ If the patient prefers a full, rounded upper pole with an obvious transition between her implant and soft tissue, a subglandular implant would be preferred even if the pinch test is less than 2 cm. ●● One must have a discussion regarding visible and pal- pable rippling of the implant if placing the implant sub- glandular and the pinch test is less than 2 cm. ■■ Capsular contracture can be reduced by using a tex- tured implant in the subglandular position, but one must consider the risks of rippling with textured implant in a patient with inadequate upper pole coverage with a pinch test of less than 2 cm. 1 Physical Assessment ■■ Assess for all asymmetries, including breast volume, IMF, nipple-areolar complex (NAC), and chest wall. ■■ Chest wall (skeletal and muscle) abnormalities or asymme- tries are often underappreciated and can significantly alter the final result ( FIG 9 ). 8 ■■ Pectus excavatum occurs occasionally, whereas pectus carinatum and Poland syndrome are rare. 9 ■■ Central deformities are typically ameliorated sufficiently by breast augmentation alone. ■■ Deep pectus excavatum deformities can be treated simul- taneously with a custom solid silicone implant made from a plaster mold, although most patients decline this option. ■■ Poland syndrome (absence of sternal head of pectoralis muscle) is best addressed with subglandular augmenta- tion as the sternal head of the pectoralis major muscle is absent. When more severe, more extensive adjunctive procedures, such as tissue expansion, fat grafting, and latissimus muscle transfer, may be required. 10 ■■ Hemithorax asymmetry due to differences in shape, pro- trusion, or regression can create an uneven breast founda- tion, suggesting different size implants despite equivalent breast volumes.

SSN:N

SSN:N

BW

BH

N:IMF

IMD

FIG 7  • Necessary physical exam breast measurements.

■■ Breast width (BW) ■■ Sternal notch to nipple (SSN:N) ■■ Breast height (BH) ■■ Nipple to IMF (N:IMF) at rest and under maximal stretch. ■■ Upper pole pinch (UPP), medial pinch (MP), and lateral pinch (LP) ■■ Intermammary distance (IMD) Pinch Test ■■ A key point of the exam is the upper pole pinch test. ■■ A pinch test of less than 2 cm indicates the need for a submuscular placement of the implant to avoid noticeable rippling ( FIG 8A ). ■■ If the pinch test is more than 2 cm (1 cm of soft tissue thickness), the patient is a candidate for a subglandular or subfascial pocket ( FIG 8B ). (The deep fascial layer will provide additional coverage over the implant to allow for subfascial placement.) ■■ Implant selection impacts adequacy of soft tissue coverage. Keep in mind the thinner the soft tissue, the greater the risk of implant palpation and rippling. ■■ Some implants are prone to more wrinkling, including underfilled saline implants and textured devices. ■■ We require a pinch test of more than 2 cm if placing the implant subfascially or subglandularly, where the soft tis- sue coverage is firm and good quality.

FIG 8  • A. Upper pole pinch test less than 2 cm and (B) more than 2 cm.