Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

1302

Part 4 Plastic Surgery of the Breast

Rectangular

Round

Pectus Excavatum

Asymmetric

FIG 9 • Examples of chest wall abnormalities.

■■ Unilateral prominence of the chest wall is often associated with scoliosis ( FIG 10 ). ■■ Subtle unilateral pectoralis hypertrophy should not affect subglandular or subfascial implant placement, but it could affect subpectoral placement and overall implant projection. IMAGING ■■ Screening mammography per the American College of Surgeons is recommended for patients over 40 years of age. ■■ Many plastic surgeons recommend a baseline mammogram at 35 or older prior to a breast augmentation, especially if a family history is present. ■■ Any additional diagnostic studies are guided by the preop- erative exam.

■■ Any palpable mass requires evaluation, usually with a diag- nostic ultrasound and/or mammogram. SURGICAL MANAGEMENT ■■ The preoperative evaluation and decision-making are a critical step in achieving optimal outcomes in breast augmentation. ■■ Capsular contracture is the leading indication for revision breast surgery after a breast augmentation and every effort should be made during planning and execution to minimize the risk of capsular contracture postoperatively. Placement of breast implants in the submuscular pocket has consis- tently demonstrated reduction in capsular contracture rates compared with the other pocket choices. 1,4 ■■ Validated steps to reduce this risk include the following: ■■ Nipple shields 11 ■■ No-touch technique 12 ■■ Use of an insertion sleeve 13 ■■ Pocket irrigation with triple antibiotics 14 ■■ Inframammary incisions 4 ■■ Use of textured implants 1,4 Preoperative Planning Incision ■■ The decision on incision placement is based on a variety of variables: ■■ Patient and surgeon preferences ■■ Anatomic considerations

FIG 10  • Left chest wall prominence compared to the right chest wall.