Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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

■■ Implant type and size ■■ Issues of capsular contracture, breast-feeding, and NAC sensation ■■ There are many potential advantages of the inframammary approach, including the following: ■■ Well-hidden scar in the fold of the breast ■■ Incisional length is unlimited, thus can accommodate any and all implant choices ■■ Excellent visualization for dissection of the implant pocket ■■ The ability to control the IMF position during incision closure ■■ Can be used for any complication revision ■■ Lower capsular contracture ■■ Minimal issue of a scar contracture creating deformity ■■ Potentially less nipple sensation changes ■■ Potential disadvantages of the inframammary incision include the following: ■■ The scar is located on the breast ■■ Scar may be more visible if breast fold is absent or if the scar becomes pigmented ■■ Must determine final IMF position preaugmentation and place scar precisely in planned new fold. ■■ Scar position more vulnerable to irritation from the bra ■■ There are many potential advantages of the periareolar approach, including the following: ■■ Scar can be camouflaged in the areolar border ■■ Direct visualization and access into the breast pocket ■■ Can lower the IMF to any location without predetermin- ing location ■■ Central access allows use in most revision cases with optimal visualization and access to the upper pole of the breast ■■ Access for parenchymal breast scoring in constricted breast deformities ■■ Potential disadvantages of the periareolar incision include the following: ■■ The scar is located on the breast ■■ Access is through a tunnel and may limit visualization in dense, heavy breasts ■■ Cannot use if areolae are too small ■■ Poor scarring possible and can create significant deformities ■■ IMF control sutures not possible when IMF is lowered ■■ Transection of breast ducts may increase bacterial contamination ■■ Potentially higher capsular contracture rates 15 ■■ Good candidates for the inframammary approach may include the following: ■■ Small areola ■■ When controlling IMF is desired ■■ Indistinct areolar border ■■ Desire for no scar on the breast ■■ Potentially when placing larger implants ■■ Desire future breast feeding as interference with lactation has been implicated with periareolar incision. 5 ■■ Concerns with nipple sensation, although no strong data to support this concern. 3,16 ■■ Good candidates for the periareolar approach may include the following: ■■ Very distinct areolar borders present

■■ When areola large enough to accommodate implant and avoid implant trauma ■■ When performing a concurrent mastopexy ■■ Indistinct or absence of IMF to hide scar ■■ When lowering IMF (IMF position does not need to be predetermined) ■■ Treatment of tuberous breasts (parenchymal scoring, IMF lowering) ■■ The incision should be as small as possible but large enough to dissect the pocket and place the implant without distort- ing or injuring the device. ■■ Incision length ranges include 3 to 4.5 cm for saline implants, 4 to 6 cm for silicone round implants, and 4.5 to 7 cm for shaped cohesive silicone implants. 17 ■■ The length of the incision would be smaller with saline than with silicone implants. Factors requiring increased incision length include the following: ●● Shaped implants (cohesiveness and gel distribution) ■■ When using the periareolar approach, the incision is made around the areola and the dissection is carried inferiorly the appropriate distance to accommodate the selected breast implant. ■■ However, when the approach is through an IMF incision, the final position of the fold postaugmentation must be predetermined so the incision can be placed accurately in that location. ■■ Before surgery, the IMF is identified and marked in the sitting position ( FIG 11A ). To determine the true IMF posi- tion, the breast is autorotated inferiorly to identify the inferior extent of the attachments of the IMF ( FIG 11B ). ■■ The distance measured from the nipple to the true fold under maximal stretch assesses the amount of lower pole skin available to accommodate the selected implant. ■■ The amount of lower pole skin required and the ultimate position of the fold is a function of many factors, including the type of implant (saline vs silicone, round vs shaped), size of implant, pocket location, and the strength and stability of the soft tissue of the lower pole. ■■ An acceptable standard that can be used is to follow the guidelines that an implant with a base diameter of 11 cm requires 7 cm, a base diameter of 12 cm requires 8 cm, and a base diameter of 13 cm requires 9 cm from nipple to fold. 18 ■■ Another useful method of estimating fold position is based on implant height and projection and can be used for round or shaped implants 17 : ■■ Optimal nipple to IMF distance = (1/2 implant projec- tion) + (1/2 implant height) ■■ IMF lowering = (optimal nipple to IMF distance) − (mea- sured nipple to IMF distance) ■■ If the measured nipple to fold distance is less than the desired or optimal distance, the fold will need to be lowered. ■■ Keep in mind that textured and smooth implants have dif- ferent effect on the lower pole skin and fold over time. A larger smooth implant will lead to more stretch on the lower pole compared to a smaller or textured implant. ●● Implant volume ●● Implant texture ●● Silicone compared to saline ●● Increased gel cohesiveness (silicone gel firmness) ●● Increase implant projection