Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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Part 4 Plastic Surgery of the Breast

Inframammary fold

A

FIG 11  • A. The inframammary fold is a natural boundary where the chest and the breast meet. B. Autorotation of the breast. N:IMF is 6 cm at rest. N:IMF is 8 cm on stretch/autorotation.

Approach

Pocket Control

■■ Pocket control is key and begins during preoperative mark- ings to design the pocket size necessary to accommodate the selected implant. ■■ Controlling the pocket involves placement of the IMF, defin- ing the medial and lateral pocket margins. ■■ This creates the desired cleavage and prevents lateral migration or malposition of the implant. ■■ Whereas smooth implants often are designed with a larger pocket to allow for implant mobility and perceived softness, pocket design should be more limited when using a textured implant. ■■ Excess movement can lead to irritation and seroma formation. ■■ When using a shaped textured implant, a controlled pocket is even more essential to minimize the risk of implant rota- tion postoperatively. ■■ This requires defining the lateral, medial, and inferior as well as the superior border and limiting the pocket to only what is required to accommodate the shaped device. ■■ The implant and pocket should ultimately have a “hand- in-glove” fit. 19 Positioning ■■ Patients are placed on the operating room table in the supine position. ■■ The arms are secured to the arm board at approximately 45 degrees to stabilize the patient in the upright position. Actual arm placement is between 45 and 60 degrees ( FIG 12 ). ■■ Some surgeons place the arms directly by the patient’s side. ■■ Having the arms abducted to 90 degrees should be avoided because this does not allow the breasts to be in a relaxed position when sitting the patient up to check adequacy of implant placement and soft tissue redraping.

■■ Before surgical preparation, 50 mL of a local field block of 1/4% lidocaine, 1/8% bupivacaine, and 1:400 000 epineph- rine is injected into breast (Table 1). ■■ A 20-mL syringe with a 22-gauge spinal needle is used to inject the anesthetic into the dermis along the planned incision line, deep to the dermis along the IMF, the medial pectoral border, the anterior axillary line, and deep to the breast parenchyma, in a fanning fashion throughout the area of planned pocket creation ( FIG 13 ). ■■ These injections provide assistance not only in operative hemostasis but also in the management of postoperative pain. ■■ This is less important in the subglandular augmentation as postoperative pain is significantly less than with a sub- muscular augmentation.

FIG 12  • Arms abducted at approximately 45 to 60 degrees in supine position.